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A critical appraisal of clinical practice guidelines on surgical treatments for spinal metastasis

  • Review Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Purpose

As an important treatment for spinal metastasis, surgery has strict applicable conditions. Although various organizations have formulated different guidelines on surgical treatment for spinal metastasis (SM), there are certain differences in the content, standardization and quality of the guidelines and it is necessary to make a critical appraisal of them. We aim to systematically review and appraise the current guidelines on surgical treatments of SM and summarize the related recommendations with the quality evaluation of supporting evidence, as to provide a reference for the standardization of surgical treatment plans, and help clinical front-line medical workers can make safe and effective clinical decisions faster.

Methods

We searched Pubmed, Web of Science, and Embase for three major databases and online guideline databases. According to certain inclusion and exclusion criteria, the latest guidelines on the surgical treatment of SM were sorted out. AGREE II was used to evaluated the guideline’s quality, and we extracted and compared the recommended treatment content of each guideline with evaluating by the evidence-grading scale.

Results

Eight guidelines from 2013 to 2019 were included. Seven guidelines are comprehensive guidelines and one related to the reconstructive surgery of SM. Five guidelines were evaluated as “recommended,” and three guidelines were evaluated as “recommended with modifications.” Regarding the indications of surgery with SM, four guidelines, seven guidelines, seven guidelines, three guidelines and three guidelines recommended surgical treatment for patients with SM with intractable pain, mechanical instability, metastatic epidural spinal cord compression (MESCC), recurrent spinal metastasis (RSM), and survival predication, respectively. Regarding the surgical strategies, three guidelines recommended minimally invasive therapy but had strict indications. Six guidelines and five guidelines recommend palliative surgery and with receiving radiation therapy, respectively. For the aggressive surgery, only one guideline recommended to apply to patients in good general conditions who has isolated symptomatic SM. Regarding the surgical reconstructions, one guideline didn’t recommend iliac bone graft and three guidelines recommended PMMA bone cement.

Conclusion

Most of the guidelines do not provide clear criteria for surgical application and provide more of a basic framework. The level of evidence for these surgical recommendations ranges from LOE B to D, and almost all guidelines recommend vertebroplasty and kyphoplasty, but for palliative and more aggressive surgery, which recommended to personalize specific surgical strategies with multidisciplinary collaboration.

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Data availability

All supporting data are available from the corresponding author upon reasonable request.

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Funding

The study was supported by the Project of Shanghai Municipal Health Commission (20204Y0165, 20224Y0165), National Natural Science Foundation of China (82205145), and Shanghai “Rising Stars of Medical Talents”-Youth Development Program-Youth Medical Talents-Specialist Program SHWSRS (2023-062) and the Project of Chinese Society of Traditional Chinese Medicine youth talent lifting (2023-QNRC2-A03).

Author information

Author notes

  1. Wenlong Yu, Dingbang Chen contributed equally to this work, are co-first authors.

Authors and Affiliations

  1. Department of Orthopedic, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China

    Wenlong Yu, Xing Ding, Liang Qiao, Yinjie Yan, Wen Mo, Junming Ma & Mengchen Yin

  2. Department of Orthopedic Oncology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China

    Dingbang Chen, Luosheng Zhang, Xin Gao & Mengchen Yin

Authors
  1. Wenlong Yu
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Correspondence to Wen Mo, Junming Ma or Mengchen Yin.

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Appendices

Appendix 1. Search strategies of all databases

PubMed

#1 Spinal Neoplasms"[Mesh].

#2 Spinal neoplasms"[Title/Abstract].

#3 spinal metastases"[Title/Abstract].

#4 spinal metastasis"[Title/Abstract].

#5 Spine metastases"[Title/Abstract].

#6 Vertebral metastases [Title/Abstract].

#7 Vertebral metastasis"[Title/Abstract].

#8 spine tumor"[Title/Abstract].

#9 Spinal Cord Neoplasm [Mesh].

#10 Spinal Cord Tumor"[Title/Abstract].

#11 Spinal Cord Neoplasm"[Title/Abstract].

#12 Spinal Cord Neoplasms"[Title/Abstract].

#13 Spinal Cord Tumors"[Title/Abstract].

#14 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13.

#15 Guideline [Publication Type].

#16 Guidelines as Topic [Mesh].

#17 Practice Guideline [Publication Type].

#18 Guidelines [Title/Abstract].

#19 Guideline [Title/Abstract].

#20 #15 or #16 or #17 or #18 or #19.

#21 #20 and #14.

Web of Science

#1 TS = Spinal neoplasms.

#2 TS = spinal metastases.

#3 TS = spinal metastasis.

#4 TS = Spine metastases.

#5 TS = spine metastasis.

#6 TS = Vertebral metastases.

