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h" xJ\xJ\*K L ~ ~ $ ) ) ) P y l " D ) g )' * ( + + + + , $, f f f f f f f 'j l R f ) ,, + + ,, ,, f + + Ag p3 p3 p3 ,, + + rd p3 ,, f p3 p3 @G lI + p / G ^d Wg 0 g H \ /m <0 4 /m 0 lI lI v /m T | ,, ,, p3 ,, ,, ,, ,, ,, f f p3 ,, ,, ,, g ,, ,, ,, ,, /m ,, ,, ,, ,, ,, ,, ,, ,, ,, ~ M : Spine Instability Neoplastic Score: Agreement across different medical and surgical specialties
Spine Instability Neoplastic Score: multispecialty agreement
Estanislao Arana, MD, MHE, PhD,1,2,3 Francisco M. Kovacs, MD, PhD,3,4 Ana Royuela, PhD,3,5,6 Beatriz Asenjo, MD,PhD,3,7 rsula Prez-Ramrez MSc 3,8, Javier Zamora, PhD,3,5,6,9 and the Spanish Back Pain Research Network Task Force for the improvement of inter-disciplinary management of spinal metastasis*
1Department of Radiology. Valencian Oncology Institute Foundation, Valencia. 2 Research Institute in Health Services Foundation. Valencia, Spain.
3Spanish Back Pain Research Network. Kovacs Foundation, Paseo de Mallorca 36, 07012 Palma de Mallorca, Spain.
4Scientific Department. Kovacs Foundation, Paseo de Mallorca 36, 07012 Palma de Mallorca, Spain
5CIBER Epidemiology and Public Health (CIBERESP), Spain.
6Clinical Biostatistics Unit. Hospital Ramn y Cajal, IRYCIS. Ctra. Colmenar Km. 9.1, 28034 Madrid, Spain
7 Department of Radiology, Hospital Regional Universitario Carlos Haya, Mlaga, Spain
8 Center for Biomaterials and Tissue Engineering, Universitat Politcnica de Valncia, Valencia, Spain
9 Barts and the London School of Medicine & Dentistry. Queen Mary University of London, UK
No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this article.
The authors do not have any financial or personal relationships with third parties that could influence this work inappropriately. The authors have no conflicts of interest to report.
Funding
Kovacs Foundation
Correspondence:
Estanislao Arana, MD,PhD
Fundacin Instituto Valenciano de Oncologa
C/ Beltrn Bguena, 19
46009 Valencia. Spain
HYPERLINK "mailto:aranae@uv.es" aranae@uv.es
Abstract
Purpose
This study aimed to assess intra and inter-observer agreement when using the SpineInstabilityNeoplasticScore(SINS).
Methods
Clinical data and imaging from 90 patients with biopsy-proven spinal metastases, were provided to 83 specialists in 44 hospitals across 14 Spanish regions. No assessment criteria were pre-established. Each clinician assessed the SINS score twice, with a minimum 6 week interval. Clinicians were blinded to assessments made by other specialists and to their own previous assessment. Intraclass Correlation Coefficient (ICC) was used to assess agreement on the SINS score. The kappa statistic was used to assess; agreement on the location of the most affected vertebral level; agreement on the SINS category (stable, potentially stable or unstable); and overall agreement with the classification established by a multidisciplinary tumor board. Subgroup analyses were performed by clinicians specialty (medical oncology, neurosurgery, radiology, orthopedic surgery a n d r a d i a t i o n o n c o l o g y ) , e x p e r i e n c e ( d"7 , 8 - 1 3 , e"1 4 y e a r s ) , a n d h o s p i t a l c a t e g o r y ( f o u r l e v e l s a c c o r d i n g t o s i z e a n d c o m p l e x i t y ) .
R e s u l t s
I n t r a a n d i n t e r - o b s e r v e r a g r e e m e n t o n t h e l o c a t i o n o f t h e m o s t a f f e c t e d l e v e l s w a s a l m o s t p e r f e c t ( > 0 . 9 4 ) . I n t r a - o b server agreement on the SINS score was excellent (ICC=0.77), while inter-observer agreement was moderate (ICC=0.55). Intra-observer agreement in SINS category was substantial (k=0.61), while inter-observer was moderate (k=0.42). Overall agreement with the tumor board classification was substantial ( = 0 . 6 1 ) . R e s u l t s w e r e s i m i l a r a c r o s s s p e c i a l t i e s , y e a r s o f e x p e r i e n c e a n d h o s p i t a l c a t e g o r y .
C o n c l u s i o n
A g r e e m e n t o n t h e a s s e s s m e n t o f m e t a s t a t i c s p i n e i n s t a b i l i t y i s m o d e r a t e . S I N S c a n h e l p i m p r o v e c o m m u n i c a t i o n a m o n g c l i n i c i a n s i n o n c o l o g y c a r e .
I ntroduction
The organ most commonly affected by metastatic cancer is the skeleton, which is also where it causes the highest morbidity.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1158/1078-0432.CCR-06-0931", "ISSN" : "1078-0432", "PMID" : "17062708", "abstract" : "The skeleton is the most common organ to be affected by metastatic cancer and the site of disease that produces the greatest morbidity. Skeletal morbidity includes pain that requires radiotherapy, hypercalcemia, pathologic fracture, and spinal cord or nerve root compression. From randomized trials in advanced cancer, it can be seen that one of these major skeletal events occurs on average every 3 to 6 months. Additionally, metastatic disease may remain confined to the skeleton with the decline in quality of life and eventual death almost entirely due to skeletal complications and their treatment. The prognosis of metastatic bone disease is dependent on the primary site, with breast and prostate cancers associated with a survival measured in years compared with lung cancer, where the average survival is only a matter of months. Additionally, the presence of extraosseous disease and the extent and tempo of the bone disease are powerful predictors of outcome. The latter is best estimated by measurement of bone-specific markers, and recent studies have shown a strong correlation between the rate of bone resorption and clinical outcome, both in terms of skeletal morbidity and progression of the underlying disease or death. Our improved understanding of prognostic and predictive factors may enable delivery of a more personalized treatment for the individual patient and a more cost-effective use of health care resources.", "author" : [ { "dropping-particle" : "", "family" : "Coleman", "given" : "Robert E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical cancer research : an official journal of the American Association for Cancer Research", "id" : "ITEM-1", "issue" : "20 Pt 2", "issued" : { "date-parts" : [ [ "2006", "10", "15" ] ] }, "page" : "6243s-6249s", "title" : "Clinical features of metastatic bone disease and risk of skeletal morbidity.", "type" : "article-journal", "volume" : "12" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=6b74ee11-3df2-47fb-85e9-3beaabe4332d" ] } ], "mendeley" : { "formattedCitation" : "1", "plainTextFormattedCitation" : "1", "previouslyFormattedCitation" : "1" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }1 There is controversy on the exact definition of spinal instability caused by spine metastatic disease, and the appropriate management.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.3892/ijo_00000818", "ISSN" : "1791-2423", "PMID" : "21109920", "abstract" : "Metastatic disease commonly occurs in the spine and incidence is likely to increase secondary to improved survival rates in many cancer patients. Despite published research on instability in patients with metastatic disease of the thoracolumbar spine, controversy exists regarding risk factors for instability and indications for surgical stabilization. The objective of this systematic review was to determine what defines instability and impending instability in patients with metastatic disease of the thoracic and lumbar spine. We systematically reviewed the medical literature in order to identify all the relevant studies concerning patients with metastatic involvement of T1-L5, in the domains of biomechanics, epidemiology, clinical issues, and radiographic parameters. Two independent observers performed study selection, methodological quality assessment, and data extraction in a blinded and objective manner for all the identified studies. We were then able to define the criteria to identify instability of the spine with metastases. A literature search and review identified 14 relevant, good quality studies for inclusion. The predictors of instability included increased tumor size, a larger cross-sectional area of bone defect, increased force of spinal loading, decreased bone density, posterior location of the tumor within the vertebrae, destruction of the costovertebral joint, pedicle destruction in the thoracolumbar spine, increased axial rigidity, and sagittal spinal deformity. Definitive conclusions cannot be reached due to lack of evidence. However, variables such as tumor size, magnitude of spinal loading, bone density, tumor location within the vertebrae and spine, and tumor type are risk factors for instability in spinal metastases. Improved clinical research methodology for this patient population is required.", "author" : [ { "dropping-particle" : "", "family" : "Weber", "given" : "Michael H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Burch", "given" : "Shane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Buckley", "given" : "Jenny", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmidt", "given" : "Meic H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vrionis", "given" : "Frank D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "International journal of oncology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2011", "1", "24" ] ] }, "page" : "5-12", "title" : "Instability and impending instability of the thoracolumbar spine in patients with spinal metastases: a systematic review.", "type" : "article-journal", "volume" : "38" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=31d9fd3c-b5ce-4c5f-bc68-5e05163070e2" ] } ], "mendeley" : { "formattedCitation" : "2", "plainTextFormattedCitation" : "2", "previouslyFormattedCitation" : "2" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }2 Several scoring systems have been proposed to standardize the diagnosis of spinal instability in these patients, and selecting those in whom surgery should be considered.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0362-2436", "PMID" : "9051884", "abstract" : "STUDY DESIGN: The associations between vertebral body collapse and the size or location of the metastatic lesions were analyzed statistically to estimate the critical point of collapse. OBJECTIVES: To determine risk factors for collapse, to estimate the predicted probability of collapse under various states of metastatic vertebral involvement, and to establish the criteria of impending collapse. SUMMARY OF BACKGROUND DATA: Pathologic vertebral collapse brings about severe pain and paralysis in patients with cancer. Prevention of collapse plays a significant role in maintaining or improving their quality of life. Because no previous study has clarified the critical point of vertebral collapse, however, the optimum timing for prophylactic treatment has been unclear. METHODS: The size and location of metastatic tumor from Th1 to L5 were evaluated radiologically for 100 thoracic and lumbar vertebrae with osteolytic lesions. The correlations between collapse and the following risk factors (x1-x4) were determined by means of a multivariate logistic regression model: x1, tumor size (the percentage of tumor occupancy in the vertebral body [% TO]); x2, pedicle destruction, x3, posterior element destruction; and x4, costovertebral joint destruction. RESULTS: Significant risk factors were costovertebral joint destruction (odds ratio, 10.17; P = 0.021) and tumor size (odds ratio of every 10% increment in %TO, 2.44; P = 0.032) in the thoracic region (Th1-Th10), whereas, tumor size (odds ratio of every 10% increment in %TO, 4.35; P = 0.002) and pedicle destruction (odds ratio, 297.08; P = 0.009) were main factors in the thoracolumbar and lumbar spine (Th10-L5). The criteria of impending collapse were: 50-60% involvement of the vertebral body with no destruction of other structures, or 25-30% involvement with costovertebral joint destruction in the thoracic spine; and 35-40% involvement of vertebral body, or 20-25% involvement with posterior elements destruction in thoracolumbar and lumbar spine. CONCLUSIONS: With respect to the timing and occurrence of vertebral collapse, there is a distinct discrepancy between the thoracic and thoracolumbar or lumbar spine. When a prophylactic treatment is required, the optimum timing and method of treatment should be selected according to the level and extent of the metastatic vertebral involvement.", "author" : [ { "dropping-particle" : "", "family" : "Taneichi", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kaneda", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Takeda", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Abumi", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Satoh", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Spine", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "1997", "3", "1" ] ] }, "page" : "239-45", "title" : "Risk factors and probability of vertebral body collapse in metastases of the thoracic and lumbar spine.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=6a7833c8-0875-4651-8fc4-58955d7d2c4f" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.ejrad.2012.07.023", "ISSN" : "1872-7727", "PMID" : "23088878", "abstract" : "Spine stability is the basic requirement to protect nervous structures and prevent the early deterioration of spinal components. All bony and soft spinal components contribute to stability, so any degenerative, traumatic or destructive lesion to any spinal structure gives rise to some degree of instability. Degenerative instability is considered a major cause of axial and radicular pain and is a frequent indication for surgery. Nevertheless the assessment of instability remains difficult in both clinical and imaging settings. All static imaging modalities, even conventional MR, the most accurate technique, are unreliable in assessing instability and chronic pain due to degenerative spine. Dynamic-positional MR is considered the most sophisticated imaging modality to evaluate abnormal spinal motion and instability. In spinal traumas, as multi-detector CT yields high-resolution reconstructions in every spatial plane, it will detect even the tiniest fractures revealing potentially unstable lesions, often avoid the routine use of MR. Nevertheless, MR remains the only modality that will directly and routinely assess soft tissue changes. Unfortunately the objectivity of MR in assessing the integrity of ligaments is not rigorously defined and its use in routine protocols to clear blunt spinal injuries remains controversial. There are no evidence-based guidelines currently available to assess the risk of spinal instability in the setting of neoplastic spinal disease, so predicting the risk of a pathological fracture or the timing of a collapse remains challenging even when the lesions are well-characterized by neuroimaging. Diagnostic difficulties lead to controversy in the choice of the best treatment in all forms of spinal instability.", "author" : [ { "dropping-particle" : "", "family" : "Izzo", "given" : "Roberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Guarnieri", "given" : "Gianluigi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Guglielmi", "given" : "Giuseppe", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Muto", "given" : "Mario", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "European journal of radiology", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2013", "1" ] ] }, "page" : "127-38", "title" : "Biomechanics of the spine. Part II: spinal instability.", "type" : "article-journal", "volume" : "82" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=a846d716-8950-421a-a866-74cd497deecf" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1245/s10434-013-3324-8", "ISSN" : "1534-4681", "PMID" : "24145995", "abstract" : "INTRODUCTION: Management of metastatic spine disease is quite complex. Advances in research have allowed surgeons and physicians to better provide chemotherapeutic agents that have proven more efficacious. Additionally, the advancement of surgical techniques and radiosurgical implementation has altered drastically the treatment paradigm for metastatic spinal disease. Nevertheless, the physician-patient relationship, including extensive discussion with the neurosurgeon, medicine team, oncologists, radiation oncologists, and psychologists, are all critical in the evaluation process and in delivering the best possible care to our patients. The future remains bright for continued improvement in the surgical and nonsurgical management of our patients with metastatic spine disease. METHODS: We include an evidence-based review of decision making strategies when attempting to determine most efficacious treatment options. Surgical treatments discussed include conventional debulking versus en bloc resection, conventional RT, and radiosurgical techniques, and minimally invasive approaches toward treating metastatic spinal disease. CONCLUSIONS: Surgical oncology is a diverse field in medicine and has undergone a significant paradigm shift over the past few decades. This shift in both medical and surgical management of patients with primarily metastatic tumors has largely been due to the more complete understanding of tumor biology as well as due to advances in surgical approaches and instrumentation. Furthermore, radiation oncology has seen significant advances with stereotactic radiosurgery and intensity-modulated radiation therapy contributing to a decline in surgical treatment of metastatic spinal disease. We analyze the entire spectrum of treating patients with metastatic spinal disease, from methods of diagnosis to the variety of treatment options available in the published literature.", "author" : [ { "dropping-particle" : "", "family" : "Kaloostian", "given" : "P E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yurter", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zadnik", "given" : "P L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sciubba", "given" : "D M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gokaslan", "given" : "Z L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of surgical oncology", "id" : "ITEM-3", "issue" : "1", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "248-62", "title" : "Current paradigms for metastatic spinal disease: an evidence-based review.", "type" : "article-journal", "volume" : "21" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=5c3fff35-6079-460b-a461-2de61cf40510" ] } ], "mendeley" : { "formattedCitation" : "3\u20135", "plainTextFormattedCitation" : "3\u20135", "previouslyFormattedCitation" : "3\u20135" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }35 However, only 14% of British clinicians managing spine metastatic disease are familiar with the available scoring systems.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s00590-014-1438-8", "ISSN" : "1633-8065", "PMID" : "24806394", "abstract" : "OBJECTIVE: The spine is the most common site for bony metastases. It can lead to the development of significant complications and morbidity if appropriate treatment is not provided. National Institute for Health and Clinical Excellence (NICE) issued new guidance in 2008 with regard to the management of patient with metastatic spinal cord compression (MSCC) to assess the awareness of the NICE guidelines for MSCC.\n\nMETHODS: We contacted doctors in oncology, trauma and orthopaedics, palliative care and general medicine and assessed their knowledge of MSCC using a questionnaire based on the salient points of the NICE guidance. This was a UK-wide questionnaire.\n\nRESULTS: We contacted 96 trainee doctors (oncology, palliative care, general medicine and orthopaedics) and found that 74\u00a0% felt adequately informed to diagnose metastatic cord compression although only 11\u00a0% considered a sensory level as a potential sign of cord compression. Neurological symptoms (91\u00a0%) were the main reason for referral to a tertiary spinal service. MRI was the investigation of choice. There was a poor knowledge of metastatic scoring systems and only 8\u00a0% would consider assessing the patient's fitness for surgery. Most of the respondents felt that they had been poorly taught at undergraduate and postgraduate level on MSSC.\n\nCONCLUSION: Our audit shows that MSCC is poorly understood in general and that greater understanding of the NICE guidance is required to allow for better management of these patients and more prompt referral for appropriate surgical assessment.", "author" : [ { "dropping-particle" : "", "family" : "Brooks", "given" : "F M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ghatahora", "given" : "Ameet", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brooks", "given" : "M C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Warren", "given" : "Hazel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Price", "given" : "Laura", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brahmabhatt", "given" : "Pranter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vauvert", "given" : "Saik", "non-dropping-particle" : "De", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "John", "given" : "Cerys", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Farnworth", "given" : "Elizabeth", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sulaiman", "given" : "Erwina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ahuja", "given" : "Sashin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "European journal of orthopaedic surgery & traumatology : orthop\u00e9die traumatologie", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014", "7" ] ] }, "page" : "S255-9", "title" : "Management of metastatic spinal cord compression: awareness of NICE guidance.", "type" : "article-journal", "volume" : "24 Suppl 1" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=fc0de957-f5ca-4204-a36d-5a60b2a8f07b" ] } ], "mendeley" : { "formattedCitation" : "6", "plainTextFormattedCitation" : "6", "previouslyFormattedCitation" : "6" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }6
