ORIGINAL ARTICLE
Bali Medical Journal (Bali MedJ) 2025, Volume 14, Number 1: 157-164
P-ISSN.2089-1180, E-ISSN: 2302-2914

Correlation between grading of
fat infiltration in multifidus muscle and
degree of facet joint arthropathy in
degenerative spondylolisthesis patients based on
lumbosacral MRI: a cross-sectional study
Chin Edward Chandra1*, Dario Agustino Nelwan2, Muhammad Ilyas2,
Andriany Qanitha3, Karya Triko Biakto4, Sri Asriyani2

Resident of Radiology Department,
Faculty of Medicine, Universitas
Hasanuddin, Dr. Wahidin Sudirohusodo
Hospital, Makassar, Indonesia;
2
Specialist and Consultant in the
Department of Radiology, Faculty of
Medicine, Universitas Hasanuddin,
Dr. Wahidin Sudirohusodo Hospital,
Makassar, Indonesia;
3
Department of Public Health, Faculty
of Medicine, Universitas Hasanuddin,
Makassar, Indonesia;
4
Specialist and Consultant in the
Department of Orthopaedics and
Traumatology, Faculty of Medicine,
Universitas Hasanuddin, Dr. Wahidin
Sudirohusodo Hospital, Makassar,
Indonesia.

ABSTRACT

1

*Corresponding author:
Chin Edward Chandra;
Resident of Radiology Department,
Faculty of Medicine, Universitas
Hasanuddin, Dr. Wahidin Sudirohusodo
Hospital, Makassar, Indonesia;
echandra32@gmail.com
Received: 2024-06-08
Accepted: 2024-08-10
Published: 2024-09-12

Background: Degenerative spondylolisthesis is a disorder caused by displacement of one vertebral body by one above
or below it due to degenerative changes. Possible contributing causes of degenerative spondylolisthesis are facet joint
osteoarthritis and inadequate muscle stabilization. The facet joint and multifidus muscle are innervated by the medial branch
of the dorsal ramus of the segmental nerve. This study aims to investigate the relationship between grading of multifidus
muscle fat infiltration and degree of facet joint arthropathy in patients with degenerative spondylolisthesis based on
lumbosacral MRI.
Methods: This research employs a cross-sectional observational design, utilizing secondary data from the Picture Archiving
and Communication System (PACS) and medical records. The aim is to investigate the relationship between the grading of
multifidus muscle fat infiltration and the severity of facet joint arthropathy in patients with degenerative spondylolisthesis,
based on non- weight-bearing lumbosacral MRI. The study includes all data stored in the PACS at our center from January
2022 until the required sample size was reached.
Results: This study analyzed 100 non-weight-bearing lumbosacral MRI samples of patients with degenerative
spondylolisthesis. The distribution of samples based on lumbar multifidus muscle fat infiltration revealed that grade 2 had
the highest prevalence at 33%. Similarly, the distribution based on facet joint arthropathy showed the highest occurrence at
grade 2, or moderate, at 45%. Significant relationships were found between gender and age with lumbar multifidus muscle
fat infiltration (p<0.05), and between gender and spinal level with facet joint arthropathy (p<0.05). Additionally, there is
a strong positive correlation (r=0.64; p<0.05) between the grading of the multifidus muscle and the degree of facet joint
arthropathy in these patients.
Conclusion: There is a strong positive and significant correlation between grading multifidus muscle and degree of facet
joint arthropathy in patients with degenerative spondylolisthesis.
Keywords: Degenerative Spondylolisthesis, Multifidus Muscle Fat Infiltration, Facet Joint Arthropathy, Lumbosacral MRI.
Cite This Article: Chandra, C.E., Nelwan, D.A., Ilyas, M., Qanitha, A., Biakto, K.T., Asriyani, S. 2025. Correlation between
grading of fat infiltration in multifidus muscle and degree of facet joint arthropathy in degenerative spondylolisthesis patients
based on lumbosacral MRI: a cross-sectional study. Bali Medical Journal 14(1): 157-164. DOI: 10.15562/bmj.v14i1.5483

INTRODUCTION
Degenerative spondylolisthesis is a
disorder caused by the displacement of
one corpus vertebrae with one above or
below it due to degenerative changes.
On plain radiographs, spondylolisthesis
is often found at CV L4 to CV L5 and
there are also some at CV L5 to CV S1
and CV L3 to CV L4.1 Degenerative
changes in the intervertebral discs are a
very important factor in assessing spinal
function in old age.2 The male to female

ratio for degenerative spondylolisthesis
is 1:5-6. Degenerative spondylolisthesis
is rarely found in ages below 50 years.
The displacement of the corpus vertebrae
is limited to 30% of the width of the
involved corpus vertebrae. The occurrence
of degenerative spondylolisthesis is
strongly associated with increasing age
in both women and men. Pregnancy,
generalized joint weakness and increased
BMI also predispose to degenerative
spondylolisthesis.3

