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A Novel Classification System for Spinal Instability in Neoplastic Disease: An Evidence-Based Approach and Expert Consensus From the Spine Oncology Study Group

Fisher, Charles G., MD, MHSc, FRCSC*; DiPaola, Christian P., MD*; Ryken, Timothy C., MD, MS; Bilsky, Mark H., MD; Shaffrey, Christopher I., MD§; Berven, Sigurd H., MD; Harrop, James S., MD; Fehlings, Michael G., MD, PhD**; Boriani, Stefano, MD††; Chou, Dean, MD‡‡; Schmidt, Meic H., MD§§; Polly, David W., MD¶¶; Biagini, Roberto, MD∥∥; Burch, Shane, MD; Dekutoski, Mark B., MD***; Ganju, Aruna, MD†††; Gerszten, Peter C., MD‡‡‡; Gokaslan, Ziya L., MD§§§; Groff, Michael W., MD¶¶¶; Liebsch, Norbert J., MD∥∥∥; Mendel, Ehud, MD****; Okuno, Scott H., MD††††; Patel, Shreyaskumar, MD‡‡‡‡; Rhines, Laurence D., MD§§§§; Rose, Peter S., MD***; Sciubba, Daniel M., MD§§§; Sundaresan, Narayan, MD¶¶¶¶; Tomita, Katsuro, MD∥∥∥∥; Varga, Peter P., MD*****; Vialle, Luiz R., MD†††††; Vrionis, Frank D., MD, MPH, PhD‡‡‡‡‡; Yamada, Yoshiya, MD§§§§§; Fourney, Daryl R., MD¶¶¶¶¶

doi: 10.1097/BRS.0b013e3181e16ae2
Health Services Research

Study Design. Systematic review and modified Delphi technique.

Objective. To use an evidence-based medicine process using the best available literature and expert opinion consensus to develop a comprehensive classification system to diagnose neoplastic spinal instability.

Summary of Background Data. Spinal instability is poorly defined in the literature and presently there is a lack of guidelines available to aid in defining the degree of spinal instability in the setting of neoplastic spinal disease. The concept of spinal instability remains important in the clinical decision-making process for patients with spine tumors.

Methods. We have integrated the evidence provided by systematic reviews through a modified Delphi technique to generate a consensus of best evidence and expert opinion to develop a classification system to define neoplastic spinal instability.

Results. A comprehensive classification system based on patient symptoms and radiographic criteria of the spine was developed to aid in predicting spine stability of neoplastic lesions. The classification system includes global spinal location of the tumor, type and presence of pain, bone lesion quality, spinal alignment, extent of vertebral body collapse, and posterolateral spinal element involvement. Qualitative scores were assigned based on relative importance of particular factors gleaned from the literature and refined by expert consensus.

Conclusion. The Spine Instability Neoplastic Score is a comprehensive classification system with content validity that can guide clinicians in identifying when patients with neoplastic disease of the spine may benefit from surgical consultation. It can also aid surgeons in assessing the key components of spinal instability due to neoplasia and may become a prognostic tool for surgical decision-making when put in context with other key elements such as neurologic symptoms, extent of disease, prognosis, patient health factors, oncologic subtype, and radiosensitivity of the tumor.

Spinal instability is poorly defined especially in neoplastic disease. The SOSG has developed a comprehensive classification system to define neoplastic spinal instability (the Spine Instability Neoplastic Score). The Spine Instability Neoplastic Score will aid oncologists and primary care physicians in determining timing of referral to spine surgeons and will aid surgeons in assessing need for surgical stabilization.

From the *Combined Neurosurgery and Orthopaedic Spine Program, Department of Orthopaedics, University of British Columbia, Vancouver, BC; †Iowa Spine and Brain Institute, Waterloo, IA; ‡Neurosurgery Service, Memorial Sloan-Kettering Cancer Center, New York, NY; §Department of Neurological Surgery, University of Virginia Medical Center, Charlottesville, VA; ¶Department of Orthopaedics, University of California, San Francisco, CA; ∥Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA;**Toronto Western Hospital Spinal Program, Department of Surgery, University of Toronto, Toronto, ON, Canada; ††Department of Orthopaedics and Traumatology, Ospedale Maggiore, Ausl Bologna, Bologna, Italy; ‡‡Department of Neurological Surgery, University of California, San Francisco, CA; §§Huntsman Cancer Institute and Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT; ¶¶Department of Orthopedics, University of Minnesota, Minneapolis, MN; ∥∥Department of Orthopedic Oncology, Regina Elena Institute, Rome, Italy; ***Department of Orthopaedics, Mayo Clinic, Rochester, MN; †††Department of Neurosurgery, Northwestern University, Chicago, IL; ‡‡‡Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA; §§§Department of Neurosurgery, Johns Hopkins University, Baltimore, MD; ¶¶¶Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA; ∥∥∥Department of Radiation Oncology, MA General Hospital, Boston, MA; ****Department of Neurological Surgery, The Ohio State University, Columbus, OH; ††††Department of Oncology & Orthopedic Oncology, Mayo Clinic, Rochester, MN; ‡‡‡‡Departments of Medical Oncology and §§§§Neurosurgery, MD Anderson Cancer Center, University of Texas, Houston, TX; ¶¶¶¶Department of Neurological Surgery, Mount Sinai Hospital, New York, NY; ∥∥∥∥Department of Orthopaedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan; *****National Center for Spinal Disorders, Budapest, Hungary; †††††Catholic University of Parana, Curitiba-Pr, Brazil; ‡‡‡‡‡H Lee Moffitt Cancer Center and Research Institute and Departments of Neurosurgery and Interdisciplinary Oncology, University of South Florida College of Medicine, Tampa, FL; §§§§§Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY; and ¶¶¶¶¶Division of Neurosurgery, University of Saskatchewan, Royal University Hospital, Saskatoon, SK, Canada.

Acknowledgment date: August 12, 2009. First revision date: October 29, 2009. Second revision date: December 3, 2009. Acceptance date: April 2, 2010.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Corporate/Industry funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Charles G. Fisher, MD, MHSc, Deparement of Orthopaedics, University of British Columbia, Blusson Spinal Cord Centre, 818 W. 10th Avenue, 6th floor, Vancouver, BC, Canada V5Z 1M9; E-mail:

© 2010 Lippincott Williams & Wilkins, Inc.