The Spinal Instability Neoplastic Score (SINS) is based on clinical data and imaging findings (Table 1), and has been suggested as the most straightforward scoring system.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/BRS.0b013e3181e16ae2", "ISSN" : "1528-1159", "PMID" : "20562730", "abstract" : "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.", "author" : [ { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "DiPaola", "given" : "Christian P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ryken", "given" : "Timothy C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bilsky", "given" : "Mark H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shaffrey", "given" : "Christopher I", 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"non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Spine", "id" : "ITEM-1", "issue" : "22", "issued" : { "date-parts" : [ [ "2010", "10", "15" ] ] }, "page" : "E1221-9", "title" : "A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group.", "type" : "article-journal", "volume" : "35" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=99e95f13-16e8-4ee1-9b36-a4b5e633e64b" ] } ], "mendeley" : { "formattedCitation" : "7", "plainTextFormattedCitation" : "7", "previouslyFormattedCitation" : "7" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }7 It was originally developed by spine surgeons, and very few studies have analyzed its reliability when used by different specialists.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : 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Clinical scenarios reviewed include asymptomatic stage 1 breast carcinoma, symptomatic stage 2 breast carcinoma, abnormal bone scan results with breast carcinoma, pathologic fracture with known metastatic breast carcinoma, asymptomatic well-differentiated and poorly differentiated prostate carcinoma, vertebral fracture with history of malignancy, non-small-cell lung carcinoma staging, symptomatic multiple myeloma, osteosarcoma staging and surveillance, and suspected bone metastasis in a pregnant patient. No single imaging modality is consistently best for the assessment of metastatic bone disease across all tumor types and clinical situations. In some cases, no imaging is indicated. 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Intraclass correlation coefficient (ICC) and Fleiss's kappa measures were occupied for reliability analysis.\n\nMETHODS: Patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected and classified for spinal stability using the SINS by orthopedic surgeons and nonorthopedic oncology specialists. ICC and Fleiss's kappa were calculated for inter- and intraobserver agreement. A comparative analysis of SINS and the actual management was also conducted.\n\nRESULTS: Interobserver ICC reliability for the SINS was 0.79; \u03ba values for location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement were 0.81, 0.58, 0.21, 0.45, 0.42, and 0.29 respectively. Intraobserver ICC for the SINS scores was 0.96; ICC values for the same components were 0.98, 0.98, 0.87, 0.88, 0.92, and 0.86, respectively. Potentially unstable lesions (SINS score\u22657) were operated on in 62.5%.\n\nCONCLUSIONS: SINS seem to be a reproducible tool that could be used equally by multiple specialists to estimate metastatic vertebral stability; however, prospective clinical validation is still pending.", "author" : [ { "dropping-particle" : "", "family" : "Campos", "given" : "Mauricio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Urrutia", "given" : "Julio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zamora", "given" : "Tom\u00e1s", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rom\u00e1n", "given" : "Javier", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Canessa", "given" : "Valentina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Borghero", "given" : "Yerko", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Palma", "given" : "Alejandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Molina", "given" : "Marcelo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The spine journal : official journal of the North American Spine Society", "id" : "ITEM-3", "issue" : "8", "issued" : { "date-parts" : [ [ "2014", "8", "1" ] ] }, "page" : "1466-9", "title" : "The Spine Instability Neoplastic Score: an independent reliability and\u00a0reproducibility analysis.", "type" : "article-journal", "volume" : "14" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=017d00c3-32ef-452d-b531-31aedc498eb7" ] } ], "mendeley" : { "formattedCitation" : "8\u201310", "plainTextFormattedCitation" : "8\u201310", "previouslyFormattedCitation" : "8\u201310" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }810 None have included physicians from all the specialties involved in the management of spine metastatic disease.
Assessing the reliability of SINS across the different specialists involved in the assessment of spine metastatic disease, may contribute to improving the decision making process on the most suitable treatment for each patient.
Therefore, the purpose of this study was to assess intra- and inter-observer agreement in: a) the calculation of the SINS score, b) the classification of spine instability based on this score, and c) the location of the most affected vertebral level, in conditions as close as possible to routine clinical practice, among a large sample of clinicians from different specialties with varied degrees of experience and working in different settings and locations.
Methods
Study design and participants
This prospective study was approved by the institutional review boards of the participating hospitals, and complied with the Guidelines for Reporting Reliability and Agreement Studies (GRRAS).ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jclinepi.2010.03.002", "ISSN" : "1878-5921", "PMID" : "21130355", "abstract" : "OBJECTIVE: Results of reliability and agreement studies are intended to provide information about the amount of error inherent in any diagnosis, score, or measurement. The level of reliability and agreement among users of scales, instruments, or classifications is widely unknown. Therefore, there is a need for rigorously conducted interrater and intrarater reliability and agreement studies. Information about sample selection, study design, and statistical analysis is often incomplete. Because of inadequate reporting, interpretation and synthesis of study results are often difficult. Widely accepted criteria, standards, or guidelines for reporting reliability and agreement in the health care and medical field are lacking. The objective was to develop guidelines for reporting reliability and agreement studies.\n\nSTUDY DESIGN AND SETTING: Eight experts in reliability and agreement investigation developed guidelines for reporting.\n\nRESULTS: Fifteen issues that should be addressed when reliability and agreement are reported are proposed. The issues correspond to the headings usually used in publications.\n\nCONCLUSION: The proposed guidelines intend to improve the quality of reporting.", "author" : [ { "dropping-particle" : "", "family" : "Kottner", "given" : "Jan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Audig\u00e9", "given" : "Laurent", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brorson", "given" : "Stig", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Donner", "given" : "Allan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gajewski", "given" : "Byron J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hr\u00f3bjartsson", "given" : "Asbj\u00f8rn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roberts", "given" : "Chris", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shoukri", "given" : "Mohamed", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Streiner", "given" : "David L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical epidemiology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2011", "1" ] ] }, "page" : "96-106", "title" : "Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed.", "type" : "article-journal", "volume" : "64" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=aee9f47b-736c-4bc4-b4d5-a934fc9669a7" ] } ], "mendeley" : { "formattedCitation" : "11", "plainTextFormattedCitation" : "11", "previouslyFormattedCitation" : "11" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }11
Selection of Hospital Departments and clinicians
At the design phase of this study, the medical specialties considered to be relevant for the management of spine metastatic spine disease, were listed as follows: neurosurgery, medical oncology, radiation oncology, radiology and orthopedic surgery.
All of the 61 Hospital Departments specializing in these clinical areas, which had previously participated in studies undertaken by the Spanish Back Pain Research Network or had expressed interest in doing so, were invited to participate in this study. Twelve Departments were located in six private hospitals and the other 71 in 37 non for profit Hospitals, belonging to, or working for, the Spanish National Health Service (SNHS). The SNHS is the tax-funded, government-run, organization which provides free health care to every resident in Spain.
The SNHS classifies Hospitals in five categories, based on the size of the catchment area, number of beds, number of clinicians, availability of high tech medical equipment and procedures, education, training and academic activity, and clinical complexity of the cases treated (i.e., being the reference hospital for specific diseases or procedures).ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "URL" : "http://www.icmbd.es/docs/resumenClusterHospitales.pdf", "accessed" : { "date-parts" : [ [ "2014", "10", "10" ] ] }, "author" : [ { "dropping-particle" : "", "family" : "Departamento de M\u00e9todos Cuantitativos en Econom\u00eda y Gesti\u00f3n", "given" : "Universidad de Las Palmas de Gran Canaria", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2007" ] ] }, "title" : "Clasificaci\u00f3n de hospitales p\u00fablicos espa\u00f1oles mediante el uso del an\u00e1lisis cluster", "type" : "webpage" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=cc9673a6-bef4-46b1-b637-a7df0981165c" ] } ], "mendeley" : { "formattedCitation" : "12", "plainTextFormattedCitation" : "12", "previouslyFormattedCitation" : "12" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }12 Category 1 is the simplest and category 5 is the most complex. Departments invited to participate were located in hospitals belonging to categories 2, 3, 4 and 5.
All clinicians who had finished their residency and worked at the participating departments were invited to act as readers in this study. Those who accepted were asked to provide the number of years they had been working in clinical practice after their residency. The Departments and clinicians did not receive any compensation for participating in this study.
Selection of patients and images
Patients and images were selected by a radiologist who worked in a category 4 hospital and did not act as a reader in this study. He revised consecutive patients in whom a tumor board (composed by a medical oncologist, a radiation oncologist, an orthopedic surgeon, a radiologist, and a pathologist, none of whom acted as r e a d e r s i n t h i s s t u d y ) h a d e s t a b l i s h e d t h e d i a g n o s i s o f s p i n e m e t a s t a t i c d i s e a s e a t e" 2 s p i n e l e v e l s a n d h a d a s s e s s e d t h e S I N S s c o r e . T h e s e c a s e s w e r e r e v i s e d i n r e v e r s e c h r o n o l o g i c a l o r d e r ( i . e . , m o r e r e c e n t c a s e s w e r e r e v i s e d f i r s t ) .
A l l i m a g e s w e r e a c q uired on the same CT and MRI systems with the same technique. The radiologist selected four images per patient; two CT scans and two MRI images, comprising at least two spine levels.
The first 90 cases which complied with inclusion criterion and not with exclusion criteria, were selected. Inclusion criterion was presenting a stage IV (AJCC classification 7th Edition, 2010) biopsy-proven spine metastatic disease. Exclusion criteria were; a) clinical history lacking data required to assess SINS, or b) imaging of insufficient quality to assess the spinal level/s affected.
Procedure
The recruiting radiologist prepared an information pack on each patient, comprising the four images and a clinical vignette stating patients age, oncologic history, clinical signs and symptoms, and whether the patient suffered from movement-related pain (Appendix Fig. A1).ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1200/JCO.2010.34.3897", "ISSN" : "1527-7755", "PMID" : "21709187", "abstract" : "Standardized indications for treatment of tumor-related spinal instability are hampered by the lack of a valid and reliable classification system. The objective of this study was to determine the interobserver reliability, intraobserver reliability, and predictive validity of the Spinal Instability Neoplastic Score (SINS).", "author" : [ { "dropping-particle" : "", "family" : "Fourney", "given" : "Daryl R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frangou", "given" : "Evan M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ryken", "given" : "Timothy C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dipaola", "given" : "Christian P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shaffrey", "given" : "Christopher I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berven", "given" : "Sigurd H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bilsky", "given" : "Mark H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harrop", "given" : "James S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boriani", "given" : "Stefano", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chou", "given" : "Dean", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmidt", "given" : "Meic H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Polly", "given" : "David W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Biagini", "given" : "Roberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Burch", "given" : "Shane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dekutoski", "given" : "Mark B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ganju", "given" : "Aruna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gerszten", "given" : "Peter C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gokaslan", "given" : "Ziya L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Groff", "given" : "Michael W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Liebsch", "given" : "Norbert J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mendel", "given" : "Ehud", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Okuno", "given" : "Scott H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "Shreyaskumar", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rhines", "given" : "Laurence D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rose", "given" : "Peter S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sciubba", "given" : "Daniel M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sundaresan", "given" : "Narayan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tomita", "given" : "Katsuro", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Varga", "given" : "Peter P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vialle", "given" : "Luiz R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vrionis", "given" : "Frank D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yamada", "given" : "Yoshiya", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical oncology : official journal of the American Society of Clinical Oncology", "id" : "ITEM-1", "issue" : "22", "issued" : { "date-parts" : [ [ "2011", "8", "1" ] ] }, "page" : "3072-7", "title" : "Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group.", "type" : "article-journal", "volume" : "29" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=269bce47-9409-4bc0-ba69-8879c75c1288" ] } ], "mendeley" : { "formattedCitation" : "8", "plainTextFormattedCitation" : "8", "previouslyFormattedCitation" : "8" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }8 Patient identity was masked and a code was assigned to each information pack. All the information packs were uploaded onto an online platform specifically designed for this study (HYPERLINK "http://www.typeform.com/"http://www.typeform.com/).
Each reader was provided with a personal password to access the information packs online. For each patient, readers were asked to report all the spinal levels in which they detected metastases (cervical, thoracic, lumbar, and/or sacral) and to calculate the SINS score based on the segment which they considered to be most affected (i.e., the target vertebral level; e.g., L1-L2). Readers were only provided with definitions included in the SINS (Table 1). No attempt was made to further explain or standardize these definitions or to homogenize the diagnostic criteria, and readers did not receive any instructions regarding the interpretation of images. They were told to use their own clinical judgment when in doubt, as they would do in every-day, routine clinical practice.
Readers assessed the information pack alone and on their own, and introduced the resulting report into the online platform. They were asked to assess the same clinical sets twice, with a minimum six-week interval. The software ensured that the minimum period was observed, and that readers had no access to their own previous reports or to their colleagues current or previous reports.
Data introduced into the platform were automatically transferred into a spreadsheet. The software engineer in charge of developing the platform, crosschecked the spreadsheet against the data introduced into the platform by the readers before sending the information to the biostatisticians in charge of statistical analysis.
Statistical analysis
Sample size was calculated at 90 patients with spine metastatic disease, assuming an Intraclass Correlation Coefficient of 0.7, a width of the confidence interval of 0.15, and that at least 5 observers per specialty would be recruited.