#7 TS = Vertebral metastasis.

#8 TS = spine tumor.

#9 TS = Spinal Cord Tumor.

#10 TS = Spinal Cord Neoplasm.

#11 TS = Spinal Cord Neoplasms.

#12 TS = Spinal Cord Tumors.

#13 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR

#14 TS = (“Guidelines” OR "Guideline”).

#15 #13 AND #14

Embase

1 spine tumor./exp.

2 Spinal neoplasms.ti,ab,kw.

3 spinal metastases.ti,ab,kw.

4 spinal metastasis.ti,ab,kw.

5 Spine metastases.ti,ab,kw.

6 spine metastasis.ti,ab,kw.

7 Vertebral metastases.ti,ab,kw.

8 Vertebral metastasis.ti,ab,kw.

9 spinal cord tumor./exp.

10 Spinal Cord Tumor.ti,ab,kw.

11 Spinal Cord Neoplasm.ti,ab,kw.

12 Spinal Cord Neoplasms.ti,ab,kw.

13 Spinal Cord Tumors.ti,ab,kw.

14 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13

15 practice guideline./exp.

16 Guidelines.ti,ab,kw.

17 Guideline.ti,ab,kw.

18 OR 17

19 AND 18

Organization

Website

Strategy

National Institute for Health and Care Excellence (NICE)

https://www.nice.org.uk/

Click “NICE guidance”

Filtered by title or keyword “spinal metastases” OR “spinal neoplasms” OR “spinal tumor”

Scottish Intercollegiate Guidelines Network (SIGN)

https://www.sign.ac.uk/

Scanned guidelines

Filtered by subspecialty “Spine”

Guidelines International Network(GIN)

https://www.g-i-n.net/

Click “International Guidelines Library”

Keyword search “spinal metastases” OR “spinal neoplasms” OR “spinal tumor”

Agency for Healthcare Research and Quality (AHRQ)

https://www.ahrq.gov/

Search all AHRQ sites

Terms searched “spinal metastases” OR “spinal neoplasms” OR “spinal tumor”

Appendix 2. Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II) instrument

Item

Description

Domain 1. Scope and purpose

Item 1

The overall objective(s) of the guideline is (are) specifically described

Item 2

The health question(s) covered by the guideline is (are) specifically described

Item 3

The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described

Domain 2. Stakeholder involvement

Item 4

The guideline development group includes individuals from all relevant professional groups

Item 5

The views and preferences of the target population (patients, public, etc.) have been sought

Item 6

The target users of the guideline are clearly defined

Domain 3. Rigor of development

Item 7

Systematic methods were used to search for evidence

Item 8

The criteria for selecting the evidence are clearly described

Item 9

The strengths and limitations of the body of evidence are clearly described

Item 10

The methods for formulating the recommendations are clearly described

Item 11

The health benefits, side effects, and risks have been considered in formulating the recommendations

Item 12

There is an explicit link between the recommendations and the supporting evidence

Item 13

The guideline has been externally reviewed by experts prior to its publication

Item 14

A procedure for updating the guideline is provided

Domain 4. Clarity of presentation

Item 15

The recommendations are specific and unambiguous

Item 16

The different options for management of the condition or health issue are clearly presented

Item 17

Key recommendations are easily identifiable

Domain 5. Applicability

Item 18

The guideline describes facilitators and barriers to its application

Item 19

The guideline provides advice and/or tools on how the recommendations can be put into practice

Item 20

The potential resource implications of applying the recommendations have been considered

Item 21

The guideline presents monitoring and/or auditing criteria

Domain 6. Editorial independence

Item 22

The views of the funding body have not influenced the content of the guideline

Item 23

Competing interests of guideline development group members have been recorded and addressed

Appendix 3. Assessment scale on level of evidence

Assessment Scale

Definition

Grade A

“High” / “There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination”/ “Consistent level 1 studies (i.e., systematic review of randomized control trials, or individual randomized control trials)”

Grade B

“Moderate” / “There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination” / “Consistent level 2 (i.e., systematic review of cohort studies, or individual cohort studies) or level 3 (i.e., systematic review of case–control studies, or individual case–control studies) studies or extrapolations from level 1 studies”

Grade C

“Low” / “There is poor evidence regarding the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds” / “Level 4 studies (i.e., case-series, poor quality cohort and case–control studies) or extrapolations from level 2 or 3 studies”

Grade D

“Very low” / “Level 5 studies (i.e., expert opinion without explicit critical appraisal) or troublingly inconsistent or inconclusive studies of any level”

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Yu, W., Chen, D., Ding, X. et al. A critical appraisal of clinical practice guidelines on surgical treatments for spinal metastasis. Eur Spine J (2024). https://doi.org/10.1007/s00586-023-08127-z

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