Open
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access:Journal
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2025; 14(1): 157-164 | doi: 10.15562/bmj.v14i1.5483

In
many
cases,
degenerative
spondylolisthesis is associated with facet
joint arthrosis and motion segment
failure. Listhesis occurs as a result of
facet joint subluxation, associated with
significant and progressive loss of cartilage
and articular remodeling.4 Facet arthrosis
or degenerative facet disease is the
most frequent form of facet pathology.
The disease mainly affects the elderly
population, occurring in almost everyone
after the age of 60 and in varying degrees
157

ORIGINAL ARTICLE

affecting most adults, suggesting that facet
arthrosis has a large role in neck pain and
back pain in the elderly population.5
The innervation of the lumbar facet
joint originates from the medial branch of
the lumbar dorsal ramus, or, as it is also
known the posterior branch of the lumbar
vertebral nerve. The vertebral nerve is
divided into four different branches,
after exiting the intervertebral foramen
respectively; communicating branches,
meningeal branches, ventral ramus, and
to a lesser extent the dorsal ramus. At the
L1-L4 level, the dorsal ramus separates at
the spinal nerve which is usually at the
right facet angle. The dorsal ramus then
crosses the vertebral foramen, which then
forms the dorsal and caudal pathways.5,6
The dorsal ramus is the point encountered
on the foramen formed by the superior
border of the adjacent transverse processes
and the inferior border of the lumbar
facet joint at each level. The last aspect of
the dorsal ramus is located at the medial
intertransverse muscle. In addition, the
middle branch also displays numerous
anastomoses with other branches, thus
forming a complex nerve plexus. The
medial branch is there branched into three
different branches; muscular, articular
and cutaneous branches, innervating the
lumbar facet joints, multifidus muscle
and superior and intervertebral ligaments.
Therefore, it becomes the basic theory that
there is a relationship between the facet
joint and the multifidus muscle.6
Based on those mentioned above, this
study aims to investigate the relationship
between the grading of multifidus muscle
fat infiltration and the degree of facet joint
arthropathy in patients with degenerative
spondylolisthesis based on lumbosacral
MRI.

METHODS
Study design and Patients Selection
This study employed a cross-sectional
observational research design using
consecutive sampling at our center from
January 2022 until the required sample
size was achieved. Secondary data was
collected through the Picture Archiving
and Communication System (PACS)
and medical records to determine the
correlation between the grading of
multifidus muscle fat infiltration and the
158

Figure 1. Evaluation of fat infiltration
of multifidus muscle based on
Goutallier classification and
facet joint arthropathy based
on Weishaupt classification.
degree of facet joint arthropathy in patients
with degenerative spondylolisthesis, based
on non-weight-bearing lumbosacral MRI.
Inclusion criteria are degenerative
spondylolisthesis patients over 50 years
old and with findings of degenerative
spondylolisthesis
from
lumbosacral
MRI. Exclusion criteria are patient with
history of spinal trauma, spinal fracture,
thoracolumbar/lumbar vertebral column
scoliosis, pars interarticularis fracture,
spinal tumor, congenital spinal defects,
history of previous vertebral surgery,
isthmic spondylolisthesis, and inadequate
image quality on MRI.
Image assessment obtained from
non-weight bearing MRI 3 Tesla
T2WI lumbosacral vertebrae at the
midline sagittal view and axial level of
spondylolisthesis.
Grading of multifidus muscle fat
infiltration
Grading of multifidus muscle fat
infiltration are compositional changes
from the degenerative process of the
lumbar multifidus muscle from muscle
composition to fat infiltration. Criteria of
grading based on Goutallier classification
are: (1) grade 0: no fat infiltration; (2)
grade 1: fatty infiltration in the form of
fine lines in the muscle; (3) grade 2: muscle
composition is more than fat composition