In order to assess agreement in the SINS score, the Intraclass Correlation Coefficient (ICC) was calculated using a two way random-effects model. For intra-observer agreement, an ICC was calculated for each one of the 83 observers, and median and 5th and 95th percentiles were estimated. For inter-observer agreement, scores from the first round were analyzed, and the ICC and its 95% Confidence Interval (95% CI) were estimated. ICC values were categorized as showing reliability to be excellent (>0.75), moderate (0.4-0.75), or poor (<0.4).ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/9781118032923", "ISBN" : "9781118032923", "author" : [ { "dropping-particle" : "", "family" : "Fleiss", "given" : "Joseph L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "chapter-number" : "1", "container-title" : "The Design and Analysis of Clinical Experiments", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "1986", "2", "8" ] ] }, "page" : "1-32", "publisher" : "John Wiley & Sons, Inc.", "publisher-place" : "Hoboken, NJ, USA", "title" : "Reliability of Measurement", "type" : "chapter" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=60730111-f9f5-4841-a753-ce1050b06f63" ] } ], "mendeley" : { "formattedCitation" : "13", "plainTextFormattedCitation" : "13", "previouslyFormattedCitation" : "13" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }13
The SINS scores were then collapsed into three categories according to the degree of stability they represent and the treatment they imply; stable (SINS score between 0 and 6), potentially unstable (7-12), or unstable (1318).ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/BRS.0b013e3181e16ae2", "ISSN" : "1528-1159", "PMID" : "20562730", "abstract" : "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.", "author" : [ { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "DiPaola", "given" : "Christian P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ryken", "given" : "Timothy C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bilsky", "given" : "Mark H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shaffrey", "given" : "Christopher I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berven", "given" : "Sigurd H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harrop", "given" : "James S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boriani", "given" : "Stefano", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chou", "given" : "Dean", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmidt", "given" : "Meic H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Polly", "given" : "David W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Biagini", "given" : "Roberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Burch", "given" : "Shane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dekutoski", "given" : "Mark B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ganju", "given" : "Aruna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gerszten", "given" : "Peter C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gokaslan", "given" : "Ziya L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Groff", "given" : "Michael W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Liebsch", "given" : "Norbert J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mendel", "given" : "Ehud", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Okuno", "given" : "Scott H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "Shreyaskumar", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rhines", "given" : "Laurence D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rose", "given" : "Peter S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sciubba", "given" : "Daniel M", 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"non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Spine", "id" : "ITEM-1", "issue" : "22", "issued" : { "date-parts" : [ [ "2010", "10", "15" ] ] }, "page" : "E1221-9", "title" : "A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group.", "type" : "article-journal", "volume" : "35" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=99e95f13-16e8-4ee1-9b36-a4b5e633e64b" ] } ], "mendeley" : { "formattedCitation" : "7", "plainTextFormattedCitation" : "7", "previouslyFormattedCitation" : "7" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }7
The unstable spine levels in each patient were classified into four categories; cervical, thoracic, lumbar or sacral.
To assess intra-observer agreement for each categorical variable, a kappa index was calculated for each one of the 83 readers, and median, 5th and 95th percentiles values were calculated. To assess inter-observer agreement, the corresponding kappa index was estimated and the 95% Confidence Interval (95% CI) was determined following the jackknife resampling method.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1093/biomet/68.3.589", "ISSN" : "0006-3444", "author" : [ { "dropping-particle" : "", "family" : "Efron", "given" : "Bradley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Biometrika", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "1981" ] ] }, "page" : "589-599", "title" : "Nonparametric estimates of standard error: The jackknife, the bootstrap and other methods", "type" : "article-journal", "volume" : "68" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=1723fdfa-fe4e-4b7e-8c35-3b143d11e8e0" ] } ], "mendeley" : { "formattedCitation" : "14", "plainTextFormattedCitation" : "14", "previouslyFormattedCitation" : "14" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }14 A weighted-kappa approach, with a bi-squared weighting scheme, was used. Kappa values were categorized as almost perfect (0.811.00), substantial (0.610.80), moderate (0.410.60), fair (0.210.40), slight (0.000.20), and poor (< 0.00).ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.2307/2529310", "ISSN" : "0006341X", "PMID" : "843571", "abstract" : "This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.", "author" : [ { "dropping-particle" : "", "family" : "Landis", "given" : "J Richard", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Koch", "given" : "Gary G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Biometrics", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "1977", "3" ] ] }, "page" : "159", "title" : "The Measurement of Observer Agreement for Categorical Data", "type" : "article-journal", "volume" : "33" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=147c3028-4ffe-4087-a045-528363e1192e" ] } ], "mendeley" : { "formattedCitation" : "15", "plainTextFormattedCitation" : "15", "previouslyFormattedCitation" : "15" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }15
Subgroup analyses for each variable were performed, in which ICC and kappa values were calculated separately depending on medical specialty, hospital category and professional experience. Degree of professional e x p e r i e n c e w a s c l a s s i f i e d a s r e c e n t l y s p e c i a l i z e d ( d" 7 y e a r s i n p r a c t i c e , a f t e r r e s i d e n c y ) , e x p e r i e n c e d ( 8 - 1 3 y e a r s ) , a n d s e n i o r s p e c i a l i s t ( e" 1 4 y e a r s ) .
T h e S I N S s c o r e s a g r e e d b y t h e t u m o r b o a r d , a n d s u b s e q u e n t l y c l a s s i f i e d a s s t a b l e , p o t e n t i a l l y unstable or unstable, were used as the gold standard to assess overall agreement. The agreement between this gold standard and the median score for each image among the 83 readers, was calculated through the kappa statistic.
Statistical package Stata v 13. (StataCorp. 2013. Stata Statistical Software: Release 13. College Station, TX: StataCorp LP) was used.
Results
Eighty-three clinicians from the 61 Hospital Departments participated in this study; 23 radiologists, 22 radiation oncologists, 16 orthopedic surgeons, 14 neurosurgeons, and eight medical oncologists. They worked in 44 hospitals, across 14 out of the 17 Spanish regions. The first 90 patients selected by the recruiting radiologist (51 women and 39 men, mean age 60.8 years) complied with the inclusion criteria, and none were excluded. These 90 patients showed metastases in 182 spinal levels. Sixteen primary pathologies were represented with breast (n=37), prostate (n=16), lung (n=12) being most popular. Table 2 shows sample characteristics.
There were more than five readers for each specialty and degree of professional experience. However, only three readers worked at category 2 hospitals; therefore, agreement for this subgroup was not calculated (Tables 3-5).
Intra-observer agreement on the SINS score was excellent (median ICC 0.767; 5th, 95th percentiles [0.538; 0.939]). Inter-observer agreement was moderate (0.546; 95% CI [0.476; 0.624]). The only exception found in subgroup analyses, was that intra-observer agreement was only moderate among medical and radiation oncologists, as well as among physicians with 8-13 years of experience (Table 3).
When the SINS scores were grouped into categories (stable, potentially unstable or unstable), intra-observer agreement in classifying the patients into these categories was substantial (median kappa 0.605; 5th, 95th percentiles [0.381; 0.880]) while inter-observer agreement was moderate (0.424; 95% CI [0.336; 0.524]). Subgroup analyses revealed the following exceptions; a) in t r a - o b s e r v e r a g r e e m e n t w a s o n l y m o d e r a t e a m o n g m e d i c a l o n c o l o g i s t s , r a d i a t i o n o n c o l o g i s t s , p h y s i c i a n s w i t h d" 7 y e a r s o f e x p e r i e n c e , a n d p h y s i c i a n s w o r k i n g i n h o s p i t a l s i n c a t e g o r i e s 3 a n d 5 ; b ) i n t e r - o b s e r v e r a g r e e m e n t w a s o n l y f a i r a m o n g o r t h o p e d i c s u r g e o n s , r a d i o l o g i s t s , p h y s i c i a n s w i t h e" 1 4 y e a r s o f c l i n i c a l e x p e r i e n c e , a n d p h y s i c i a n s w o r k i n g i n c a t e g o r y 5 h o s p i t a l s ( T a b l e 4 ) .
I n t r a - a n d i n t e r - o b s e r v e r a g r e e m e n t i n t h e i d e n t i f i c a t i o n o f t h e p o t e n t i a l l y u n s t a b l e s p i n a l l e v e l / s , b a s e d o n t h e c a t e g o r i es grouping the SINS scores, was almost perfect (median kappa 0.971; 5th, 95th percentiles [0.871; 1.000] and 0.944; 95% CI [0.922; 0.970], respectively). Subgroup analyses did not show any differences (Table 5).
Overall agreement with the tumor board classification was substantial (kappa [95%CI]; 0.610 [0.437; 0.792]) All patients classified by the tumor board as unstable were rated w i t h e" 7 S I N S p o i n t s . H o w e v e r , a m o n g t h e 1 4 p a t i e n t s w h o w e r e c l a s s i f i e d a s s t a b l e b y t h e t u m o r b o a r d , n i n e w e r e r a t e d w i t h a m e d i a n S I N S s c o r e s u g g e s t i n g p o t e n t i a l l y u n s t a b l e ( T a b l e 6 ) .
D i s c u s s i o n
R e s u l t s f r o m t h i s s t u d y s h o w t h a t t h e r e i s a m o d e r ate inter-observer agreement in determining the SINS score and in using this score to classify patients into three categories according to spine stability. They also show that this classification largely matches the consensus-based classification established by a multi-disciplinary tumor board, and that there is an almost perfect agreement in the identification of the unstable spine levels in each patient (Tables 3-6). These results are generally consistent across all the specialties involved in managing spine metastatic disease, irrespective of the number of years of experience and the size and complexity of the hospitals where the specialists work. The excellent agreement in the selection of the target level is reassuring, since disagreement is the major source of variability when assessing oncology patients individual response to treatment.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/RLI.0000000000000048", "ISSN" : "1536-0210", "PMID" : "24651664", "abstract" : "PURPOSE: We conducted a systematic analysis of factors (manual vs automated and unidimensional vs 3-dimensional size assessment, and impact of different target lesion selection) contributing to variability of response categorization in the Response Evaluation Criteria for Solid Tumors 1.1. PATIENTS AND METHODS: A total of 41 female patients (58.1 \u00b1 13.2 years old) with metastatic breast cancer underwent contrast-enhanced thoracoabdominal computed tomography for initial staging and first follow-up after systemic chemotherapy. Data were independently interpreted by 3 radiologists with 5 to 9 years of experience. In addition, response was evaluated by a computer-assisted diagnosis system that allowed automated unidimensional and 3-dimensional assessment of target lesions. RESULTS: Overall, between-reader agreement was moderate (\u03ba = 0.53), with diverging response classification observed in 19 of 41 patients (46%). In 25 patients, readers had chosen the same, and in 16, readers had chosen different target lesions. Selection of the same target lesions was associated with a 76% rate of agreement (19/25) with regard to response classification; selection of different target lesions was associated with an 81% rate of disagreement (13/16) (P < 0.001). After dichotomizing response classes according to their therapeutic implication in progressive versus nonprogressive, disagreement was observed in 11 of 41 patients (27%) (\u03ba = 0.57). In 9 of these 11 patients, readers had chosen different target lesions. Disagreement rates due to manual versus automated or unidimensional versus volumetric size measurements were less important (11/41 and 6/41; 27% and 15%, respectively). CONCLUSIONS: A major source of variability is not the manual or unidimensional measurement, but the variable choice of target lesions between readers. Computer-assisted diagnosis-based analysis or tumor volumetry can help avoid variability due to manual or unidimensional measurements only but will not solve the problem of target lesion selection.", "author" : [ { "dropping-particle" : "", "family" : "Keil", "given" : "Sebastian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barabasch", "given" : "Alexandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dirrichs", "given" : "Timm", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bruners", "given" : "Philipp", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hansen", "given" : "Nienke Lynn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bieling", "given" : "Heribert B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Br\u00fcmmendorf", "given" : "Tim H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kuhl", "given" : "Christiane K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Investigative radiology", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "2014", "8" ] ] }, "page" : "509-17", "title" : "Target lesion selection: an important factor causing variability of response classification in the Response Evaluation Criteria for Solid Tumors 1.1.", "type" : "article-journal", "volume" : "49" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=41e97570-60a9-435e-90bd-a95e6f881ea3" ] } ], "mendeley" : { "formattedCitation" : "16", "plainTextFormattedCitation" : "16", "previouslyFormattedCitation" : "16" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }16
Some previous studies found the inter-observer agreement in the SINS score to be excellent,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1200/JCO.2010.34.3897", "ISSN" : "1527-7755", "PMID" : "21709187", "abstract" : "Standardized indications for treatment of tumor-related spinal instability are hampered by the lack of a valid and reliable classification system. The objective of this study was to determine the interobserver reliability, intraobserver reliability, and predictive validity of the Spinal Instability Neoplastic Score (SINS).", "author" : [ { "dropping-particle" : "", "family" : "Fourney", "given" : "Daryl R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frangou", "given" : "Evan M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ryken", "given" : "Timothy C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dipaola", "given" : "Christian P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shaffrey", "given" : "Christopher I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berven", "given" : "Sigurd H", 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"non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical oncology : official journal of the American Society of Clinical Oncology", "id" : "ITEM-1", "issue" : "22", "issued" : { "date-parts" : [ [ "2011", "8", "1" ] ] }, "page" : "3072-7", "title" : "Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group.", "type" : "article-journal", "volume" : "29" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=269bce47-9409-4bc0-ba69-8879c75c1288" ] } ], "mendeley" : { "formattedCitation" : "8", "plainTextFormattedCitation" : "8", "previouslyFormattedCitation" : "8" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }8,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.2214/AJR.13.12269", "ISSN" : "1546-3141", "PMID" : "25247954", "abstract" : "OBJECTIVE: The spinal instability neoplastic scale (SINS) is a new classification system for tumor-related spinal instability. The SINS may prove to be a valuable tool for radiologists to communicate with oncologists and surgeons in a standardized evidence-based manner. The objective of this study was to determine the inter- and intraobserver reliability and validity of the SINS among radiologists.\n\nMATERIALS AND METHODS: Thirty-seven radiologists from 10 international sites used the SINS to categorize the degree of spinal instability in 30 patients with spinal tumors. To assess validity, we compared the SINS scores assigned by the radiologists with the SINS scores of 11 spine oncology surgeons (reference standard). Each total SINS score (range, 0-18 points) was converted into one of the following three clinical categories: 0-6 points, stable; 7-12 points, potentially unstable; and 13-18 points, unstable. In addition, each total SINS score was converted into a binary scale: 0-6 points was defined as stable, and 7-18 points was considered a current or possible instability for which surgical consultation is recommended.\n\nRESULTS: Radiologists using the SINS binary scale showed excellent (\u03ba = 0.88) validity, substantial (\u03ba = 0.76) interobserver agreement, and excellent (\u03ba = 0.82) intraobserver reproducibility. Radiologists rated all unstable cases and 621 of 629 (98.7%) potentially unstable cases with a SINS score of 7 or more points, thus appropriately initiating a referral for surgical assessment.\n\nCONCLUSION: SINS is a reliable tool for radiologists rating tumor-related spinal instability. It accurately discriminates between stable and potentially unstable or unstable lesions and, therefore, can guide the need for surgical consultation.", "author" : [ { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Versteeg", "given" : "Anne L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schouten", "given" : "Rowan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boriani", "given" : "Stefano", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Varga", "given" : "Peter P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rhines", "given" : "Laurence D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Heran", "given" : "Manraj K S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kawahara", "given" : "Norio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fourney", "given" : "Daryl", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reynolds", "given" : "Jeremy J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gokaslan", "given" : "Ziya L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "AJR. American journal of roentgenology", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2014", "10" ] ] }, "page" : "869-74", "title" : "Reliability of the spinal instability neoplastic scale among radiologists: an assessment of instability secondary to spinal metastases.", "type" : "article-journal", "volume" : "203" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=0b1fd2b5-5d94-46b3-9dc4-ff32281b2ac7" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.spinee.2013.08.044", "ISSN" : "1878-1632", "PMID" : "24275615", "abstract" : "BACKGROUND: Metastatic vertebral instability has not yet been clearly defined in the literature; there still exists a paucity of reliable criteria to assess the risk of vertebral collapse.\n\nPURPOSE: We performed an independent interobserver and intraobserver agreement evaluation of the Spine Instability Neoplastic Score (SINS) and correlated the score with selected clinical cases and the treatment they received.\n\nSTUDY DESIGN: Independent reliability study for the newly created SINS.\n\nPATIENT SAMPLE: Thirty patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected from the orthopedic surgery and radiotherapy department's databases.\n\nOUTCOME MEASURES: Patients were rated and classified for spinal stability using SINS. Intraclass correlation coefficient (ICC) and Fleiss's kappa measures were occupied for reliability analysis.