The North American Spine Society (NASS) has released four evidence-based documents to help guide the diagnosis and treatment of adults with vertebral fractures.
According to NASS, the Clinical Guidelines were based on a strict analytical process which included a strength of the recommendations based solely on the quality of the literature for each developed question.
The authors conducted a comprehensive literature review and extensive vetting process. Ultimately, the author’s recommendations were derived from high-quality evidence and helped to expose knowledge gaps which could form the basis for future research.
Concurrently with these guidelines, NASS developed Appropriate Use Criteria to determine appropriate (or reasonable) recommendations regardless of the available level of evidence. Through a rigorous, transparent process including a literature search, scenario writing, and rating, the assembled multidisciplinary group developed recommendations to specify when it is appropriate to use a vertebral fracture repair procedure.
Charles H. Cho, M.D., professor of radiology at Harvard University and lead author of “Evidence Based Clinical Guidelines for Multidisciplinary Spine Care”, said, “The definition of acute compression fracture in these guidelines now incorporates clinical evaluation and imaging findings rather than timing of the fracture. This will help select all the patients with acute fractures that can benefit from intervention, and it will also include those patients who continue to have pain despite prolonged duration of symptoms.”
“We wanted to identify a defined patient group that could benefit from treatment regardless of time of onset of the fracture,” added Dr. Cho, “thus, acute fracture is defined based on clinical diagnosis and imaging diagnosis. The biggest challenge was listening to all the different specialty members in the committee and focused outside stakeholders, while maintaining evidence-based recommendations. Working through this challenge created a strong document that can help all of our patients.”
The section led by Dr. Cho: “Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care” covers:
- Diagnosis and Treatment of Adults with Neoplastic Vertebral Fractures
- Diagnosis and Treatment of Adults with Osteoporotic Vertebral Compression Fractures
Charles Reitman, M.D., Vice Chairman, Orthopaedics and Physical Medicine; co-director, Spine Center at the Medical University of South Carolina and lead author of “Appropriate Use Criteria”, said, “The Clinical Practice Guidelines and Appropriate Use Criteria are tremendously complementary documents. They not only provide the spine specialist with contemporary levels of evidence on this topic as well as key knowledge gaps, but also a validated decision-making process for the most common clinical scenarios, regardless of the available evidence.”
“The combination of these documents makes this an extremely practical set of documents for clinical practice and for academic educational purposes.”
OTW asked Dr. Reitman to describe a common clinical scenario that uses a validated decision-making process without a great deal of evidence: “Within this Appropriate Use Criteria, the timing for anticoagulation following spine surgery for patients with spinal cord injury, the data was very limited in terms of high-level studies, but early intervention within 24 hours of surgery was determined to be appropriate in this scenario. This is with the caveat that there is no specific information on baseline coagulopathy.”
As for the challenging aspects of developing these guidelines, he noted, “One of the bigger challenges was the lack of high-level data resulting in a fair amount of controversy. There was a lot of discussion around experience and risks and benefits of anticoagulation particularly in the early intervention group.”
“Another interesting discussion point was defining/understanding appropriate within the rating group. There were several scenarios that were controversial, and ultimately rated appropriate even though that would not necessarily be the practice of the individual rater. Appropriate means that it would be reasonable to do with favorable risk/benefit profile.”
The section led by Dr. Reitman, Appropriate Use Criteria, covers:
- Appropriate Use Criteria for Neoplastic Vertebral Fracture
- Appropriate Use Criteria for Osteoporotic Vertebral Fracture
Multi-Disciplinary Review and Recommendations
Finally, NASS selected a truly multi-disciplinary team to review the literature and discuss guidelines and appropriate use criteria for vertebral fracture treatment. Here is the list of all the practice specialties represented:
- Neurosurgery
- Orthopedic Surgery
- Physical Medicine & Rehabilitation
- Chiropractic Care
- Physical Therapy
- Anesthesiology
- Research
- Radiology
- Nursing
Outline of the Final document
The Diagnosis and Treatment of Adults with Neoplastic Vertebral Fractures includes 22 clinical questions with 20 recommendation statements. The Diagnosis and Treatment of Adults with Osteoporotic Vertebral Compression Fractures guideline includes 29 clinical questions with 70 recommendation statements.
While high-level evidence for treating spinal disorders is ideal, the authors found that it was not always available. If the authors did not find sufficient evidence, then they did not posit answers to questions.
Each recommendation earned a grade from the work group depending on the strength of the available scientific evidence:
A = Recommended
B = Suggested
C = May be Considered
I = Insufficient or Conflicting Evidence
Each Clinical Guideline is divided into seven different sections:
- Natural History
- Cost Effectiveness
- Clinical Diagnosis
- Medical Treatment
- Imaging Diagnosis
- Interventional Treatment
- Surgical Treatment