Figure 2. Measurement of spinal canal
ratio to determine degenerative
spondylolisthesis.
(fat infiltration less than 50%); (4) grade
3: muscle composition is equal to fat
composition (fat infiltration +/- 50%); (5)
grade 4: more fat composition than muscle
composition (fat infiltration more than
50%) (Figure 1).
Degree of facet joint arthropathy
The features of osteoarthritis of the facet
joint are characterized by irregularity of
the facet joint surface, narrowing of the
facet joint and or sclerotic subchondral
and or subchondral cyst. Criteria of
grading are: (1) grade 1 or normal: no
signs of degeneration (normal facet joint
space (2-4 mm), no sclerosis and no
osteophytes); (2) grade 2 or mild: joint
space is narrowed and/or there are mild
osteophytes; (3) grade 3 or moderate:
subchondral sclerosis and/or moderate
osteophytes; (4) grade 4 or severe: severe
osteophytes and/or subchondral cyst
(Figure 2).
Statistical analysis
Univariate analysis
Univariate analysis aims to explain or
describe the characteristics of each variable
studied. There are 7 variables in this
study that have categorical data, namely
variables of age, gender, body mass index,
activity, spinal level, grading of multifidus
muscle fat infiltration and degree of facet
joint arthropathy. Univariate analysis will
describe the number/value of the number
and percentage of each group of variables

Bali Medical Journal 2025; 14(1): 157-164 | doi: 10.15562/bmj.v14i1.5483

ORIGINAL ARTICLE

of gender, body mass index, activity,
spinal level, degree of degenerative
spondylolisthesis, degree of facet joint
arthropathy and grading of fat infiltration
of multifidus muscle.
Bivariate analysis
Bivariate analysis aims to determine the
relationship between the two variables
studied. Bivariate analysis in this study
aims to analyze whether there is a
relationship between age, gender, body
mass index, history of physiotherapy
activities, and spinal level with grading
of multifidus muscle fat infiltration, and
degree of facet joint arthropathy.
Categorical variables were analyzed
using Chi-square test in normal
distribution data, while Fisher exact
test was used in non-normal data. To
determine the relationship between
grading of multifidus muscle fat
infiltration and the degree of facet joint
arthropathy in patients with degenerative
spondylolisthesis, Spearman test was used.
P values less than 0.05 were considered as
statistically significant. This study using
SPSS software version 26.0 for Windows.

RESULTS
A total of 100 patients were retrieved
from medical records of our radiology
department for non-weight bearing
lumbosacral MRI examination in patients
with degenerative spondylolisthesis from
January 2022 to March 2024 who met the
inclusion and exclusion criteria.
Table 1 presents the characteristics
of the study patients. The data indicates
that women comprised the majority with
63 samples (63%), while male accounted
for 37 samples (37%). The age group
with the highest representation was 5665 years, with 49 samples (49%), and the
least represented was those over 65 years,
with 17 samples (17%). The most common
BMI category was obesity, with 46 samples
(46%), whereas the underweight category
had the fewest, with 3 samples (3%).
Regarding activity levels, patients with
light activity were the most numerous at
54%, while those with heavy activity were
the least at 9%. Concerning physiotherapy
history, 69 patients (69%) had no history
of physiotherapy, while 31 patients (31%)
had such a history. For spinal levels, the

Table 1.

Patients’ characteristics
Variables
Male
Female

Gender

N
37
63

%
37
63

34
49
17

34
49
17

3
24
27
46
54
37
9
15
62
23

3
24
27
46
54
37
9
15
62
23

Mean± SD

Age (years)

59.4±6.8
50-55 years
56-65 years
> 65 years

BMI (kg/m2)

24.2±2.8

Underweight (< 18.5)
Normal (18.5 – 22.9)
Overweight (23 – 24.9)
Obese (> 25)
Light
Activity
Moderate
Heavy
Level of spinal
L3-L4
spondylolisthesis L4-L5
L5-S1

Table 2.

Distribution of study
spondylolisthesis grading

samples

based

Grading degenerative spondylolisthesis
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5

Table 3.

degenerative
%
98
2
0
0
0

Distribution of study samples based on lumbar multifidus muscle fat
infiltration

Grading lumbar multifidus muscle fat
infiltration
Grade 1
Grade 2
Grade 3
Grade 4

Table 4.