\n\nMETHODS: Patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected and classified for spinal stability using the SINS by orthopedic surgeons and nonorthopedic oncology specialists. ICC and Fleiss's kappa were calculated for inter- and intraobserver agreement. A comparative analysis of SINS and the actual management was also conducted.\n\nRESULTS: Interobserver ICC reliability for the SINS was 0.79; \u03ba values for location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement were 0.81, 0.58, 0.21, 0.45, 0.42, and 0.29 respectively. Intraobserver ICC for the SINS scores was 0.96; ICC values for the same components were 0.98, 0.98, 0.87, 0.88, 0.92, and 0.86, respectively. Potentially unstable lesions (SINS score\u22657) were operated on in 62.5%.\n\nCONCLUSIONS: SINS seem to be a reproducible tool that could be used equally by multiple specialists to estimate metastatic vertebral stability; however, prospective clinical validation is still pending.", "author" : [ { "dropping-particle" : "", "family" : "Campos", "given" : "Mauricio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Urrutia", "given" : "Julio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zamora", "given" : "Tom\u00e1s", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rom\u00e1n", "given" : "Javier", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Canessa", "given" : "Valentina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Borghero", "given" : "Yerko", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Palma", "given" : "Alejandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Molina", "given" : "Marcelo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The spine journal : official journal of the North American Spine Society", "id" : "ITEM-2", "issue" : "8", "issued" : { "date-parts" : [ [ "2014", "8", "1" ] ] }, "page" : "1466-9", "title" : "The Spine Instability Neoplastic Score: an independent reliability and\u00a0reproducibility analysis.", "type" : "article-journal", "volume" : "14" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=017d00c3-32ef-452d-b531-31aedc498eb7" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "1980-5322", "PMID" : "23525318", "abstract" : "OBJECTIVES: To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties.\n\nMETHODS: Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient.\n\nRESULTS: Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases.\n\nCONCLUSIONS: This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.", "author" : [ { "dropping-particle" : "", "family" : "Teixeira", "given" : "William Gemio Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Coutinho", "given" : "Pedro Ricardo de Mesquita", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marchese", "given" : "Luiz Delboni", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Narazaki", "given" : "Douglas Kenji", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cristante", "given" : "Alexandre Foga\u00e7a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Teixeira", "given" : "Manoel Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Barros Filho", "given" : "Tarc\u00edsio Eloy Pessoa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Camargo", "given" : "Olavo Pires", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinics (S\u00e3o Paulo, Brazil)", "id" : "ITEM-3", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "1" ] ] }, "page" : "213-8", "title" : "Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator.", "type" : "article-journal", "volume" : "68" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=61319ca4-3f56-4d6f-a2d3-289237a4707c" ] }, { "id" : "ITEM-4", "itemData" : { "DOI" : "10.1186/1748-717X-9-69", "ISSN" : "1748-717X", "PMID" : "24594004", "abstract" : "BACKGROUND: The Spinal Instability Neoplastic Score (SINS) categorizes tumor related spinal instability. It has the potential to streamline the referral of patients with established or potential spinal instability to a spine surgeon. This study aims to define the inter- and intra-observer reliability and validity of SINS among radiation oncologists. METHODS: Thirty-three radiation oncologists, across ten international sites, rated 30 neoplastic spinal disease cases. For each case, the total SINS (0-18 points), three clinical categories (stable: 0-6 points, potentially unstable: 7-12 points, and unstable: 13-18 points), and a binary scale ('stable': 0-6 points and 'current or possible instability'; surgical consultation recommended: 7-18 points) were recorded. Evaluation was repeated 6-8 weeks later. Inter-observer agreement and intra-observer reproducibility were calculated by means of the kappa statistic and translated into levels of agreement (slight, fair, moderate, substantial, and excellent). Validity was determined by comparing the ratings against a spinal surgeon's consensus standard. RESULTS: Radiation oncologists demonstrated substantial (\u03ba=0.76) inter-observer and excellent (\u03ba=0.80) intra-observer reliability when using the SINS binary scale ('stable' versus 'current or possible instability'). Validity of the binary scale was also excellent (\u03ba=0.85) compared with the gold standard. None of the unstable cases was rated as stable by the radiation oncologists ensuring all were appropriately recommended for surgical consultation. CONCLUSIONS: Among radiation oncologists SINS is a highly reliable, reproducible, and valid assessment tool to address a key question in tumor related spinal disease: Is the spine 'stable' or is there 'current or possible instability' that warrants surgical assessment?", "author" : [ { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schouten", "given" : "Rowan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Versteeg", "given" : "Anne L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boriani", "given" : "Stefano", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Varga", "given" : "Peter Pal", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rhines", "given" : "Laurence D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kawahara", "given" : "Norio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fourney", "given" : "Daryl", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Weir", "given" : "Lorna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reynolds", "given" : "Jeremy J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sahgal", "given" : "Arjun", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gokaslan", "given" : "Ziya L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Radiation oncology (London, England)", "id" : "ITEM-4", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "69", "title" : "Reliability of the Spinal Instability Neoplastic Score (SINS) among radiation oncologists: an assessment of instability secondary to spinal metastases.", "type" : "article-journal", "volume" : "9" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=1c49dc5e-089d-43b2-870b-4da1f846c4f0" ] } ], "mendeley" : { "formattedCitation" : "10, 17\u201319", "plainTextFormattedCitation" : "10, 17\u201319", "previouslyFormattedCitation" : "10, 17\u201319" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }10, 1719 while this study only found moderate agreement. Differences in methods can account for this; the current study aimed to assess intra- and inter-observer agreement in conditions as close as possible to routine clinical practice; all patients showed metastases in at least two spine levels, and identification of the target vertebral level was based on clinical judgment, as in routine practice.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/RLI.0000000000000048", "ISSN" : "1536-0210", "PMID" : "24651664", "abstract" : "PURPOSE: We conducted a systematic analysis of factors (manual vs automated and unidimensional vs 3-dimensional size assessment, and impact of different target lesion selection) contributing to variability of response categorization in the Response Evaluation Criteria for Solid Tumors 1.1. PATIENTS AND METHODS: A total of 41 female patients (58.1 \u00b1 13.2 years old) with metastatic breast cancer underwent contrast-enhanced thoracoabdominal computed tomography for initial staging and first follow-up after systemic chemotherapy. Data were independently interpreted by 3 radiologists with 5 to 9 years of experience. In addition, response was evaluated by a computer-assisted diagnosis system that allowed automated unidimensional and 3-dimensional assessment of target lesions. RESULTS: Overall, between-reader agreement was moderate (\u03ba = 0.53), with diverging response classification observed in 19 of 41 patients (46%). In 25 patients, readers had chosen the same, and in 16, readers had chosen different target lesions. Selection of the same target lesions was associated with a 76% rate of agreement (19/25) with regard to response classification; selection of different target lesions was associated with an 81% rate of disagreement (13/16) (P < 0.001). After dichotomizing response classes according to their therapeutic implication in progressive versus nonprogressive, disagreement was observed in 11 of 41 patients (27%) (\u03ba = 0.57). In 9 of these 11 patients, readers had chosen different target lesions. Disagreement rates due to manual versus automated or unidimensional versus volumetric size measurements were less important (11/41 and 6/41; 27% and 15%, respectively). CONCLUSIONS: A major source of variability is not the manual or unidimensional measurement, but the variable choice of target lesions between readers. Computer-assisted diagnosis-based analysis or tumor volumetry can help avoid variability due to manual or unidimensional measurements only but will not solve the problem of target lesion selection.", "author" : [ { "dropping-particle" : "", "family" : "Keil", "given" : "Sebastian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barabasch", "given" : "Alexandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dirrichs", "given" : "Timm", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bruners", "given" : "Philipp", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hansen", "given" : "Nienke Lynn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bieling", "given" : "Heribert B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Br\u00fcmmendorf", "given" : "Tim H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kuhl", "given" : "Christiane K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Investigative radiology", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "2014", "8" ] ] }, "page" : "509-17", "title" : "Target lesion selection: an important factor causing variability of response classification in the Response Evaluation Criteria for Solid Tumors 1.1.", "type" : "article-journal", "volume" : "49" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=41e97570-60a9-435e-90bd-a95e6f881ea3" ] } ], "mendeley" : { "formattedCitation" : "16", "plainTextFormattedCitation" : "16", "previouslyFormattedCitation" : "16" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }16 Moreover, a high number of readers participated, they had different backgrounds and worked in hospitals which were located in different regions, most readers had never met their colleagues in person, and agreement was assessed among different readers, and not among their individual scores and their global mean score.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1200/JCO.2010.34.3897", "ISSN" : "1527-7755", "PMID" : "21709187", "abstract" : "Standardized indications for treatment of tumor-related spinal instability are hampered by the lack of a valid and reliable classification system. The objective of this study was to determine the interobserver reliability, intraobserver reliability, and predictive validity of the Spinal Instability Neoplastic Score (SINS).", "author" : [ { "dropping-particle" : "", "family" : "Fourney", "given" : "Daryl R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frangou", "given" : "Evan M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ryken", "given" : "Timothy C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dipaola", "given" : "Christian P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shaffrey", "given" : "Christopher I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berven", "given" : "Sigurd H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bilsky", "given" : "Mark H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harrop", "given" : "James S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boriani", "given" : "Stefano", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chou", "given" : "Dean", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmidt", "given" : "Meic H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Polly", "given" : "David W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Biagini", "given" : "Roberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Burch", "given" : "Shane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dekutoski", "given" : "Mark B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ganju", "given" : "Aruna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gerszten", "given" : "Peter C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gokaslan", "given" : "Ziya L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Groff", "given" : "Michael W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Liebsch", "given" : "Norbert J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mendel", "given" : "Ehud", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Okuno", "given" : "Scott H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "Shreyaskumar", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rhines", "given" : "Laurence D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rose", "given" : "Peter S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sciubba", "given" : "Daniel M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sundaresan", "given" : "Narayan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tomita", "given" : "Katsuro", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Varga", "given" : "Peter P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vialle", "given" : "Luiz R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vrionis", "given" : "Frank D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yamada", "given" : "Yoshiya", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical oncology : official journal of the American Society of Clinical Oncology", "id" : "ITEM-1", "issue" : "22", "issued" : { "date-parts" : [ [ "2011", "8", "1" ] ] }, "page" : "3072-7", "title" : "Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group.", "type" : "article-journal", "volume" : "29" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=269bce47-9409-4bc0-ba69-8879c75c1288" ] } ], "mendeley" : { "formattedCitation" : "8", "plainTextFormattedCitation" : "8", "previouslyFormattedCitation" : "8" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }8,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "1980-5322", "PMID" : "23525318", "abstract" : "OBJECTIVES: To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties.\n\nMETHODS: Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient.\n\nRESULTS: Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases.\n\nCONCLUSIONS: This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.", "author" : [ { "dropping-particle" : "", "family" : "Teixeira", "given" : "William Gemio Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Coutinho", "given" : "Pedro Ricardo de Mesquita", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marchese", "given" : "Luiz Delboni", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Narazaki", "given" : "Douglas Kenji", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cristante", "given" : "Alexandre Foga\u00e7a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Teixeira", "given" : "Manoel Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Barros Filho", "given" : "Tarc\u00edsio Eloy Pessoa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Camargo", "given" : "Olavo Pires", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinics (S\u00e3o Paulo, Brazil)", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "1" ] ] }, "page" : "213-8", "title" : "Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator.", "type" : "article-journal", "volume" : "68" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=61319ca4-3f56-4d6f-a2d3-289237a4707c" ] } ], "mendeley" : { "formattedCitation" : "18", "plainTextFormattedCitation" : "18", "previouslyFormattedCitation" : "18" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }18 Furthermore, contrarily to some previous studies, the current one did not implement any measures to improve agreement,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.2214/ajr.182.4.1820867", "ISSN" : "0361-803X", "PMID" : "15039154", "author" : [ { "dropping-particle" : "", "family" : "Obuchowski", "given" : "Nancy A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "AJR. American journal of roentgenology", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2004", "4" ] ] }, "page" : "867-9", "title" : "How many observers are needed in clinical studies of medical imaging?", "type" : "article-journal", "volume" : "182" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=a2d05015-cb1a-4383-8178-163f1142cf38" ] } ], "mendeley" : { "formattedCitation" : "20", "plainTextFormattedCitation" : "20", "previouslyFormattedCitation" : "20" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }20 such as training, offering a stipend to readers, agreeing on diagnostic criteria, or using standardized nomenclature linked to examples available online.13ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jclinepi.2007.04.014", "ISSN" : "0895-4356", "PMID" : "18083458", "abstract" : "OBJECTIVE: To systematically review studies of observer agreement among doctors classifying proximal humeral fractures according to the Neer system. STUDY DESIGN AND SETTING: A systematic review. We searched for observational studies in which doctors classified proximal humeral fractures according to the Neer system, and randomized trials of any intervention aimed at improving agreement. We analyzed potential eligible studies independently, and data were extracted using pretested forms. Authors were contacted for missing information. Summary statistics for observer agreement were noted, and the methodological quality was assessed. RESULTS: We included 11 observational studies (88 observers and 468 cases). Mean kappa-values for interobserver agreement ranged from 0.17 to 0.52. Agreement did not improve through selection of experienced observers, advanced imaging modalities, or simplification of the classification system. Intra-observer agreement was moderately higher than interobserver agreement. One randomized trial (14 observers and 42 cases) reported a clear effect of training (mean kappa-value 0.62 after training compared to no training 0.34). CONCLUSION: We found a consistently low level of observer agreement. The widely held belief that experts disagree less than nonexperts could not be supported. One randomized trial indicated that training improves agreement among both experts and nonexperts.", "author" : [ { "dropping-particle" : "", "family" : "Brorson", "given" : "Stig", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hr\u00f3bjartsson", "given" : "Asbj\u00f8rn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical epidemiology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2008", "1" ] ] }, "page" : "7-16", "title" : "Training improves agreement among doctors using the Neer system for proximal humeral fractures in a systematic review.", "type" : "article-journal", "volume" : "61" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=bed5335c-db54-4096-b3ec-e63833b813f5" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.3348/kjr.2014.15.5.578", "ISSN" : "2005-8330", "PMID" : "25246818", "abstract" : "OBJECTIVE: To evaluate the efficacy of a mammography boot camp (MBC) to improve radiologists' performance in interpreting mammograms in the National Cancer Screening Program (NCSP) in Korea. MATERIALS AND METHODS: Between January and July of 2013, 141 radiologists were invited to a 3-day educational program composed of lectures and group practice readings using 250 digital mammography cases. The radiologists' performance in interpreting mammograms were evaluated using a pre- and post-camp test set of 25 cases validated prior to the camp by experienced breast radiologists. Factors affecting the radiologists' performance, including age, type of attending institution, and type of test set cases, were analyzed. RESULTS: The average scores of the pre- and post-camp tests were 56.0 \u00b1 12.2 and 78.3 \u00b1 9.2, respectively (p < 0.001). The post-camp test scores were higher than the pre-camp test scores for all age groups and all types of attending institutions (p < 0.001). The rate of incorrect answers in the post-camp test decreased compared to the pre-camp test for all suspicious cases, but not for negative cases (p > 0.05). CONCLUSION: The MBC improves radiologists' performance in interpreting mammograms irrespective of age and type of