Appropriate Use Criteria

Neoplastic Vertebral Compression Fracture

Results

Based on inclusion criteria and level of evidence, manuscripts were reviewed in detail and evidentiary tables completed which formed the basis for the level of evidence for each scenario which raters used to inform their rating.2-60 The completed evidentiary tables along with results of all individual final ratings will be found on the NASS website, www.spine.org.

Medical Management

Medical management was rated as appropriate with agreement in 431 (99.8%) scenarios and uncertain or disagreement in 1 (0.2%) scenario (Table 4).

Radiation Treatment

Radiation therapy was rated as appropriate with agreement in 216 (50%) scenarios and uncertain or disagreement in 216 (50%) scenarios.

Radiosensitivity was the most important modifier (Figure 1A), and all 216 scenarios including a ‘radiosensitive’ modifier were rated as appropriate with agreement. Radiation therapy was never rated as rarely appropriate (Table 5).

Ablation

Ablation was rated as rarely appropriate in 232 (53.7%) scenarios and uncertain or disagreement in 200 (46.3%) scenarios (Table 6).

Spinal stenosis was the most important modifier (Figure 1B) and ablation was never rated as appropriate with agreement.

Cement Augmentation

Cement augmentation was rated as appropriate with agreement in 18 (4.2%) scenarios, rarely appropriate in 121 (28%) scenarios, and uncertain or disagreement in 293 (67.8%) scenarios (Table 7).

Spinal stenosis was the most important variable for rating appropriateness of cement augmentation (Figure 1C). Scenarios without stenosis or neurologic changes, stable fractures with <80% height loss and intact posterior wall, and VAS pain scores > 6 had an 88% probability of being rated as appropriate with agreement (Figure 2).

Surgery

Surgery was rated as appropriate with agreement in 150 (34.7%) scenarios, uncertain or disagreement in 254 (58.8%) scenarios, and rarely appropriate in 28 (6.5%) scenarios (Table 8).

The most important variables determining final appropriateness rating (in order) were stability, spinal stenosis and prognosis (Figure 1D). Scenarios with spinal stenosis with neurologic changes and an unstable fracture pattern had a 98% probability of being rated as appropriate (Figure 3).

Disagreement

For scenarios with a median rater score between 7 to 9 for surgical treatment, the adjusted odds of each modifier resulting in a final rating of “Uncertain or Disagreement”, rather than “Appropriate with Agreement”, were computed (Figure 4). Except for fracture morphology, all modifiers were significantly associated with odds of disagreement (p < 0.05). Modifiers significantly associated with increased odds of disagreement included low pain scores or nonmechanical pain, low level function, poor prognosis, absence of stenosis, absence of neurological changes, and a stable fracture.