N
98
2
0
0
0

on

Total (N=100)

Percentage (%)

25
33
25
17

25
33
25
17

Distribution of study samples based on the degree of facet joint
arthropathy

Grading facet joint osteoarthritis
Grade 1
Grade 2
Grade 3
Grade 4

Total (N=100)
6
45
30
19

L4-L5 level had the highest number of
samples at 62 (62%), and the L3-L4 level
had the fewest at 15 samples (15%).
Table 2 displays the frequency and
percentage of samples according to the
grading of degenerative spondylolisthesis.
The data indicates that grade 1 is the most
prevalent, with 98 samples (98%), while
grade 2 is the least common, with only
2 samples (2%). This suggests that the

Bali Medical Journal 2025; 14(1): 157-164 | doi: 10.15562/bmj.v14i1.5483

Percentage (%)
6
45
30
19

majority of degenerative spondylolisthesis
patients at our center had grade I. Notably,
there were no patients with grade III-V
degenerative spondylolisthesis.
Table 3 presents the frequency and
percentage of samples based on the
grading of lumbar multifidus muscle fat
infiltration. The data reveals a relatively
even distribution, with degree 2 having the
highest occurrence at 33 samples (33%),
159

ORIGINAL ARTICLE

Table 5.

Factors associated with grading of multifidus fat infiltration
Variables

Gender
Age
BMI

Activity
Level of spinal

Grade 1
(n=25)
20 (80.0)
5 (20.0)
10 (40.0)
11 (44.0)
4 (16.0)
1 (4.0)
7 (28.0)
5 (20.0)
12 (48.0)
19 (76.0)
4 (16.0)
2 (8.0)
3 (12.0)
12 (48.0)
10 (40.0)

Male
Female
50-55 years
56-65 years
> 65 years
Underweight (< 18.5)
Normal (18.5 – 22.9)
Overweight (23 – 24.9)
Obesity (> 25)
Light
Moderate
Heavy
L3-L4
L4-L5
L5-S1

Fat infiltration of the lumbar multifidus muscle
Grade 2
Grade 3
Grade 4
(n=33)
(n=25)
(n=17)
9 (27.3)
6 (24.0)
2 (11.8)
24 (72,7)
19 (76.0)
15 (88.2)
16 (48,5)
4 (16.0)
4 (23.5)
14 (42,4)
14 (56.0)
10 (58.8)
3 (9.1)
7 (28.0)
3 (17.6)
1 (3.0)
1 (4.0)
0 (0.0)
10 (30.3)
4 (16.0)
3 (17.6)
7 (21.2)
8 (32.0)
7 (41.2)
15 (45.5)
12 (48.0)
7 (41.2)
17 (51.5)
13 (52.0)
5 (29.4)
12 (36.4)
10 (40.0)
11 (64.7)
4 (12.1)
2 (8.0)
1 (5.9)
7 (21.2)
4 (16.0)
1 (5.9)
19 (57.6)
19 (76.0)
12 (70.6)
7 (21.2)
2 (8.0)
4 (23.5)

p
<0.001*
0.035*
0.994
0.074
0.098

*Statistically significant if p-value less than 0.05

Table 6.

Factors associated with the degree of facet joint arthropathy
Variables

Gender
Age
BMI

Activity
Level of spinal

Grade 1
(n=25)
4 (66.7)
2 (33.3)
3 (50.0)
3 (50.0)
0 (0.0)
0 (0.0)
3 (50.0)
0 (0.0)
3 (50.0)
6 (100.0)
0 (0.0)
0 (0.0)
0 (0.0)
2 (33.3)
4 (66.7)

Male
Female
50-55 years
56-65 years
> 65 years
Underweight (< 18.5)
Normal (18.5 – 22.9)
Overweight (23 – 24.9)
Obesity (> 25)
Light
Moderate
Heavy
L3-L4
L4-L5
L5-S1

Facet joint arthropathy
Grade 2
Grade 3
(n=33)
(n=25)
22 (48.2)
8 (26.7)
23 (51.1)
22 (73.3)
13 (28.9)
11 (36.7)
23 (51.1)
14 (46.7)
9 (20.0)
5 (16.7)
2 (4.4)
1 (3.3)
13 (28.9)
6 (20.0)
10 (22.2)
9 (30.0)
20 (44.4)
14 (46.7)
23 (51.1)
18 (60.0)
15 (33.3)
11 (36.7)
7 (15.6)
1 (3.3)
11 (24.4)
2 (6.7)
23 (24.4)
23 (76.7)
11 (24.4)
5 (16.7)

Grade 4
(n=17)
3 (15.8)
16 (84.2)
7 (36.8)
9 (47.4)
3 (15.8)
0 (0.0)
2 (10.5)
8 (42.1)
9 (47.4)
7 (36.8)
11 (57.9)
1 (5.3)
2 (10.5)
14 (73.3)
3 (15.6)

P
0.026*
0.568
0.751

0.060

0.031*

*Statistically significant if p-value less than 0.05

Table 7.