attending institution. Improved interpretation is observed for suspicious cases, but not for negative cases.", "author" : [ { "dropping-particle" : "", "family" : "Lee", "given" : "Eun Hye", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jun", "given" : "Jae Kwan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jung", "given" : "Seung Eun", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kim", "given" : "You Me", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Choi", "given" : "Nami", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Korean journal of radiology : official journal of the Korean Radiological Society", "id" : "ITEM-2", "issue" : "5", "issued" : { "date-parts" : [ [ "2014", "9" ] ] }, "page" : "578-85", "title" : "The efficacy of mammography boot cAMP to improve the performance of radiologists.", "type" : "article-journal", "volume" : "15" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=6688fc3f-10cd-44c3-9545-377141067721" ] } ], "mendeley" : { "formattedCitation" : "21, 22", "manualFormatting" : ",", "plainTextFormattedCitation" : "21, 22", "previouslyFormattedCitation" : "21, 22" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" },ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1186/1748-717X-9-69", "ISSN" : "1748-717X", "PMID" : "24594004", "abstract" : "BACKGROUND: The Spinal Instability Neoplastic Score (SINS) categorizes tumor related spinal instability. It has the potential to streamline the referral of patients with established or potential spinal instability to a spine surgeon. This study aims to define the inter- and intra-observer reliability and validity of SINS among radiation oncologists. METHODS: Thirty-three radiation oncologists, across ten international sites, rated 30 neoplastic spinal disease cases. For each case, the total SINS (0-18 points), three clinical categories (stable: 0-6 points, potentially unstable: 7-12 points, and unstable: 13-18 points), and a binary scale ('stable': 0-6 points and 'current or possible instability'; surgical consultation recommended: 7-18 points) were recorded. Evaluation was repeated 6-8 weeks later. Inter-observer agreement and intra-observer reproducibility were calculated by means of the kappa statistic and translated into levels of agreement (slight, fair, moderate, substantial, and excellent). Validity was determined by comparing the ratings against a spinal surgeon's consensus standard. RESULTS: Radiation oncologists demonstrated substantial (\u03ba=0.76) inter-observer and excellent (\u03ba=0.80) intra-observer reliability when using the SINS binary scale ('stable' versus 'current or possible instability'). Validity of the binary scale was also excellent (\u03ba=0.85) compared with the gold standard. None of the unstable cases was rated as stable by the radiation oncologists ensuring all were appropriately recommended for surgical consultation. CONCLUSIONS: Among radiation oncologists SINS is a highly reliable, reproducible, and valid assessment tool to address a key question in tumor related spinal disease: Is the spine 'stable' or is there 'current or possible instability' that warrants surgical assessment?", "author" : [ { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schouten", "given" : "Rowan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Versteeg", "given" : "Anne L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boriani", "given" : "Stefano", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Varga", "given" : "Peter Pal", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rhines", "given" : "Laurence D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kawahara", "given" : "Norio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fourney", "given" : "Daryl", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Weir", "given" : "Lorna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reynolds", "given" : "Jeremy J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sahgal", "given" : "Arjun", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gokaslan", "given" : "Ziya L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Radiation oncology (London, England)", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "69", "title" : "Reliability of the Spinal Instability Neoplastic Score (SINS) among radiation oncologists: an assessment of instability secondary to spinal metastases.", "type" : "article-journal", "volume" : "9" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=1c49dc5e-089d-43b2-870b-4da1f846c4f0" ] } ], "mendeley" : { "formattedCitation" : "19", "plainTextFormattedCitation" : "19", "previouslyFormattedCitation" : "19" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }19
In fact, the moderate inter-observer agreement found when using the SINS score to assess spine instability, is in line with what has been found in spine imaging in general. Moderate agreement has been found among radiologists when assessing spine degenerative disease through MRI,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.3174/ajnr.A2448", "ISSN" : "1936-959X", "PMID" : "21493764", "abstract" : "The CTF nomenclature had not been tested in clinical practice. The purpose of this study was to compare the reliability and diagnostic confidence in the interpretation of disk contours on lumbar 1.5T MR imaging when using the CTF and the Nordic nomenclatures.", "author" : [ { "dropping-particle" : "", "family" : "Arana", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kovacs", "given" : "F M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Royuela", "given" : "a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Estremera", "given" : "a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saras\u00edbar", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Amengual", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Galarraga", "given" : "I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mart\u00ednez", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Muriel", "given" : "a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Abraira", "given" : "V", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zamora", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Campillo", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "AJNR. American journal of neuroradiology", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "1143-8", "title" : "Influence of nomenclature in the interpretation of lumbar disk contour on MR imaging: a comparison of the agreement using the combined task force and the nordic nomenclatures.", "type" : "article-journal", "volume" : "32" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=03f4f2dd-6b8c-4a46-9c1a-0d6c7775f838" ] } ], "mendeley" : { "formattedCitation" : "23", "plainTextFormattedCitation" : "23", "previouslyFormattedCitation" : "23" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }23 and among spine surgeons when using a cervical injury nomenclature system,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/BRS.0b013e318221a56d", "ISSN" : "1528-1159", "PMID" : "21587109", "abstract" : "STUDY DESIGN: Radiographic measurement study.\n\nOBJECTIVE: To develop a standardized cervical injury nomenclature system to facilitate description, communication, and classification among health care providers. The reliability and reproducibility of this system was then examined.\n\nSUMMARY OF BACKGROUND DATA: Description of subaxial cervical injuries is critical for treatment decision making and comparing scientific reports of outcomes. Despite a number of available classification systems, surgeons, and researchers continue to use descriptive nomenclature, such as \"burst\" and \"teardrop\" fractures, to describe injuries. However, there is considerable inconsistency with use of such terms in the literature.\n\nMETHODS: Eleven distinct injury types and associated definitions were established for the subaxial cervical spine and subsequently refined by members of the Spine Trauma Study Group. A series of 18 cases of patients with a broad spectrum of subaxial cervical spine injuries was prepared and distributed to surgeon raters. Each rater was provided with the full nomenclature document and asked to select primary and secondary injury types for each case. After receipt of the raters' first round of classifications, the cases were resorted and returned to the raters for a second round of review. Interrater and intrarater reliabilities were calculated as percent agreement and Cohen kappa (\u03ba) values. Intrarater reliability was assessed by comparing a given rater's diagnosis from the first and second rounds.\n\nRESULTS: Nineteen surgeons completed the first and second rounds of the study. Overall, the system demonstrated 56.4% interrater agreement and 72.8% intrarater agreement. Overall, interrater \u03ba values demonstrated moderate agreement while intrarater \u03ba values showed substantial agreement. Analyzed by injury types, only four (burst fractures, lateral mass fractures, flexion teardrop fractures, and anterior distraction injuries) demonstrated greater than 50% interrater agreement.\n\nCONCLUSION: This study demonstrated that, even in ideal circumstances, there is only moderate agreement among raters regarding cervical injury nomenclature. It is hoped that more familiarity with the proposed system will increase reproducibility in the future. Additional research is required to establish the clinical utility of this novel nomenclature schema.", "author" : [ { "dropping-particle" : "", "family" : "Bono", "given" : "Christopher M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schoenfeld", "given" : "Andrew", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gupta", "given" : "Giri", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harrop", "given" : "James S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Anderson", "given" : "Paul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "Alpesh a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dimar", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Aarabi", "given" : "Bizhan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dailey", "given" : "Andrew", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vaccaro", "given" : "Alexander R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gahr", "given" : "Ralf", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shaffrey", "given" : "Christopher", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Anderson", "given" : "David G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rampersaud", "given" : "Raj", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Spine", "id" : "ITEM-1", "issue" : "17", "issued" : { "date-parts" : [ [ "2011", "8", "1" ] ] }, "page" : "E1140-4", "title" : "Reliability and reproducibility of subaxial cervical injury description system: a standardized nomenclature schema.", "type" : "article-journal", "volume" : "36" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=035c8f9f-8bfb-4047-92ce-f01bcd84abd7" ] } ], "mendeley" : { "formattedCitation" : "24", "plainTextFormattedCitation" : "24", "previouslyFormattedCitation" : "24" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }24 or assessing complex injuries of the lumbar spine.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s00586-012-2602-7", "ISSN" : "1432-0932", "PMID" : "23208081", "abstract" : "PURPOSE: The diagnostic assessment and prognostic value of the posterior ligamentous complex (PLC) remains a controversial topic in the management of patients with thoracolumbar spinal injury. The purpose of this review was to critically appraise the literature and present an overview of the: (1) precision, (2) accuracy, and (3) validity of detecting PLC injuries in patients with thoracic and lumbar spine trauma. METHODS: Studies evaluating the precision, accuracy and/or validity of detecting and managing PLC injuries in patients with thoracic and/or lumbar spine injuries were searched through the Medline database (1966 to September 2011). References were retrieved and evaluated individually and independently by two authors. RESULTS: Twenty-one eligible studies were identified. Few studies reported the use of countermeasures for sampling and measurement bias. In nine agreement studies, the PLC was assessed in various ways, ranging from use of booklets to a complete set of diagnostic imaging. Inter-rater and intra-rater kappa values ranged from 0.188 to 0.915 and 0.455 to 0.840, respectively. In nine accuracy studies, magnetic resonance (MR) imaging was most often (n = 6) compared with intra-operative findings. In general, MR imaging tended to demonstrate relatively high negative predictive values and relatively low positive predictive values for PLC injuries. CONCLUSIONS: A wide variety of methods have been applied in the evaluation of precision and accuracy of PLC injury detection, leaving spinal surgeons with a multitude of variable results. There is scant clinical evidence demonstrating the true prognostic value of detected PLC injuries in patients with thoracic and lumbar spine injuries. We recommend the conduct of longitudinal clinical follow-up studies on those cases assessed for precision and/or accuracy of PLC injuries.", "author" : [ { "dropping-particle" : "", "family" : "Middendorp", "given" : "Joost J", "non-dropping-particle" : "van", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "Alpesh A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schuetz", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Joaquim", "given" : "Andrei F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2013", "3" ] ] }, "page" : "461-74", "title" : "The precision, accuracy and validity of detecting posterior ligamentous complex injuries of the thoracic and lumbar spine: a critical appraisal of the literature.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=0af9b8e6-9ba3-4223-a15c-651e78a3480d" ] } ], "mendeley" : { "formattedCitation" : "25", "plainTextFormattedCitation" : "25", "previouslyFormattedCitation" : "25" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }25 The most acknowledged classification of primary spinal tumors also leads to a moderate inter-observer agreement.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/BRS.0b013e3181971283", "ISSN" : "1528-1159", "PMID" : "19214098", "abstract" : "STUDY DESIGN: Reliability analysis based on expert panel case series review and grading per the Enneking and Weinstein-Boriani-Biagini classification systems.\n\nOBJECTIVE: To assess the reliability of the Enneking and Weinstein-Boriani-Biagini classification systems.\n\nSUMMARY OF BACKGROUND DATA: The Enneking and Weinstein-Boriani-Biagini (WBB) classifications were developed to stage and facilitate treatment planning in patients with primary spine tumors. To date, their interobserver and intraobserver reliability has not been assessed-a fundamental step in facilitating broader clinical and research use.\n\nMETHODS: Clinical information, imaging studies, and biopsy results were compiled from 15 selected patients with primary spinal tumors. Eighteen spine surgeons independently estimated and scored the cases for Enneking grade, tumor and metastasis categories, Enneking stage, Enneking-recommended surgical margin, WBB zones and layers, and WBB-recommended surgical procedures, with a second assessment performed after random resorting of cases. Interobserver and intraobserver reliability of each category were assessed by percent agreement or proportional overlap. The Fleiss, Cohen, and Mezzich kappa statistics (kappa) were then applied, determined by the type of variable analyzed.\n\nRESULTS: The kappa statistics for interobserver reliability were 0.82, 0.22, 0.00, 0.57, 0.47, 0.31, 0.58, and 0.54 for the fields of Enneking grade, tumor and metastasis categories, Enneking stage, Enneking-recommended surgical margin, WBB zones and layers, and WBB-recommended surgical procedures, respectively. The kappa statistics for intraobserver reliability were 0.97, 0.53, 0.47, 0.82, 0.67, 0.63, 0.79, and 0.79 for the same respective fields. According to Landis and Koch, the ranges of kappa values of 0.00 to 0.20, 0.21 to 0.40, 0.41 to 0.60, 0.61 to 0.80, and >0.80 imply slight, fair, moderate, substantial, and near-perfect agreement, respectively.\n\nCONCLUSION: Results indicate moderate interobserver reliability and substantial and near-perfect intraobserver reliability for both the Enneking and WBB classification in terms of staging and guidance for treatment, despite a less than moderate interobserver reliability in interpreting the Enneking local tumor extension and WBB sector. Before incorporating the classifications in the clinical practice and research studies, further work is required to investigate the validity of the classifications.", "author" : [ { "dropping-particle" : "", "family" : "Chan", "given" : "Patrick", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boriani", "given" : "Stefano", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fourney", "given" : "Daryl R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Biagini", "given" : "Roberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dekutoski", "given" : "Mark B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ryken", "given" : "Timothy C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gokaslan", "given" : "Ziya L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vrionis", "given" : "Frank D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harrop", "given" : "James S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmidt", "given" : "Meic H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vialle", "given" : "Luis R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gerszten", "given" : "Peter C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rhines", "given" : "Laurence D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ondra", "given" : "Stephen L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pratt", "given" : "Stuart R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Spine", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2009", "3", "15" ] ] }, "page" : "384-91", "title" : "An assessment of the reliability of the Enneking and Weinstein-Boriani-Biagini classifications for staging of primary spinal tumors by the Spine Oncology Study Group.", "type" : "article-journal", "volume" : "34" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=6a0f7081-4951-4303-8435-bf2ca0835e34" ] } ], "mendeley" : { "formattedCitation" : "26", "plainTextFormattedCitation" : "26", "previouslyFormattedCitation" : "26" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }26
As opposed to what has been found in this study (Tables 3-5), a previous report found agreement to be higher among physicians with more years of experience.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "1980-5322", "PMID" : "23525318", "abstract" : "OBJECTIVES: To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties.\n\nMETHODS: Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient.\n\nRESULTS: Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases.\n\nCONCLUSIONS: This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.", "author" : [ { "dropping-particle" : "", "family" : "Teixeira", "given" : "William Gemio Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Coutinho", "given" : "Pedro Ricardo de Mesquita", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marchese", "given" : "Luiz Delboni", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Narazaki", "given" : "Douglas Kenji", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cristante", "given" : "Alexandre Foga\u00e7a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Teixeira", "given" : "Manoel Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Barros Filho", "given" : "Tarc\u00edsio Eloy Pessoa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Camargo", "given" : "Olavo Pires", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinics (S\u00e3o Paulo, Brazil)", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "1" ] ] }, "page" : "213-8", "title" : "Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator.", "type" : "article-journal", "volume" : "68" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=61319ca4-3f56-4d6f-a2d3-289237a4707c" ] } ], "mendeley" : { "formattedCitation" : "18", "plainTextFormattedCitation" : "18", "previouslyFormattedCitation" : "18" }, "properties" : { "noteIndex" : 0 }, "schema" : " h t t p s : / / g i t h u b . c o m / c i t a t i o n - s t y l e - l a n g u a g e / s c h e m a / r a w / m a s t e r / c s l - c i t a t i o n . j s o n " } 1 8 T h e f a c t t h a t a l l p h y s i c i a n s w h o p a r t i c i p a t e d i n t h e c u r r e n t s t u d y h a d u n d e r g o n e e" 4 y e a r s o f c l i n i c a l t r a i n i n g t o b e c o m e c e r t i f i e d s p e c i a l i s t s , m a y a c c o u n t f o r t h i s difference. Paradoxically, in the current study, the physicians with the highest degree of experience showed the smallest inter-observer agreement when their SINS ratings were collapsed into three categories. However, although their median kappa value was smaller than the one for physicians with less experience, the 5th-95th percentiles largely overlap (Table 4).
