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Appropriate use criteria for neoplastic compression fractures. Spine J 2025 Jan 13

Date

01/16/2025

Pubmed ID

39814207

DOI

10.1016/j.spinee.2024.12.028

Scopus ID

2-s2.0-85216282794 (requires institutional sign-in at Scopus site)   1 Citation

Abstract

BACKGROUND CONTEXT: Clinical outcomes are directly related to patient selection and treatment indications for improved quality of life. With emphasis on quality and value, it is essential that treatment recommendations are optimized.

PURPOSE: The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) is to determine the appropriate (ie, reasonable) multidisciplinary treatment recommendations for patients with metastatic neoplastic vertebral fractures across a spectrum of more common clinical scenarios.

STUDY DESIGN: A Modified Delphi process.

PATIENT SAMPLE: Systematic Review OUTCOME MEASURES: Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain," or "Rarely Appropriate" based on the median final rating among the raters.

METHODS: The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of neoplastic vertebral fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC work group determined key modifiers and adopted the standard definitions developed by CPG, with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a 9-point scale on 2 separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1-3), uncertain / maybe appropriate (4-6), or appropriate (7-9). Consensus was not mandatory.

RESULTS: Medical management was essentially always appropriate. Radiation therapy was appropriate 50% of the time and uncertain otherwise, and directly related to radiosensitivity of the tumor. Ablation was never rated appropriate with agreement, and about 50% of the time was rated as uncertain. For cement augmentation, the scenarios without stenosis or neurological changes, stable fractures with less than 80% height loss and intact posterior wall, and higher VAS pain scores accounted for 88% probability of an appropriate rating. Otherwise, cement augmentation was uncertain 68% of the time. Surgery was rated as appropriate with agreement in 35%, and uncertain or appropriate with disagreement in 59% of scenarios. The most important variables determining final rating for surgery (in order) were stability, spinal stenosis, and prognosis.

CONCLUSIONS: Multidisciplinary appropriate treatment criteria were generated based on the RAND methodology. Recommendations were made for medical treatment, ablation, radiation, cement augmentation, and surgery based on 432 practical clinical scenarios. This document provides comprehensive evidence-based recommendations for evaluation and treatment of metastatic neoplastic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Author List

Cho CH, Hills JM, Anderson PA, Annaswamy TM, Cassidy RC, Craig CM, DeMicco RC, Easa JE, Kreiner DS, Mazanec DJ, O'Toole JE, Rappard G, Ravinsky RA, Schoenfeld AJ, Shin JH, Whitcomb GL, Reitman CA

Author

Gregory L. Whitcomb DC Associate Professor in the Neurosurgery department at Medical College of Wisconsin