Relationship between grading of fat infiltration of multifidus muscle and degree of facet joint arthropathy in
patients with degenerative spondylolisthesis
Variables

Grading lumbar multifidus muscle fat
infiltration

Grade I
Grade II
Grade III
Grade IV

Grade 1
4 (66.7)
2 (33.3)
0 (0.0)
0 (0.0)

Grading Facet joint arthropathy
Grade 2
Grade 3
18 (40.0)
3 (10.0)
18 (40.0)
12 (40.0)
9 (20.0)
7 (23.3)
0 (0.0)
8 (26.7)

Grade 4
0 (0.0)
1 (5.3)
9 (47.4)
9 (47.4)

p

< 0.001*

*Statistically significant if p-value less than 0.05

while degree 4 has the lowest at 17 samples
(17%).
Table 4 details the frequency and
percentage of samples based on facet joint
osteoarthritis. The data indicates that
160

degree 2, or moderate osteoarthritis, is
the most common with 45 samples (45%),
while degree 1, or normal, is the least
common with 6 samples (6%).

Table 5 illustrates the relationship
between gender, age, BMI, physiotherapy
history, and activity level with lumbar
multifidus muscle fat infiltration. In terms
of gender, grade I fat infiltration is more

Bali Medical Journal 2025; 14(1): 157-164 | doi: 10.15562/bmj.v14i1.5483

ORIGINAL ARTICLE

common in men (20 samples, 80%), while
grades II, III, and IV are more prevalent
in women with 24 samples (72.7%), 19
samples (76%), and 15 samples (88.2%),
respectively. Statistical test results show
a significant relationship between
gender and lumbar multifidus muscle fat
infiltration (p < 0.001).
In terms of age, grade I lumbar
multifidus muscle fat infiltration is most
common in the 56- 65 age group, with
11 samples (44%). Grade II is more
frequent in the 46-55 age group, with 16
samples (48.5%). Grade III is also most
common in the 56-65 age group, with 14
samples (56%). Similarly, grade IV is most
prevalent in the 56-65 age group, with 10
samples (58.8%). Statistical test results
show a significant relationship between
age and lumbar multifidus muscle fat
infiltration (p = 0.035).
For BMI, grade I lumbar multifidus
muscle fat infiltration is most common
among obese individuals, with 12 samples
(48%). Grade II is also more prevalent in
obesity, with 15 samples (45.5%). Grade
III is most frequent among the obese, with
12 samples (48%). Grade IV is equally
common in both obese and overweight
individuals, with 7 samples (41.2%)
each. Statistical test results indicate no
significant relationship between BMI and
lumbar multifidus muscle fat infiltration
(p = 0.994).
In terms of activity, Grade I lumbar
multifidus muscle fat infiltration was
predominantly found in light activity, with
19 samples accounting for 76%. Grade
II infiltration was also more common in
light activity, with 17 samples making up
51.5%. Similarly, Grade III infiltration was
more prevalent in light activity, with 13
samples representing 52%, and Grade IV
infiltration was most frequent in activity,
with 11 samples comprising 64.7%. The
statistical test results showed a p-value of
0.074 (p>0.05), indicating that there is no
significant relationship between activity
level and lumbar multifidus muscle fat
infiltration.
Regarding the spinal level history,
Grade I lumbar multifidus muscle fat
infiltration is most common at the L4-L5
level, with 12 samples (48%). Grade II
infiltration is also more frequent at L4L5, with 19 samples (57.6%). Similarly,

Grade III infiltration is predominantly
found at L4-L5, with 19 samples (76%),
and Grade IV infiltration is more common
at L4-L5, with 12 samples (70.6%). The
statistical test results showed a p-value
of 0.098 (p>0.05), indicating that there is
no significant relationship between spinal
level and lumbar multifidus muscle fat
infiltration.
Table 6 outlines the factors associated
with facet joint arthropathy. In terms of
gender, degree I (normal) arthropathy
was more common in males, with 4
samples (66.7%). Degree II (mild) was
more frequent in females, with 23 samples
(51.1%). Degree III (moderate) was
also more prevalent in females, with 22
samples (73.3%), and degree IV (severe)
was predominantly found in females,
with 16 samples (84.2%). Statistical test
results showed a p-value of 0.026 (p <
0.05), indicating a significant relationship
between gender and changes in facet joint
arthropathy.
Regarding age, degree I (normal)
arthropathy was most common in the 4655 and 56-65 age ranges, with 3 samples
each (50%). Degree II (mild) was most
prevalent in the 56-65 age range, with 23
samples (51.1%). Degree III (moderate)
was also most common in the 56-65 age
range, with 14 samples (46.7%), and degree
IV (severe) was most prevalent in the 5665 age range, with 9 samples (47.4%). The
statistical test results showed a p-value of
0.568 (p > 0.05), indicating no significant
relationship between age and facet joint
osteoarthritis.
Based on BMI, degree I (normal) facet
joint arthropathy is most prevalent in
individuals with obesity and those with
a normal BMI, each having 3 samples
(50%). Degree II (mild) arthropathy is
most common in obese individuals, with
20 samples (44.4%). Degree III (moderate)
arthropathy is most frequent in overweight
individuals, with 9 samples (30%), and
degree IV (severe) arthropathy is most
prevalent in obese individuals, with 9
samples (47.4%). Statistical test results
showed a p-value of 0.751 (p > 0.05),
indicating no significant relationship
between BMI and facet joint osteoarthritis.
In terms of activity, degree I
(normal) facet joint arthropathy is most
common in individuals with a history of