The assessment of imaging by spine surgeons is usually considered as the gold standard for deciding whether surgery is appropriate for a patient with metastatic spine disease,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.2214/AJR.13.12269", "ISSN" : "1546-3141", "PMID" : "25247954", "abstract" : "OBJECTIVE: The spinal instability neoplastic scale (SINS) is a new classification system for tumor-related spinal instability. The SINS may prove to be a valuable tool for radiologists to communicate with oncologists and surgeons in a standardized evidence-based manner. The objective of this study was to determine the inter- and intraobserver reliability and validity of the SINS among radiologists.\n\nMATERIALS AND METHODS: Thirty-seven radiologists from 10 international sites used the SINS to categorize the degree of spinal instability in 30 patients with spinal tumors. To assess validity, we compared the SINS scores assigned by the radiologists with the SINS scores of 11 spine oncology surgeons (reference standard). Each total SINS score (range, 0-18 points) was converted into one of the following three clinical categories: 0-6 points, stable; 7-12 points, potentially unstable; and 13-18 points, unstable. In addition, each total SINS score was converted into a binary scale: 0-6 points was defined as stable, and 7-18 points was considered a current or possible instability for which surgical consultation is recommended.\n\nRESULTS: Radiologists using the SINS binary scale showed excellent (\u03ba = 0.88) validity, substantial (\u03ba = 0.76) interobserver agreement, and excellent (\u03ba = 0.82) intraobserver reproducibility. Radiologists rated all unstable cases and 621 of 629 (98.7%) potentially unstable cases with a SINS score of 7 or more points, thus appropriately initiating a referral for surgical assessment.\n\nCONCLUSION: SINS is a reliable tool for radiologists rating tumor-related spinal instability. It accurately discriminates between stable and potentially unstable or unstable lesions and, therefore, can guide the need for surgical consultation.", "author" : [ { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Versteeg", "given" : "Anne L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schouten", "given" : "Rowan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boriani", "given" : "Stefano", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Varga", "given" : "Peter P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rhines", "given" : "Laurence D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Heran", "given" : "Manraj K S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kawahara", "given" : "Norio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fourney", "given" : "Daryl", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reynolds", "given" : "Jeremy J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gokaslan", "given" : "Ziya L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "AJR. American journal of roentgenology", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2014", "10" ] ] }, "page" : "869-74", "title" : "Reliability of the spinal instability neoplastic scale among radiologists: an assessment of instability secondary to spinal metastases.", "type" : "article-journal", "volume" : "203" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=0b1fd2b5-5d94-46b3-9dc4-ff32281b2ac7" ] } ], "mendeley" : { "formattedCitation" : "17", "plainTextFormattedCitation" : "17", "previouslyFormattedCitation" : "17" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }17 and a previous study found that the inter-observer agreement in the SINS score is higher among spine surgeons than among other specialists.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "1980-5322", "PMID" : "23525318", "abstract" : "OBJECTIVES: To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties.\n\nMETHODS: Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient.\n\nRESULTS: Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases.\n\nCONCLUSIONS: This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.", "author" : [ { "dropping-particle" : "", "family" : "Teixeira", "given" : "William Gemio Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Coutinho", "given" : "Pedro Ricardo de Mesquita", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marchese", "given" : "Luiz Delboni", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Narazaki", "given" : "Douglas Kenji", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cristante", "given" : "Alexandre Foga\u00e7a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Teixeira", "given" : "Manoel Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Barros Filho", "given" : "Tarc\u00edsio Eloy Pessoa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Camargo", "given" : "Olavo Pires", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinics (S\u00e3o Paulo, Brazil)", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "1" ] ] }, "page" : "213-8", "title" : "Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator.", "type" : "article-journal", "volume" : "68" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=61319ca4-3f56-4d6f-a2d3-289237a4707c" ] } ], "mendeley" : { "formattedCitation" : "18", "plainTextFormattedCitation" : "18", "previouslyFormattedCitation" : "18" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }18 This was not the case in the current study, where differences across specialties were inconsistent, small, and likely to be clinically meaningless (Tables 3-5).ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jclinepi.2010.03.002", "ISSN" : "1878-5921", "PMID" : "21130355", "abstract" : "OBJECTIVE: Results of reliability and agreement studies are intended to provide information about the amount of error inherent in any diagnosis, score, or measurement. The level of reliability and agreement among users of scales, instruments, or classifications is widely unknown. Therefore, there is a need for rigorously conducted interrater and intrarater reliability and agreement studies. Information about sample selection, study design, and statistical analysis is often incomplete. Because of inadequate reporting, interpretation and synthesis of study results are often difficult. Widely accepted criteria, standards, or guidelines for reporting reliability and agreement in the health care and medical field are lacking. The objective was to develop guidelines for reporting reliability and agreement studies.\n\nSTUDY DESIGN AND SETTING: Eight experts in reliability and agreement investigation developed guidelines for reporting.\n\nRESULTS: Fifteen issues that should be addressed when reliability and agreement are reported are proposed. The issues correspond to the headings usually used in publications.\n\nCONCLUSION: The proposed guidelines intend to improve the quality of reporting.", "author" : [ { "dropping-particle" : "", "family" : "Kottner", "given" : "Jan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Audig\u00e9", "given" : "Laurent", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brorson", "given" : "Stig", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Donner", "given" : "Allan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gajewski", "given" : "Byron J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hr\u00f3bjartsson", "given" : "Asbj\u00f8rn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Roberts", "given" : "Chris", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shoukri", "given" : "Mohamed", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Streiner", "given" : "David L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical epidemiology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2011", "1" ] ] }, "page" : "96-106", "title" : "Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed.", "type" : "article-journal", "volume" : "64" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=aee9f47b-736c-4bc4-b4d5-a934fc9669a7" ] } ], "mendeley" : { "formattedCitation" : "11", "plainTextFormattedCitation" : "11", "previouslyFormattedCitation" : "11" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }11 The large sample size in this study, the high number of participating clinicians from each specialty and the fact that, as opposed to other studies,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1200/JCO.2010.34.3897", "ISSN" : "1527-7755", "PMID" : "21709187", "abstract" : "Standardized indications for treatment of tumor-related spinal instability are hampered by the lack of a valid and reliable classification system. The objective of this study was to determine the interobserver reliability, intraobserver reliability, and predictive validity of the Spinal Instability Neoplastic Score (SINS).", "author" : [ { "dropping-particle" : "", "family" : "Fourney", "given" : "Daryl R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frangou", "given" : "Evan M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ryken", "given" : "Timothy C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dipaola", "given" : "Christian P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shaffrey", "given" : "Christopher I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berven", "given" : "Sigurd H", 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"non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Liebsch", "given" : "Norbert J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mendel", "given" : "Ehud", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Okuno", "given" : "Scott H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "Shreyaskumar", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rhines", "given" : "Laurence D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rose", "given" : "Peter S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sciubba", "given" : "Daniel M", 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"non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical oncology : official journal of the American Society of Clinical Oncology", "id" : "ITEM-1", "issue" : "22", "issued" : { "date-parts" : [ [ "2011", "8", "1" ] ] }, "page" : "3072-7", "title" : "Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group.", "type" : "article-journal", "volume" : "29" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=269bce47-9409-4bc0-ba69-8879c75c1288" ] } ], "mendeley" : { "formattedCitation" : "8", "plainTextFormattedCitation" : "8", "previouslyFormattedCitation" : "8" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }8,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "1980-5322", "PMID" : "23525318", "abstract" : "OBJECTIVES: To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties.\n\nMETHODS: Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient.\n\nRESULTS: Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases.\n\nCONCLUSIONS: This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.", "author" : [ { "dropping-particle" : "", "family" : "Teixeira", "given" : "William Gemio Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Coutinho", "given" : "Pedro Ricardo de Mesquita", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marchese", "given" : "Luiz Delboni", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Narazaki", "given" : "Douglas Kenji", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cristante", "given" : "Alexandre Foga\u00e7a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Teixeira", "given" : "Manoel Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Barros Filho", "given" : "Tarc\u00edsio Eloy Pessoa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Camargo", "given" : "Olavo Pires", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinics (S\u00e3o Paulo, Brazil)", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "1" ] ] }, "page" : "213-8", "title" : "Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator.", "type" : "article-journal", "volume" : "68" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=61319ca4-3f56-4d6f-a2d3-289237a4707c" ] } ], "mendeley" : { "formattedCitation" : "18", "plainTextFormattedCitation" : "18", "previouslyFormattedCitation" : "18" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }18 none of the readers participated in the definition of the gold standard, and those who were not spine surgeons were specialists who also manage spine metastatic disease in routine practice, can account for this difference in results.
Inter-observer agreement does not necessarily mean external validity, since consensus may not represent the actual truth;ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1148/radiol.10100252", "ISSN" : "1527-1315", "PMID" : "20851935", "author" : [ { "dropping-particle" : "", "family" : "Bankier", "given" : "Alexander a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Levine", "given" : "Deborah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Halpern", "given" : "Elkan F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kressel", "given" : "Herbert Y", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Radiology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2010", "10" ] ] }, "page" : "14-7", "title" : "Consensus interpretation in imaging research: is there a better way?", "type" : "article-journal", "volume" : "257" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=ce05dbe8-989b-410e-9a0d-e347119ac971" ] } ], "mendeley" : { "formattedCitation" : "27", "plainTextFormattedCitation" : "27", "previouslyFormattedCitation" : "27" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }27 sometimes clinicians agree on measures which are not evidence-based or effective.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1179/1743132814Y.0000000365", "ISSN" : "1743-1328", "PMID" : "24716730", "abstract" : "Treatment modalities for metastatic spine disease have significantly expanded over the last two decades. This expansion occurred in many different fields. Improvement in surgical techniques and instrumentation now allow the oncologic spine surgeons to effectively circumferentially decompress the neural elements without compromising stability. Percutaneous techniques, both vertebral augmentation and pre-operative endovascular embolization procedures, also greatly benefit patients suffering from spinal column metastasis. Imaging technology advances has contributed to better pre-operative planning and the development of highly conformational radiation techniques, thus permitting the delivery of high-dose radiation to tumors, while avoiding radiotoxicity to the spinal cord and other vital structures. These new developments, combined with evidence-based stability and disease-specific quality of life scores now allow not only better treatment, but also a solid foundation for high-quality research. Spine oncology literature currently suffers from a lack of high-quality evidence due to low prevalence of the disease and complex methodological issues. However, when following evidence-based medicine principles, which incorporate best available evidence, clinical expertise and patient preference, sound, evidence-based recommendations can be made regarding the abovementioned treatment modalities.", "author" : [ { "dropping-particle" : "", "family" : "Dea", "given" : "Nicolas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Neurological research", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2014", "6" ] ] }, "page" : "524-9", "title" : "Evidence-based medicine in metastatic spine disease.", "type" : "article-journal", "volume" : "36" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=f4bb0567-4a63-4ff8-aebf-875cf66a7d7e" ] } ], "mendeley" : { "formattedCitation" : "28", "plainTextFormattedCitation" : "28", "previouslyFormattedCitation" : "28" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }28 In fact, the correlation between imaging and histopathology findings is low in some types of cancer,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0971-5916", "PMID" : "25027081", "abstract" : "BACKGROUND & OBJECTIVES: Staging of cervical carcinoma is done clinically using International Federation of Obstetrics and Gynecology (FIGO) guidelines. It is based on physical examination findings and also includes results of biopsy, endoscopy and conventional radiological tests like chest radiograph, intravenous urography and barium enema. These conventional radiological investigations have largely been replaced by computed tomography (CT) and magnetic resonance imaging (MRI) at present. FIGO staging system does not consider CT and MRI mandatory; however, use of these modalities are encouraged. This prospective study was conducted to determine the role of CT in staging work up in women diagnosed with cervical carcinoma. METHODS: Fifty three women diagnosed with cervical carcinoma were evaluated with contrast enhanced CT scan of abdomen and pelvis. CT scan images were especially evaluated to determine tumour size, invasion of parmetrium, pelvic walls, rectum, urinary bladder and ureters, pelvic or retroperitoneal lymphadenopathy and distant metastases. CT findings were associated with clinical findings and staging, including findings from cystoscopy and sigmoidoscopy. RESULTS: There was a poor agreement between clinical and CT staging of cervical carcinoma. Primary tumour was demonstrated on CT in 36 (70%) of 53 patients. CT underestimated the parametrial, vaginal and pelvic wall invasion when compared with physical examination. CT overestimated the urinary bladder and rectal invasion when compared with cysto-sigmoidoscopy, however, CT had 100 per cent negative predictive value (NPV) to exclude bladder and rectal involvement. CT detection of lymph node enlargement and lung metastases influenced the management. INTERPRETATION & CONCLUSIONS: Our findings show that CT scan does not reliably correlate with clinical FIGO staging of cervical cancer. However, it can detect urinary obstruction as well as nodal or distant metastases and thus improves the clinical FIGO staging.", "author" : [ { "dropping-particle" : "V", "family" : "Prasad", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Thulkar", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hari", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sharma", "given" : "D N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kumar", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Indian journal of medical research", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2014", "5" ] ] }, "page" : "714-9", "title" : "Role of computed tomography (CT) scan in staging of cervical carcinoma.", "type" : "article-journal", "volume" : "139" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=36bc25af-62b9-44cc-9fd9-c2042027d970" ] } ], "mendeley" : { "formattedCitation" : "29", "plainTextFormattedCitation" : "29", "previouslyFormattedCitation" : "29" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }29 differences between SINS classification and real surgical outcomes have been documented,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.spinee.2013.08.044", "ISSN" : "1878-1632", "PMID" : "24275615", "abstract" : "BACKGROUND: Metastatic vertebral instability has not yet been clearly defined in the literature; there still exists a paucity of reliable criteria to assess the risk of vertebral collapse.\n\nPURPOSE: We performed an independent interobserver and intraobserver agreement evaluation of the Spine Instability Neoplastic Score (SINS) and correlated the score with selected clinical cases and the treatment they received.\n\nSTUDY DESIGN: Independent reliability study for the newly created SINS.\n\nPATIENT SAMPLE: Thirty patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected from the orthopedic surgery and radiotherapy department's databases.\n\nOUTCOME MEASURES: Patients were rated and classified for spinal stability using SINS. Intraclass correlation coefficient (ICC) and Fleiss's kappa measures were occupied for reliability analysis.\n\nMETHODS: Patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected and classified for spinal stability using the SINS by orthopedic surgeons and nonorthopedic oncology specialists. ICC and Fleiss's kappa were calculated for inter- and intraobserver agreement. A comparative analysis of SINS and the actual management was also conducted.\n\nRESULTS: Interobserver ICC reliability for the SINS was 0.79; \u03ba values for location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement were 0.81, 0.58, 0.21, 0.45, 0.42, and 0.29 respectively. Intraobserver ICC for the SINS scores was 0.96; ICC values for the same components were 0.98, 0.98, 0.87, 0.88, 0.92, and 0.86, respectively. Potentially unstable lesions (SINS score\u22657) were operated on in 62.5%.\n\nCONCLUSIONS: SINS seem to be a reproducible tool that could be used equally by multiple specialists to estimate metastatic vertebral stability; however, prospective clinical validation is still pending.", "author" : [ { "dropping-particle" : "", "family" : "Campos", "given" : "Mauricio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Urrutia", "given" : "Julio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zamora", "given" : "Tom\u00e1s", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rom\u00e1n", "given" : "Javier", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Canessa", "given" : "Valentina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Borghero", "given" : "Yerko", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Palma", "given" : "Alejandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Molina", "given" : "Marcelo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The spine journal : official journal of the North American Spine Society", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "2014", "8", "1" ] ] }, "page" : "1466-9", "title" : "The Spine Instability Neoplastic Score: an independent reliability and\u00a0reproducibility analysis.", "type" : "article-journal", "volume" : "14" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=017d00c3-32ef-452d-b531-31aedc498eb7" ] } ], "mendeley" : { "formattedCitation" : "10", "plainTextFormattedCitation" : "10", "previouslyFormattedCitation" : "10" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }10 and the intrinsic characteristics of some types of tumor make it impossible to achieve high levels of agreement in clinical decisions.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0368-2811", "PMID" : "10089946", "abstract" : "BACKGROUND: The pathology section of the Japan National Surgical Adjuvant Study of Breast Cancer protocol study was set up to establish histological criteria for assessing high-risk node-negative breast cancers and standardize the subjective criteria used by collaborating pathologists for nuclear grading of cancers. METHODS: In order to standardize the nuclear atypia criteria, five slide conferences were held. A total of 57 observers assigned nuclear atypia scores to 119 breast carcinomas that were presented using a slide projector or a TV monitor and discussed their histological findings. The percentage interobserver agreements per tumor and per conference and kappa value per conference were estimated and compared among the conferences. The percentage intraobserver reproducibility per tumor between the last two conferences was compared with the percentage interobserver agreement for 20 tumors. The kappa value was also calculated for each of 27 observers to evaluate scoring reproducibility. RESULTS: The percentage interobserver agreement per conference was constant (75-78%) throughout the five meetings and the rate of tumors with > 80% agreement per tumor became higher in later conferences. The kappa value was 0.42, 0.25, 0.42, 0.51 and 0.50 for the first, second, third, fourth and fifth conferences, respectively. The tumors with a lower percentage interobserver agreement also had a lower percentage intraobserver reproducibility and such scoring variations were attributed to the intermediate nature of the degree of tumor atypia. In 26 of 27 observers, intraobserver agreement for 20 tumors was estimated from the kappa value to range from moderate to almost perfect. CONCLUSION: We concluded that the repeated slide conferences conducted by the pathology section were an effective means of standardizing the subjective histopathological criteria used to assess tumors. However, the achievement of a good scoring agreement would be difficult for tumors with an intermediate degree of atypia.", "author" : [ { "dropping-particle" : "", "family" : "Tsuda", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Akiyama", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kurosumi", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sakamoto", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Watanabe", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Japanese journal of clinical oncology", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "1999", "3" ] ] }, "page" : "68-73", "publisher-place" : "H. Tsuda, Pathology Division, National Cancer Center Research Institute, Tokyo, Japan.", "title" : "The efficacy and limitations of repeated slide conferences for improving interobserver agreement when judging nuclear atypia of breast cancer. The Japan National Surgical Adjuvant Study of Breast Cancer (NSAS-BC) Pathology Section.", "type" : "article-journal", "volume" : "29" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=29ca2f72-2bed-4d1b-b119-e0da855e74c1" ] } ], "mendeley" : { "formattedCitation" : "30", "plainTextFormattedCitation" : "30", "previouslyFormattedCitation" : "30" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }30 Moreover, agreement when using a scoring system, does not necessarily mean that the recommended treatment is appropriate or that it will improve outcomes.
