Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care

Diagnosis and Treatment of Adults with Neoplastic Vertebral Fractures

Summary of Questions & Recommendations

Natural History Clinical Questions	Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence
Natural History Question 1: Does underlying histology affect the natural history of metastatic neoplastic vertebral fractures?	A systematic review of the literature yielded no studies to adequately address this question.
Natural History Question 2: Aside from the effects of underlying histology, what are the expected outcomes of neoplastic vertebral fractures in the absence of treatment directed at the fracture or underlying disease?	A systematic review of the literature yielded no studies to adequately address this question.

Cost-Effectiveness Question	Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence
Cost-Effectiveness Question 1: In the treatment of neoplastic vertebral fractures, what is the comparative cost-effectiveness of: (a) medical and/or radiation therapy alone vs (b) vertebral augmentation (with or without radiation therapy) vs (c) thermal ablation, radiofrequency ablation or cryoablation with or without augmentation vs (d) operative fusion/fixation?	A systematic review of the literature yielded no studies to adequately address this question.

Clinical Diagnosis Question	Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence
Clinical Diagnosis Question 1: Which elements (individual or in combination) of a history, symptoms, and/or physical examination are most sensitive and specific for identifying a patient with neoplastic vertebral fracture?	A systematic review of the literature yielded no studies to adequately address this question.

Medical Treatment Questions	Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence
Medical Treatment Question 1: How do nonpharmacologic treatments (eg, bracing, physical therapy, acupuncture, massage, cannabis, exercise) compare in terms of reducing severity and duration of pain and disability in neoplastic vertebral fractures?	A systematic review of the literature yielded no studies to adequately address this question.
Medical Treatment Question 2: Do restrictions on patient activity alter outcomes in patients with neoplastic vertebral fractures?	A systematic review of the literature yielded no studies to adequately address this question.
Medical Treatment Question 3: How do pharmacologic treatments (nonchemotherapeutic) and nonpharmacologic treatments compare with interventional treatments in terms of reducing severity and duration of pain and disability in neoplastic vertebral fractures?	There is insufficient evidence to make a recommendation for or against interventional treatment as compared to non-interventional pharmacologic treatments and non-pharmacologic treatments in terms of reducing severity and duration of pain and disability in adults with neoplastic vertebral fractures. Grade of Recommendation: I
Medical Treatment Question 4: Does timing or sequencing of interventions (eg, analgesics, bisphosphonates, chemotherapy, XRT, stereotactic XRT, bracing, surgery, or vertebral augmentation) improve patient outcomes?	There is insufficient evidence to make a recommendation for or against sequencing of radiation therapy and vertebral augmentation in adults with neoplastic vertebral fractures. Grade of Recommendation: I There is insufficient evidence to make a recommendation for or against timing of non-interventional therapy or vertebral augmentation in adults with neoplastic vertebral fractures. Grade of Recommendation: I
Medical Treatment Question 5: Do general and individualized physical therapy programs differ in pain and functional outcomes for patients with neoplastic vertebral fractures?	A systematic review of the literature yielded no studies to adequately address this question.

Imaging Diagnosis Question	Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence
Imaging Diagnosis Question 1: Which imaging modalities and findings are most sensitive and specific for the accurate diagnosis of and treatment planning for neoplastic vertebral fractures?	Findings on routine MRI sequences are suggested as a method to differentiate osteoporotic from neoplastic vertebral fractures. Grade of Recommendation: B Specific MRI sequences are suggested to differentiate osteoporotic from neoplastic vertebral fractures. Grade of Recommendation: B Diffusion weighted imaging (DWI) is suggested as a MR sequence to distinguish osteoporotic from neoplastic vertebral fractures. Grade of Recommendation: B Contrast enhanced perfusion MRI is suggested as a method to differentiate between osteoporotic and neoplastic vertebral compression fractures. Grade of Recommendation: B PET scan is suggested to differentiate between osteoporotic and neoplastic vertebral compression fractures. Grade of Recommendation: B There is insufficient evidence to make a recommendation for or against the use of bone scans to differentiate osteoporotic from neoplastic vertebral compression fractures. Grade of Recommendation: I There is insufficient evidence to make a recommendation for or against the use of CT to differentiate osteoporotic from neoplastic vertebral compression fractures. Grade of Recommendation: I

Imaging Diagnosis Question

Guideline Recommendation

See recommendation for supporting text

A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence

Imaging Diagnosis Question 1: Which imaging modalities and findings are most sensitive and specific for the accurate diagnosis of and treatment planning for neoplastic vertebral fractures?

Findings on routine MRI sequences are suggested as a method to differentiate osteoporotic from neoplastic vertebral fractures.

Grade of Recommendation: B

Specific MRI sequences are suggested to differentiate osteoporotic from neoplastic vertebral fractures.

Grade of Recommendation: B

Diffusion weighted imaging (DWI) is suggested as a MR sequence to distinguish osteoporotic from neoplastic vertebral fractures.