Bali Medical Journal 2025; 14(1): 157-164 | doi: 10.15562/bmj.v14i1.5483

physiotherapy, with 4 samples (66.7%).
Degree II (mild) arthropathy is most
prevalent in those without a history of
physiotherapy, with 35 samples (77.8%).
Degree III (moderate) arthropathy is also
most common in those without a history
of physiotherapy, with 19 samples (63.3%),
and degree IV (severe) arthropathy is
most prevalent in individuals without a
history of physiotherapy, with 13 samples
(68.4%). The statistical test results showed
a p-value of 0.060 (p > 0.05), indicating no
significant relationship between activity
and facet joint osteoarthritis.
At the spinal level, degree I (normal)
facet joint arthropathy is most common
at the L5-S1 level, with 4 samples (66.7%).
Degree II (mild) arthropathy is most
prevalent at the L4-L5 level, with 23
samples (51.1%). Degree III (moderate)
arthropathy is also most common at the
L4-L5 level, with 23 samples (76.7%), and
degree IV (severe) arthropathy is most
prevalent at the L4-L5 level, with 14 samples
(73.7%). Statistical test results showed a
p-value of 0.031 (p < 0.05), indicating a
significant relationship between spinal
level and facet joint arthropathy.
Table 7 illustrates the relationship
between the grading of fatty infiltration
in the musculus multifidus and the degree
of facet joint arthropathy in patients with
degenerative spondylolisthesis. Using ChiSquare or Fisher Exact test analysis, it was
determined that there is an association
between the grading of fatty infiltration in
the musculus multifidus and the degree of
facet joint arthropathy in these patients.
Further analysis with the Spearman test
revealed a strong positive correlation
between the grading of fatty infiltration
and the degree of facet joint arthropathy,
with a p-value of less than 0.001 (p < 0.05)
and a correlation coefficient (r) of 0.641.

DISCUSSION
In this study, 100 patients with degenerative
spondylolisthesis
who
underwent
lumbosacral magnetic resonance imaging
examinations were analyzed. The sample
included 63 women (63%) and 37 men
(37%), reflecting the higher prevalence
of degenerative spondylolisthesis in
women with a gender ratio of 6.4:1.7,8
In terms of age distribution, the highest
percentage was in the 56-65 years age
161

ORIGINAL ARTICLE

group, comprising 49 samples (49%),
while the fewest were aged over 65 years,
with 17 samples (17%). Another study
similarly reported the largest group in
the 60-69 years age range, accounting
for 59% of their 22 samples.9 Regarding
BMI, the majority were classified as obese,
with 46 samples (46%), while the fewest
were underweight, with 3 samples (3%).
Jacobsen et al., also found a BMI above
24.4, categorizing as obese, in patients with
degenerative spondylolisthesis.10 In terms
of activity level, the highest percentage of
patients engaged in light activities, with
54 samples (54%), and the lowest in heavy
activities, with 9 samples (9%). Research
by Ishimoto et al., identified drivers and
farmers/fishermen, who often perform
heavy activities, as the most affected
occupations.11 Additionally, narrative
research by Akkawi et al., indicated that
L4/L5 is the most common spinal level for
spondylolisthesis, which was consistent
with the findings of this study.12
This study presents the percentage
of samples based on the grading of
degenerative spondylolisthesis. The results
indicate that grade 1 has the highest
occurrence, with 98 samples (98%), while
grade 2 is the least common, with only
2 samples (2%). Narrative research by
Akkawi et al.,12 supports these findings,
showing that vertebral slip in degenerative
spondylolisthesis rarely exceeds 30% and
is most frequently found in grade I, with
grade II being quite uncommon.
In this study, the distribution of
samples based on lumbar multifidus
muscle fat infiltration showed that grade
2 had the highest number of samples,
with 33 samples (33%), while grade 4
had the fewest, with 17 samples (17%).
Contrastingly, research by Wahyudhy et
al., found that grade III was present in 11
out of 20 samples.9 Additionally, Faur et
al., reported that the gender distribution
in multifidus fat infiltration indicated a
higher percentage of women in the group
with mild fat infiltration, equivalent to
grade II Goutallier.13
This study found that the highest
percentage of samples based on facet joint
arthropathy was in degree 2 (moderate),
with 45 samples (45%), while the lowest
was degree 1 (normal), with 6 samples
(6%). In contrast, Wahyudhy et al.,
162