Nevertheless, even though improvement in the quality of care does not necessarily translate immediately into better clinical results,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1093/jnci/djs502", "ISSN" : "1460-2105", "PMID" : "23274388", "abstract" : "BACKGROUND: Despite the widespread use of tumor boards, few data on their effects on cancer care exist. We assessed whether the presence of a tumor board, either general or cancer specific, was associated with recommended cancer care, outcomes, or use in the Veterans Affairs (VA) health system.\n\nMETHODS: We surveyed 138 VA medical centers about the presence of tumor boards and linked cancer registry and administrative data to assess receipt of stage-specific recommended care, survival, or use for patients with colorectal, lung, prostate, hematologic, and breast cancers diagnosed in the period from 2001 to 2004 and followed through 2005. We used multivariable logistic regression to assess associations of tumor boards with the measures, adjusting for patient sociodemographic and clinical characteristics. All statistical tests were two-sided.\n\nRESULTS: Most facilities (75%) had at least one tumor board, and many had several cancer-specific tumor boards. Presence of a tumor board was associated with only seven of 27 measures assessed (all P < .05), and several associations were not in expected directions. Rates of some recommended care (eg, white blood cell growth factors with cyclophosphamide, adriamycin, vincristine, and prednisone in diffuse large B-cell lymphoma) were lower in centers with hematologic-specialized tumor boards (39.4%) than in centers with general tumor boards (61.3%) or no tumor boards (56.4%; P = .002). Only one of 27 measures was statistically significantly associated with tumor boards after applying a Bonferroni correction for multiple comparisons.\n\nCONCLUSIONS: We observed little association of multidisciplinary tumor boards with measures of use, quality, or survival. This may reflect no effect or an effect that varies by structural and functional components and participants' expertise.", "author" : [ { "dropping-particle" : "", "family" : "Keating", "given" : "Nancy L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Landrum", "given" : "Mary Beth", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lamont", "given" : "Elizabeth B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bozeman", "given" : "Samuel R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shulman", "given" : "Lawrence N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McNeil", "given" : "Barbara J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of the National Cancer Institute", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "1", "16" ] ] }, "page" : "113-21", "title" : "Tumor boards and the quality of cancer care.", "type" : "article-journal", "volume" : "105" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=49277b57-069f-404e-8939-51320178bc39" ] } ], "mendeley" : { "formattedCitation" : "31", "plainTextFormattedCitation" : "31", "previouslyFormattedCitation" : "31" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }31 good communication among the different specialists involved in the management of oncology patients leads to consistency of care, which is a prerequisite for effectiveness in oncology patients.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.healthpol.2014.09.006", "ISSN" : "1872-6054", "PMID" : "25271171", "abstract" : "Multidisciplinary teams (MDTs) are considered the gold standard of cancer care in many healthcare systems, but a clear definition of their format, scope of practice and operational criteria is still lacking. The aims of this review were to assess the impact of MDTs on patient outcomes in cancer care and identify their objectives, organisation and ability to engage patients in their care. We conducted a systematic review of the literature in the Medline database. Fifty-one peer-reviewed papers were selected from November 2005 to June 2012. MDTs resulted in better clinical and process outcomes for cancer patients, with evidence of improved survival among colorectal, head and neck, breast, oesophageal and lung cancer patients in the study period. Also, it was observed that MDTs have been associated with changes in clinical diagnostic and treatment decision-making with respect to urological, pancreatic, gastro-oesophageal, breast, melanoma, bladder, colorectal, prostate, head and neck and gynaecological cancer. Evidence is consistent in showing positive consequences for patients' management in multiple dimensions, which should encourage the development of structured multidisciplinary care, minimum standards and exchange of best practices.", "author" : [ { "dropping-particle" : "", "family" : "Prades", "given" : "Joan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Remue", "given" : "Eline", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hoof", "given" : "Elke", "non-dropping-particle" : "van", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Borras", "given" : "Josep M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Health policy (Amsterdam, Netherlands)", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014", "9", "18" ] ] }, "title" : "Is it worth reorganising cancer services on the basis of multidisciplinary teams (MDTs)? A systematic review of the objectives and organisation of MDTs and their impact on patient outcomes.", "type" : "article-journal", "volume" : "(in press)" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=e01aa946-a96c-4a79-82f5-9b89dd11193f" ] } ], "mendeley" : { "formattedCitation" : "32", "plainTextFormattedCitation" : "32", "previouslyFormattedCitation" : "32" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }32 Future studies should compare the reliability and prognostic validity of different scoring systems, such as the SINS and the Tainechi scores,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s00066-014-0651-z", "ISSN" : "1439-099X", "PMID" : "24687563", "abstract" : "PURPOSE: This retrospective analysis was performed to evaluate osteolytic bone lesions of breast cancer in the thoracic and lumbar spine after radiotherapy (RT) in terms of stability using a validated scoring system.\n\nMETHODS: The stability of 157 osteolytic metastases, treated from January 2000 to January 2012, in 115 patients with breast cancer was evaluated retrospectively using the Taneichi score. Predictive factors for stability were analyzed and survival rates were calculated.\n\nRESULTS: Eighty-five (54%) lesions were classified as unstable prior to RT. After 3 and 6 months, 109 (70%) and 124 (79%) lesions, respectively, were classified as stable. Thirty fractures were detected prior to RT, and after RT seven cases (4.5%) with pathologic fractures were found within 6 months. None of the examined predictive factors showed significant correlation with stability 6 months after RT. After a median follow-up of 16.7 months, Kaplan-Meier estimates revealed an overall survival of 83% after 5 years.\n\nCONCLUSION: The majority of patients showed an improved or unchanged stability of the involved vertebral bodies after 6 months. The patients showed only minor cancer-related morbidity during follow-up and reached comparably high survival rates.", "author" : [ { "dropping-particle" : "", "family" : "Schlampp", "given" : "Ingmar", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rieken", "given" : "Stefan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Habermehl", "given" : "Daniel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bruckner", "given" : "Thomas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "F\u00f6rster", "given" : "Robert", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Debus", "given" : "J\u00fcrgen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rief", "given" : "Harald", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Strahlentherapie und Onkologie : Organ der Deutschen R\u00f6ntgengesellschaft ... [et al]", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "2014", "9" ] ] }, "page" : "792-7", "title" : "Stability of spinal bone metastases in breast cancer after radiotherapy: a retrospective analysis of 157 cases.", "type" : "article-journal", "volume" : "190" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=cbcde9c3-637a-4ed2-88e6-499d43e98bb0" ] } ], "mendeley" : { "formattedCitation" : "33", "plainTextFormattedCitation" : "33", "previouslyFormattedCitation" : "33" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }33,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0362-2436", "PMID" : "9051884", "abstract" : "STUDY DESIGN: The associations between vertebral body collapse and the size or location of the metastatic lesions were analyzed statistically to estimate the critical point of collapse. OBJECTIVES: To determine risk factors for collapse, to estimate the predicted probability of collapse under various states of metastatic vertebral involvement, and to establish the criteria of impending collapse. SUMMARY OF BACKGROUND DATA: Pathologic vertebral collapse brings about severe pain and paralysis in patients with cancer. Prevention of collapse plays a significant role in maintaining or improving their quality of life. Because no previous study has clarified the critical point of vertebral collapse, however, the optimum timing for prophylactic treatment has been unclear. METHODS: The size and location of metastatic tumor from Th1 to L5 were evaluated radiologically for 100 thoracic and lumbar vertebrae with osteolytic lesions. The correlations between collapse and the following risk factors (x1-x4) were determined by means of a multivariate logistic regression model: x1, tumor size (the percentage of tumor occupancy in the vertebral body [% TO]); x2, pedicle destruction, x3, posterior element destruction; and x4, costovertebral joint destruction. RESULTS: Significant risk factors were costovertebral joint destruction (odds ratio, 10.17; P = 0.021) and tumor size (odds ratio of every 10% increment in %TO, 2.44; P = 0.032) in the thoracic region (Th1-Th10), whereas, tumor size (odds ratio of every 10% increment in %TO, 4.35; P = 0.002) and pedicle destruction (odds ratio, 297.08; P = 0.009) were main factors in the thoracolumbar and lumbar spine (Th10-L5). The criteria of impending collapse were: 50-60% involvement of the vertebral body with no destruction of other structures, or 25-30% involvement with costovertebral joint destruction in the thoracic spine; and 35-40% involvement of vertebral body, or 20-25% involvement with posterior elements destruction in thoracolumbar and lumbar spine. CONCLUSIONS: With respect to the timing and occurrence of vertebral collapse, there is a distinct discrepancy between the thoracic and thoracolumbar or lumbar spine. When a prophylactic treatment is required, the optimum timing and method of treatment should be selected according to the level and extent of the metastatic vertebral involvement.", "author" : [ { "dropping-particle" : "", "family" : "Taneichi", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kaneda", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Takeda", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Abumi", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Satoh", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Spine", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "1997", "3", "1" ] ] }, "page" : "239-45", "title" : "Risk factors and probability of vertebral body collapse in metastases of the thoracic and lumbar spine.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=6a7833c8-0875-4651-8fc4-58955d7d2c4f" ] } ], "mendeley" : { "formattedCitation" : "3", "plainTextFormattedCitation" : "3", "previouslyFormattedCitation" : "3" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }3 and assess whether their use, or measures to improve inter-observer agreement, actually lead to improved outcomes.