Grade of Recommendation: B

Contrast enhanced perfusion MRI is suggested as a method to differentiate between osteoporotic and neoplastic vertebral compression fractures.

Grade of Recommendation: B

PET scan is suggested to differentiate between osteoporotic and neoplastic vertebral compression fractures.

Grade of Recommendation: B

There is insufficient evidence to make a recommendation for or against the use of bone scans to differentiate osteoporotic from neoplastic vertebral compression fractures.

Grade of Recommendation: I

There is insufficient evidence to make a recommendation for or against the use of CT to differentiate osteoporotic from neoplastic vertebral compression fractures.

Grade of Recommendation: I

Interventional Treatment Questions	Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence
Interventional Treatment Question 1: What are the criteria/indications/contraindications for vertebral augmentation in patients with neoplastic vertebral fractures?	Vertebral augmentation is suggested as a safe and effective procedure in adults with neoplastic vertebral fractures with intractable back pain despite medical management and/or those at risk of vertebral collapse, although caution is recommended because of the potential for cement extrusion. Grade of Recommendation: B Vertebral augmentation is suggested for the treatment of neoplastic vertebral fractures from multiple myeloma. Grade of Recommendation: B There is insufficient evidence to make a recommendation for or against the transoral approach in malignant C2 lesions for vertebral augmentation as a palliative procedure for adults with neoplastic vertebral fractures. Grade of Recommendation: I
Interventional Treatment Question 2: How do interventional treatments (augmentation, thermal ablation, radiofrequency ablation and cryoablation) compare to medical treatments in reducing severity and duration of pain and disability in patients with neoplastic vertebral fractures?	A systematic review of the literature yielded no studies to adequately address the thermal ablation, cryoablation and radiofrequency ablation components of this question. Vertebral augmentation is recommended for the improvement of pain and functional outcomes in the treatment of neoplastic vertebral fractures. Grade of Recommendation: A
Interventional Treatment Question 3: Are there specific characteristics of the fracture or the patient that influence outcomes in patients with neoplastic vertebral fractures undergoing vertebral augmentation?	Vertebral augmentation is suggested to be a safe treatment option with low rate of clinical complications in neoplastic vertebral fractures with cortical wall defects. Grade of Recommendation: B There is insufficient evidence to make a recommendation for or against the relationship between increasing age and a favorable response to treatment of neoplastic vertebral fractures with vertebral augmentation. Grade of Recommendation: I
Interventional Treatment Question 4: What is the risk of treating multiple vertebral levels at one time, for patients with multi-level neoplastic vertebral fractures?	Vertebral augmentation may be considered as a safe treatment of multilevel neoplastic vertebral fractures at one time. Grade of Recommendation: C
Interventional Treatment Question 5: What is the incidence and risk factors for adjacent vertebral body fractures after vertebral augmentation for neoplastic vertebral fractures?	There is insufficient and conflicting evidence to make a recommendation for or against the incidence or risk factors for adjacent vertebral fractures after vertebral augmentation for neoplastic vertebral fractures. Grade of Recommendation: I
Interventional Treatment Question 6: Does the addition of vertebral augmentation to radiation therapy improve outcomes in patients with neoplastic vertebral fractures?	There is insufficient evidence to make a recommendation for or against the addition of vertebral augmentation to radiation therapy as it relates to outcomes in adults with neoplastic vertebral fractures. Grade of Recommendation: I
Interventional Treatment Question 7: Does the prophylactic use of vertebral augmentation reduce the risk of vertebral fracture after stereotactic radiotherapy for vertebral metastasis?	A systematic review of the literature yielded no studies to adequately address this question.
Interventional Treatment Question 8: Does physical therapy after augmentation affect patient outcomes, including pain and function?	A systematic review of the literature yielded no studies to adequately address this question.

Surgical Treatment Questions	Guideline Recommendation See recommendation for supporting text A: Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence
Surgical Question 1: Does surgical fixation with or without fusion improve outcomes in patients with neoplastic vertebral fractures compared to nonoperative care or interventional procedures?	A systematic review of the literature yielded no studies to adequately address this question.
Surgical Question 2: Does the use of minimally invasive surgical approaches (eg, percutaneous pedicle screws, muscle-sparing decompression/arthrodesis techniques) improve outcomes compared to open surgical approaches in patients undergoing surgery for neoplastic vertebral fracture?	A systematic review of the literature yielded no studies to adequately address this question.
Surgical Question 3: In patients undergoing surgery for neoplastic vertebral fractures, are clinical and radiological outcomes affected by the types of implants used?	There is insufficient evidence to make a recommendation for or against the use of specific implants in adults undergoing surgery for neoplastic vertebral fractures. Grade of Recommendation: I
Surgical Question 4: In patients undergoing surgery for neoplastic vertebral fractures, are clinical and radiological outcomes affected by the use of vertebral augmentation of the implants, of the fractured vertebral body, or of adjacent levels?	A systematic review of the literature yielded no studies to adequately address this question.