Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care

Diagnosis and Treatment of Adults with Neoplastic Vertebral Fractures

Introduction

Objective

The objective of the North American Spine Society (NASS) Clinical Guideline for the Diagnosis and Treatment of Adults with Neoplastic Vertebral Fractures is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of adult patients with neoplastic vertebral fractures in order to provide guidance to promote accurate diagnosis and effective treatment. This guideline is based upon a systematic review of the evidence and reflects contemporary treatment concepts for neoplastic vertebral fractures as reflected in the highest quality clinical literature available on this subject as of October 2020. The goals and expected benefits of the guideline recommendations are to assist in delivering optimum management of neoplastic vertebral fractures.

Scope, Purpose and Intended User

This document was developed by the North American Spine Society’s Clinical Practice Guidelines Committee as an educational tool to assist practitioners who treat adult patients with neoplastic vertebral fractures. The goal is to provide a tool that assists practitioners in improving the quality and efficiency of care delivered to these patients. The NASS Clinical Guideline for the Diagnosis and Treatment of Adults with Neoplastic Vertebral Fractures outlines a reasonable evaluation of patients with neoplastic vertebral fractures and outlines treatment options for adult patients with this condition.

THIS GUIDELINE DOES NOT REPRESENT A “STANDARD OF CARE,” nor is it intended as a fixed treatment protocol. It is anticipated that there will be patients who will require less or more treatment than the average. It is also acknowledged that in atypical cases, treatment falling outside this guideline will sometimes be necessary. This guideline should not be seen as prescribing the type, frequency or duration of intervention. Treatment should be based on the individual patient’s need and provider’s professional judgment and experience. This document is designed to function as a guideline and should not be used as the sole reason for authorization or denial of treatment and services. This guideline is not intended to expand or restrict a health care provider’s scope of practice or to supersede applicable ethical standards or provisions of law.

Patient Population

The patient population for this guideline encompasses adults (18 years or older) with neoplastic vertebral fracture(s) defined as fracture of the vertebral body due to loss or destruction of cortical or trabecular bone structural integrity from a primary or metastatic neoplastic process. Fractures may or may not be symptomatic and may or may not result in clinically significant deformity and/or neurologic deficit.

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Definition & Inclusion/Exclusion Criteria

Definition: Fracture of the vertebral body due to loss or destruction of cortical or trabecular bone structural integrity from a primary or metastatic neoplastic process. Fractures may or may not be symptomatic and may or may not result in clinically significant deformity and/or neurologic deficit.

Inclusion Criteria:

Age ≥ 18 years
Spine or sacral fractures
Single or multiple level fractures
Simple or complex fractures
With or without pain. Pain may be axial, radicular, generalized or combination.

Exclusion Criteria:

Acute or chronic spine infection including epidural abscess, discitis, and/or osteomyelitis
Major trauma
Prior surgery at the affected level
Isolated intradural tumor

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Glossary

Acute Fracture: This is a newly developed definition for the diagnosis of acute compression fracture that is used in this guideline. The definition uses clinical and imaging evaluation for the diagnosis that is uniform for all patients, and it does not rely on arbitrary time demarcation.

Clinical diagnosis of acute fracture: Identifiable sudden onset of pain with continued pain and radiograph/computed tomography showing compression fracture localized to the site of pain.

Imaging diagnosis of acute fracture: Unable to identify the onset of pain with continued pain. MRI shows vertebral compression with edema localized to the site of pain. Serial radiographs or computed tomography shows new or further compression of the fracture. If MRI is contraindicated, then a bone scintigraphy may show increased activity at the site of the vertebral compression.

Note:

Selecting a set time to differentiate acute from nonacute fracture is arbitrary and should not be used.
In patients with prolonged pain, if there is edema in the MRI, then the patient is considered to have a component of unhealed fracture.
If the MRI has no edema, then it is not unhealed fracture
If the description is vague and does not provide enough detail to classify as acute, as outlined below, consider downgrading the article (still include if it meets all inclusion criteria)

Augmentation: Addition of cement to the vertebral body through a needle with or without the use of cavity producing balloon, and without addition of a permanent non cement device

Burst Fracture: The term burst fracture often refers to high axial load injury from major trauma, which is excluded. The rare use of the term burst fracture as it refers to complex neoplastic or osteoporotic fractures is included.

Complex Fracture: Complex fracture refers to severe fractures from neoplastic or osteoporotic causes.

Hemangioma and nondestructive tumors only include if the study clearly states that there is bone destruction in addition to intrinsic tumor, per this guideline’s definition. For example, exclude benign hemangioma and other tumors that permeate through the marrow without trabecular destruction. (Exclude studies that do not specify bone destruction.)

Magnetic Resonance Imaging (MRI): MRI with edema was selected as one of the two methods of diagnosis of acute compression fracture. Although the literature search results for this guideline did not include specific validation studies for MRI, the standard of medical care is that MRI with bone marrow edema is accepted as acute fracture.

Trauma: Minor injury, such as falling while walking or standing is not considered major trauma and is included.

Surgery: If a study does not state prior spine surgery, it is interpreted as no prior spine surgery.

Use of Acronyms: Throughout the guideline, readers will see many acronyms with which they may not be familiar. First use will always include the full

Nomenclature for Medical Treatment: Throughout the guideline, readers will see that what has traditionally been referred to as “nonoperative,” “nonsurgical,” or “conservative” care is now referred to as medical treatment. The term medical is meant to encompass pharmacological treatment, physical therapy, exercise therapy, manipulative therapy, modalities, and various types of external stimulators.

Nomenclature for Interventional Treatment: Interventional treatment is considered as a separate category from Medical Treatment and Surgical Treatment. Interventional Treatment often uses image guidance with instruments such as fluoroscopy, computed tomography, magnetic resonance imaging, ultrasound, or endoscopy, with the target visualized on a monitor screen.

Nomenclature for Surgical Treatment: Surgical treatment implies direct visualization of the treatment target with or without optical visual aids.