A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group


Charles G. Fisher, University of British Columbia
Christian P. DiPaola, University of Massachusetts Medical SchoolFollow
Timothy C. Ryken, Iowa Spine and Brain Institute
Mark H. Bilsky, Memorial Sloan-Kettering Cancer Center
Christopher I. Shaffrey, University of Virginia Medical Center
Sigurd H. Berven, University of California
James S. Harrop, Thomas Jefferson University
Michael G. Fehlings, University of Toronto
Stefano Boriani, Ospedale Maggiore
Dean Chou, Ospedale Maggiore
Meic H. Schmidt, University of Utah
David W. Polly, University of Minnesota
Roberto Biagini, Regina Elena Institute
Shane Burch, University of California
Mark B. Dekutoski, Mayo Clinic
Aruna Ganju, Northwestern University
Peter C. Gerszten, University of Pittsburgh Medical Center
Ziya L. Gokaslan, University of Pittsburgh Medical Center
Michael W. Groff, Beth Israel Deaconess Medical Center
Norbert J. Liebach, MA General Hospital
Ehud Mendel, The Ohio State University
Scott H. Okuno, Mayo Clinic
Shreyaskumar Patel, University of Texas
Laurence D. Rhines, University of Texas
Peter S. Rose, Mayo Clinic
Daniel M. Sciubba, Johns Hopkins University
Narayan Sundaresan, Mount Sinai Hospital
Katsuro Tomita, Kanazawa University School of Medicine
Peter P. Varga, National Center for Spinal Disorders
Luiz R. Vialle, Catholic University of Parana
Frank D. Vrionis, University of South Florida College of Medicine
Yoshiya Yamada, Memorial Sloan-Kettering Cancer Center
Daryl R. Fourney, Royal University Hospital

UMMS Affiliation

Department of Orthopedics and Physical Rehabilitation

Publication Date


Document Type



Spine; Neoplastic Processes; Spinal Neoplasms


Orthopedics | Rehabilitation and Therapy


STUDY DESIGN: Systematic review and modified Delphi technique.

OBJECTIVE: To use an evidence-based medicine process using the best available literature and expert opinion consensus to develop a comprehensive classification system to diagnose neoplastic spinal instability.

SUMMARY OF BACKGROUND DATA: Spinal instability is poorly defined in the literature and presently there is a lack of guidelines available to aid in defining the degree of spinal instability in the setting of neoplastic spinal disease. The concept of spinal instability remains important in the clinical decision-making process for patients with spine tumors.

METHODS: We have integrated the evidence provided by systematic reviews through a modified Delphi technique to generate a consensus of best evidence and expert opinion to develop a classification system to define neoplastic spinal instability.

RESULTS: A comprehensive classification system based on patient symptoms and radiographic criteria of the spine was developed to aid in predicting spine stability of neoplastic lesions. The classification system includes global spinal location of the tumor, type and presence of pain, bone lesion quality, spinal alignment, extent of vertebral body collapse, and posterolateral spinal element involvement. Qualitative scores were assigned based on relative importance of particular factors gleaned from the literature and refined by expert consensus.

CONCLUSION: The Spine Instability Neoplastic Score is a comprehensive classification system with content validity that can guide clinicians in identifying when patients with neoplastic disease of the spine may benefit from surgical consultation. It can also aid surgeons in assessing the key components of spinal instability due to neoplasia and may become a prognostic tool for surgical decision-making when put in context with other key elements such as neurologic symptoms, extent of disease, prognosis, patient health factors, oncologic subtype, and radiosensitivity of the tumor.

DOI of Published Version



Spine (Phila Pa 1976). 2010 Oct 15;35(22):E1221-9. Link to article on publisher's site

Journal/Book/Conference Title



At the time of publication, Christian P. DiPaola was not yet affiliated with the University of Massachusetts Medical School.

Related Resources

Link to Article in PubMed