reported that degree 4 was the most
common, with 15 out of 20 samples.9
However, Chou et al., found that degree
2 was the most prevalent, with 196 out of
440 samples.14
This study concludes that there is a
significant relationship between gender
and age with lumbar multifidus muscle
fat infiltration. Faur et al., observed that
women had a higher percentage of mild
fat infiltration in the multifidus muscle,
corresponding to grade II Goutallier.13
There are gender-specific differences
in muscle fatty infiltration: in women,
paraspinal
muscle
degeneration,
characterized by greater intramuscular fat
infiltration, tends to begin in the fourth
decade of life, while in men, it begins in
the fifth decade. This suggests an earlier
onset of muscle fat infiltration in women
and a sex-dependent decline in muscle
quality with age. Additionally, general fat
distribution varies significantly between
sexes and by age, with women having
higher abdominal subcutaneous adipose
tissue and men having higher visceral
adipose tissue.15,16
Oxidative stress in the degeneration
process causes muscle atrophy. This is
proven by a study in their research stating
that the multifidus muscle experiences
changes related to age, such as a decrease
in size and an increase in fatty infiltration.
Fat infiltration of the multifidus muscle
occurs when a certain amount of fatty
tissue replaces the normal architecture of
the muscle and
accumulates between the multifidus
muscle and the vertebral endplate.13 In
research by Chou et al., also mentioned
that the risk of multifidus muscle fat
atrophy increases with age.14
This study found a significant
correlation between gender and spinal
level in relation to facet joint arthropathy.
Tiwari et al., reported that facet joint
osteoarthritis is more prevalent in women
(80%) compared to men (68.8%).17
Kalichman et al., observed that 66.7% of
women and 59.6% of men suffer from this
condition.18 Another study by Ko et al.,
also identified a gender- related difference
in facet joint osteoarthritis.19 Dzefi-Tettey
et al., strengthen these findings, showing
that lumbar facet joint arthrosis is more
frequent in women than in men.20 The

hormonal changes during menopause,
such as reduced estrogen levels, contribute
to cartilage loss and a higher risk of
arthritis, including lumbar facet joint
arthrosis.
The study by Fujiwara et al., supports
the idea that gender differences affect
the occurrence of facet joint arthrosis,
indicating that women are more
susceptible to the condition.21 This
research involved a cadaveric analysis
comparing lumbar spine motion segments
between men and women with similar
clinical profiles. The findings revealed
that women’s motion segments displayed
greater movement during lateral bending,
flexion, and extension. Increased motion
of spinal segments has been linked to
excessive wear, potentially leading to a
higher incidence of facet joint arthrosis.22
Similarly, Chua et al., identified female
gender as an independent risk factor for
facet arthropathy, noting a significant
rise in the prevalence of facet joint
osteoarthritis in women, particularly
around menopause.23 Estrogen deficiency
was found to accelerate facet degeneration
and multifidus muscle atrophy in women
with lumbar spinal stenosis, contributing
to clinical progression.
Kalichman et al., also observed that
the prevalence of lumbar facet joint
osteoarthritis increases with age, with the
highest occurrence at the L4-L5 level.18
The first discovery of vertebral synovial
or subchondral cysts was made by Von
Gruker in 1880 during a postmortem
examination. These cysts are most
frequently found at the L4-L5 facet joint
(65%), but also appear at the L5-S1 (31%)
and L3-L4 (4%) levels.21,24 A study also
revealed a significant relationship between
spinal level and the degree of facet joint
arthropathy.25 Fujiwara et al., further
supported this by finding that the median
level of facet joint arthropathy at L4-L5
was significantly higher than at L3-L4
(p<0.05), while no significant differences
were found between L3-L4 and L5-S1
or between L4- L5 and L5-S1.21 Several
publications indicate that degenerative
spondylolisthesis, typically associated with
facet joint arthropathy, predominantly
occurs at the L4-L5 level and, to a lesser
extent, at the L5-S1 level.21,26
In this study, a strong positive

Bali Medical Journal 2025; 14(1): 157-164 | doi: 10.15562/bmj.v14i1.5483

ORIGINAL ARTICLE

correlation (p<0.05, r=0.641) was found
between multifidus muscle grading and the
degree of facet joint arthropathy in patients
with degenerative spondylolisthesis. This
correlation is attributed to the similar
innervation of the lumbar facet joint and
the multifidus muscle, both of which are
innervated by the medial branch of the
lumbar vertebral dorsal ramus.6 Chua et
al., also demonstrated a strong relationship
between facet overhang and the deep part
of the multifidus muscle.23 Their study
indicated that higher degrees of facet
joint osteoarthritis were associated with
greater multifidus muscle fat atrophy,
particularly at the L4-5 level. This finding
is expected to enhance the understanding
of the pathophysiology and epidemiology
of lumbar spine degeneration. Further,
Cui et al., also showed that multifidus fat
infiltration grading is strongly associated
with facet joint osteoarthritis in the lower
lumbar spine, regardless of age and gender.
While the multifidus cross-sectional area
is not independently linked to facet joint
osteoarthritis, it has limited value as
an indicator of low back pain or spinal
pathology. The current findings suggest
that facet joint osteoarthritis should be
viewed as a failure of the entire joint
structure, including adjacent ligaments
and muscles, rather than merely as a failure
of the facet joint cartilage. Additionally,
the study reported that bilateral multifidus
muscle size asymmetry is independently
associated with facet joint osteoarthritis,
specifically at the L5-S1 level.26
Limitation of the study, including the
following: this study utilized non-weightbearing MRI, which may introduce bias
in measuring the degree of vertebral
slip, potentially leading to errors in
grading spondylolisthesis; it employed
a qualitative approach to determine
multifidus muscle grading, resulting in
a high potential for bias; and it used a
retrospective design, which is prone to
selective bias. Therefore, further research is
recommended using weight-bearing MRI
to minimize bias in measuring vertebral
slip in spondylolisthesis. Future studies
should adopt a prospective design to avoid
selective bias. Additionally, quantitative
measurement of multifidus muscle fat
infiltration is suggested to achieve more
accurate grading. Future research could

also incorporate control variables or focus
on non-degenerative spondylolisthesis
to identify factors associated with
degenerative spondylolisthesis, which can
be analyzed using the multivariate logistic
regression method.

CONCLUSION
In conclusion, the majority of patients
with degenerative spondylolisthesis in
our study are obese women aged 56-65
years who engage in light activity, with
most cases involving degeneration at
the L4-L5 level. Most patients exhibited
grade I degenerative spondylolisthesis,
with no cases of grade III-V observed.
The grading distribution of multifidus
muscle fat infiltration in these patients is
evenly spread across grades I-IV, while
the highest percentage of facet joint
arthropathy is at grade 2 (45%). Factors
associated with lumbar multifidus muscle
fat infiltration include gender and age,
while those associated with facet joint
arthropathy include gender and spinal
level. There is a strong, positive, and
significant correlation between the grading
of multifidus muscle and the degree of
facet joint arthropathy in patients with
degenerative spondylolisthesis.

ACKNOWLEDGEMENTS
This study was supported by the
Department of Radiology, Faculty of
Medicine, Hasanuddin University for
their assistance in providing, assisting and
obtaining the text which form the basis for
this manuscript.

CONFLICT OF INTEREST
The Authors declare that they have no
conflict of interest.

ETHICS CONSIDERATION
This study research meets ethical
requirements and received approval to be
carried out from the Ethics Committee
for Biomedical Health Research in
humans, Faculty of Medicine, Hasanuddin
University, Makassar. Number: 233/
UN4.6.4.5.31/PP36/2024. Data collected
are secondary data from the radiology
system of Dr. Wahidin Sudirohusodo
General Hospital.

Bali Medical Journal 2025; 14(1): 157-164 | doi: 10.15562/bmj.v14i1.5483

FUNDING
This research team funded this research.

AUTHOR CONTRIBUTION
All authors contribute equally to this study
from the conceptual framework, data
acquisition, and data analysis until the
study are interpreted through publication.

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