This study has some potential limitations. Readers only analyzed four selected images per case. Providing all the readers with all the images available for each patient might have changed the degree of agreement. However, this is the usual procedure for assessing reliability, since it ensures that all the readers analyze the same images.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1200/JCO.2010.34.3897", "ISSN" : "1527-7755", "PMID" : "21709187", "abstract" : "Standardized indications for treatment of tumor-related spinal instability are hampered by the lack of a valid and reliable classification system. The objective of this study was to determine the interobserver reliability, intraobserver reliability, and predictive validity of the Spinal Instability Neoplastic Score (SINS).", "author" : [ { "dropping-particle" : "", "family" : "Fourney", "given" : "Daryl R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frangou", "given" : "Evan M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ryken", "given" : "Timothy C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dipaola", "given" : "Christian P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shaffrey", "given" : "Christopher I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berven", "given" : "Sigurd H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bilsky", "given" : "Mark H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harrop", "given" : "James S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boriani", "given" : "Stefano", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chou", "given" : "Dean", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmidt", "given" : "Meic H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Polly", "given" : "David W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Biagini", "given" : "Roberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Burch", "given" : "Shane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dekutoski", "given" : "Mark B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ganju", "given" : "Aruna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gerszten", "given" : "Peter C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gokaslan", "given" : "Ziya L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Groff", "given" : "Michael W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Liebsch", "given" : "Norbert J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mendel", "given" : "Ehud", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Okuno", "given" : "Scott H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patel", "given" : "Shreyaskumar", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rhines", "given" : "Laurence D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rose", "given" : "Peter S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sciubba", "given" : "Daniel M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sundaresan", "given" : "Narayan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tomita", "given" : "Katsuro", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Varga", "given" : "Peter P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vialle", "given" : "Luiz R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vrionis", "given" : "Frank D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yamada", "given" : "Yoshiya", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fisher", "given" : "Charles G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical oncology : official journal of the American Society of Clinical Oncology", "id" : "ITEM-1", "issue" : "22", "issued" : { "date-parts" : [ [ "2011", "8", "1" ] ] }, "page" : "3072-7", "title" : "Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group.", "type" : "article-journal", "volume" : "29" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=269bce47-9409-4bc0-ba69-8879c75c1288" ] } ], "mendeley" : { "formattedCitation" : "8", "plainTextFormattedCitation" : "8", "previouslyFormattedCitation" : "8" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }8,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.radonc.2008.10.023", "ISSN" : "1879-0887", "PMID" : "19062118", "abstract" : "BACKGROUND AND PURPOSE: To investigate the inter-observer variation of target contouring when using the GYN GEC-ESTRO recommendations for MR image-guided brachytherapy (IGBT) for cervical cancer.\n\nMATERIALS AND METHODS: Nineteen cervical cancer patients, treated by radiotherapy at the Institut Gustave Roussy (IGR) in France (n=9) or at the Medical University of Vienna (AKH) in Austria (n=10) were included in this study. IGBT was used for all patients. Two radiation oncologists, one from IGR and the other from AKH, outlined the target volumes on MRI at the time of brachytherapy according to the GYN GEC-ESTRO recommendations. The absolute, common and encompassing volumes and their conformity indices (CIs) were assessed for the GTV, HR CTV and IR CTV. D90 and D100 for each volume were assessed. Visual evaluation was made to assess the reasons for the most frequent inter-observer differences.\n\nRESULTS: The mean volumes of GTV and HR CTV did not differ significantly between the observers, p>0.05. Significant differences were observed only for the mean volumes of the IR CTV of both centres, p<0.05. CIs ranged from 0.5 to 0.7. DVH-parameter analyses did not reveal any statistical differences, except for the D100 for the GTV at AKH, and the D90 for the IR CTV at IGR, p<0.05. Underlying reasons for inter-observer differences included image contrast adjustment and neglecting to consider anatomical borders.\n\nCONCLUSIONS: The results of this inter-observer study show that the application of the GYN GEC-ESTRO recommendations for IGBT contouring at two different institutions with two different traditions for applicators, CTV assessment, MR image acquisition and dose prescription is feasible, and it produces acceptable inter-observer variability.", "author" : [ { "dropping-particle" : "", "family" : "Dimopoulos", "given" : "Johannes C A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vos", "given" : "Veronique", "non-dropping-particle" : "De", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berger", "given" : "Daniel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Petric", "given" : "Primoz", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dumas", "given" : "Isabelle", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kirisits", "given" : "Christian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shenfield", "given" : "Carey B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Haie-Meder", "given" : "Christine", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "P\u00f6tter", "given" : "Richard", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2009", "5" ] ] }, "page" : "166-72", "title" : "Inter-observer comparison of target delineation for MRI-assisted cervical cancer brachytherapy: application of the GYN GEC-ESTRO recommendations.", "type" : "article-journal", "volume" : "91" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=1565b25b-8808-48f2-b51e-3199f75f3f43" ] } ], "mendeley" : { "formattedCitation" : "34", "plainTextFormattedCitation" : "34", "previouslyFormattedCitation" : "34" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }34 Agreement in every feature of the SINS was not analyzed, and some items have shown to lead to only poor to fair agreement,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1200/JCO.2010.34.3897", "ISSN" : "1527-7755", "PMID" : "21709187", "abstract" : "Standardized indications for treatment of tumor-related spinal instability are hampered by the lack of a valid and reliable classification system. The objective of this study was to determine the interobserver reliability, intraobserver reliability, and predictive validity of the Spinal Instability Neoplastic Score (SINS).", "author" : [ { "dropping-particle" : "", "family" : "Fourney", "given" : "Daryl R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Frangou", "given" : "Evan M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ryken", "given" : "Timothy C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dipaola", "given" : "Christian P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shaffrey", "given" : "Christopher I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berven", "given" : "Sigurd H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bilsky", "given" : "Mark H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harrop", "given" : "James S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boriani", "given" : "Stefano", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chou", "given" : "Dean", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schmidt", "given" : "Meic H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Polly", "given" : "David W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Biagini", "given" : "Roberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Burch", "given" : "Shane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dekutoski", "given" : "Mark B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ganju", "given" : "Aruna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gerszten", "given" : "Peter C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gokaslan", "given" : "Ziya L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Groff", "given" : "Michael W", 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"non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical oncology : official journal of the American Society of Clinical Oncology", "id" : "ITEM-1", "issue" : "22", "issued" : { "date-parts" : [ [ "2011", "8", "1" ] ] }, "page" : "3072-7", "title" : "Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group.", "type" : "article-journal", "volume" : "29" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=269bce47-9409-4bc0-ba69-8879c75c1288" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.spinee.2013.08.044", "ISSN" : "1878-1632", "PMID" : "24275615", "abstract" : "BACKGROUND: Metastatic vertebral instability has not yet been clearly defined in the literature; there still exists a paucity of reliable criteria to assess the risk of vertebral collapse.\n\nPURPOSE: We performed an independent interobserver and intraobserver agreement evaluation of the Spine Instability Neoplastic Score (SINS) and correlated the score with selected clinical cases and the treatment they received.\n\nSTUDY DESIGN: Independent reliability study for the newly created SINS.\n\nPATIENT SAMPLE: Thirty patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected from the orthopedic surgery and radiotherapy department's databases.\n\nOUTCOME MEASURES: Patients were rated and classified for spinal stability using SINS. Intraclass correlation coefficient (ICC) and Fleiss's kappa measures were occupied for reliability analysis.\n\nMETHODS: Patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected and classified for spinal stability using the SINS by orthopedic surgeons and nonorthopedic oncology specialists. ICC and Fleiss's kappa were calculated for inter- and intraobserver agreement. A comparative analysis of SINS and the actual management was also conducted.\n\nRESULTS: Interobserver ICC reliability for the SINS was 0.79; \u03ba values for location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement were 0.81, 0.58, 0.21, 0.45, 0.42, and 0.29 respectively. Intraobserver ICC for the SINS scores was 0.96; ICC values for the same components were 0.98, 0.98, 0.87, 0.88, 0.92, and 0.86, respectively. Potentially unstable lesions (SINS score\u22657) were operated on in 62.5%.\n\nCONCLUSIONS: SINS seem to be a reproducible tool that could be used equally by multiple specialists to estimate metastatic vertebral stability; however, prospective clinical validation is still pending.", "author" : [ { "dropping-particle" : "", "family" : "Campos", "given" : "Mauricio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Urrutia", "given" : "Julio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zamora", "given" : "Tom\u00e1s", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rom\u00e1n", "given" : "Javier", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Canessa", "given" : "Valentina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Borghero", "given" : "Yerko", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Palma", "given" : "Alejandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Molina", "given" : "Marcelo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The spine journal : official journal of the North American Spine Society", "id" : "ITEM-2", "issue" : "8", "issued" : { "date-parts" : [ [ "2014", "8", "1" ] ] }, "page" : "1466-9", "title" : "The Spine Instability Neoplastic Score: an independent reliability and\u00a0reproducibility analysis.", "type" : "article-journal", "volume" : "14" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=017d00c3-32ef-452d-b531-31aedc498eb7" ] }, { "id" : "ITEM-3", "itemData" : { "ISSN" : "1980-5322", "PMID" : "23525318", "abstract" : "OBJECTIVES: To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties.\n\nMETHODS: Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient.\n\nRESULTS: Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases.\n\nCONCLUSIONS: This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.", "author" : [ { "dropping-particle" : "", "family" : "Teixeira", "given" : "William Gemio Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Coutinho", "given" : "Pedro Ricardo de Mesquita", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marchese", "given" : "Luiz Delboni", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Narazaki", "given" : "Douglas Kenji", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cristante", "given" : "Alexandre Foga\u00e7a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Teixeira", "given" : "Manoel Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Barros Filho", "given" : "Tarc\u00edsio Eloy Pessoa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Camargo", "given" : "Olavo Pires", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinics (S\u00e3o Paulo, Brazil)", "id" : "ITEM-3", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "1" ] ] }, "page" : "213-8", "title" : "Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator.", "type" : "article-journal", "volume" : "68" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=61319ca4-3f56-4d6f-a2d3-289237a4707c" ] } ], "mendeley" : { "formattedCitation" : "8, 10, 18", "plainTextFormattedCitation" : "8, 10, 18", "previouslyFormattedCitation" : "8, 10, 18" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }8, 10, 18 while others, such as vertebral osteolysis and kyphotic deformity, predict the occurrence of compression fracture after radiotherapy better than the whole SINS score.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.14245/kjs.2014.11.3.103", "ISSN" : "1738-2262", "PMID" : "25346753", "abstract" : "OBJECTIVE: Stereotactic radiosurgery (SRS) is an emerging treatment modality for malignant spinal tumors. After SRS, some patients suffered from pain aggravation due to development of vertebral compression fracture (VCF). In these cases, surgery should be considered. METHODS: This study consisted of 72 patients who underwent SRS due to spinal tumors. In them, whether post-SRS VCF developed or not was investigated. We retrospectively analyzed their medical records and radiological imaging data. VCF was diagnosed with X-ray and magnetic resonance imaging (MRI). The incidence, time to development and risk factors for VCF were investigated. Age, sex, whole vertebral body involvement rate, vertebral body osteolysis rate, pre-SRS spinal deformity, spinal instability neoplastic score (SINS), spinal canal encroachment, lesion level, and radiation dose were analyzed as potential risk factors. A multi-variate logistic regression model was used for statistical analysis. RESULTS: In our study population, VCF was observed in 26 patients (36%). The mean time to VCF development was 1.5 months. Using uni-variate analyses, the significant risk factors were pre-SRS spinal deformity, SINS, vertebral body osteolysis rate, and whole vertebral body involvement rate. However, using multi-variate analyses, the only significant risk factor was vertebral body osteolysis rate. The patients whose vertebral body was destroyed by more than 60% showed an 8.4 times higher risk of VCF than those who had vertebral body destruction of less than 60%(p=0.016). CONCLUSION: The most significant prognostic factor for post-SRS VCF was vertebral body osteolysis rate, rather than whole vertebral body involvement rate. When more than 60% of the vertebral body was destroyed, the risk of VCF or spinal deformity was high.", "author" : [ { "dropping-particle" : "", "family" : "Sung", "given" : "Sang-Hyun", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chang", "given" : "Ung-Kyu", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Korean Journal of Spine", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2014", "9" ] ] }, "page" : "103-8", "title" : "Evaluation of risk factors for vertebral compression fracture after stereotactic radiosurgery in spinal tumor patients.", "type" : "article-journal", "volume" : "11" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=6548d6d6-1112-4aaa-a262-5a24b3b2b43e" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.ijrobp.2012.04.034", "ISSN" : "1879-355X", "PMID" : "22658511", "abstract" : "PURPOSE: Vertebral compression fractures (VCFs) are increasingly observed after spine stereotactic body radiation therapy (SBRT). The aim of this study was to determine the risk of VCF after spine SBRT and identify clinical and dosimetric factors predictive for VCF. The analysis incorporated the recently described Spinal Instability Neoplastic Score (SINS) criteria.\n\nMETHODS AND MATERIALS: The primary endpoint of this study was the development of a de novo VCF (ie, new endplate fracture or collapse deformity) or fracture progression based on an existing fracture at the site of treatment after SBRT. We retrospectively scored 167 spinal segments in 90 patients treated with spine SBRT according to each of the 6 SINS criteria. We also evaluated the presence of paraspinal extension, prior radiation, various dosimetric parameters including dose per fraction (\u226520 Gy vs <20 Gy), age, and histology.\n\nRESULTS: The median follow-up was 7.4 months. We identified 19 fractures (11%): 12 de novo fractures (63%) and 7 cases of fracture progression (37%). The mean time to fracture after SBRT was 3.3 months (range, 0.5-21.6 months). The 1-year fracture-free probability was 87.3%. Multivariate analysis confirmed that alignment (P=.0003), lytic lesions (P=.007), lung (P=.03) and hepatocellular (P<.0001) primary histologies, and dose per fraction of 20 Gy or greater (P=.004) were significant predictors of VCF.\n\nCONCLUSIONS: The presence of kyphotic/scoliotic deformity and the presence of lytic tumor were the only predictive factors of VCF based on the original 6 SINS criteria. We also report that patients with lung and hepatocellular tumors and treatment with SBRT of 20 Gy or greater in a single fraction are at a higher risk of VCF.", "author" : [ { "dropping-particle" : "", "family" : "Cunha", "given" : "Marcelo V R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Al-Omair", "given" : "Ameen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Atenafu", "given" : "Eshetu G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Masucci", "given" : "Giuseppina Laura", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Letourneau", "given" : "Daniel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Korol", "given" : "Renee", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yu", "given" : "Eugene", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Howard", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lochray", "given" : "Fiona", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Costa", "given" : "Leodante B", "non-dropping-particle" : "da", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sahgal", "given" : "Arjun", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "International journal of radiation oncology, biology, physics", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2012", "11", "1" ] ] }, "page" : "e343-9", "title" : "Vertebral compression fracture (VCF) after spine stereotactic body radiation therapy (SBRT): analysis of predictive factors.", "type" : "article-journal", "volume" : "84" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=946e3370-125c-4b02-98a4-e764e04281af" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1200/JCO.2013.50.1411", "ISSN" : "1527-7755", "PMID" : "23960179", "abstract" : "PURPOSE: Vertebral compression fracture (VCF) is increasingly recognized as an adverse event after spine stereotactic body radiotherapy (SBRT). We report a multi-institutional study aimed at clarifying the risk and predictive factors associated with VCF. PATIENTS AND METHODS: A total of 252 patients with 410 spinal segments treated with SBRT were included. The primary outcome was the development of VCF (a new VCF or progression of a baseline VCF). In addition to various patient-, treatment-, and tumor-specific factors, the Spinal Instability Neoplastic Scoring (SINS) system was applied to determine predictive value. RESULTS: The median follow-up was 11.5 months (range, 0.03 to 113 months). The median and mean overall survival rates were 16 and 26 months, respectively. We observed 57 fractures (57 of 410, 14%), with 47% (27 of 57) new fractures and 53% (30 of 57) fracture progression. The median time to VCF was 2.46 months (range, 0.03 to 43.01 months), and 65% occurred within the first 4 months. The 1- and 2-year cumulative incidences of fracture were 12.35% and 13.49%, respectively. Multivariable analysis identified dose per fraction (greatest risk for \u2265 24 Gy v 20 to 23 Gy v \u2264 19 Gy), in addition to three of the six original SINS criteria: baseline VCF, lytic tumor, and spinal deformity, as significant predictors of VCF. CONCLUSION: Caution must be observed when treating with \u2265 20 Gy/fraction, in particular, for patients with lytic tumor, spinal misalignment, and a baseline VCF. Frequent short-term follow-up is required, as nearly two thirds of all VCF occurred within the first 4 months. We also conclude that SINS may have utility in predicting patients at high risk of SBRT-induced VCF.", "author" : [ { "dropping-particle" : "", "family" : "Sahgal", "given" : "Arjun", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Atenafu", "given" : "Eshetu G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chao", "given" : "Sam", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Al-Omair", "given" : "Ameen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boehling", "given" : "Nicholas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Balagamwala", "given" : "Ehsan H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cunha", "given" : "Marcelo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Thibault", "given" : "Isabelle", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Angelov", "given" : "Lilyana", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brown", "given" : "Paul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Suh", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rhines", "given" : "Laurence D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fehlings", "given" : "Michael G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chang", "given" : "Eric", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical oncology : official journal of the American Society of Clinical Oncology", "id" : "ITEM-3", "issue" : "27", "issued" : { "date-parts" : [ [ "2013", "9", "20" ] ] }, "note" : "10.1200/JCO.2013.50.1411 ", "page" : "3426-31", "title" : "Vertebral compression fracture after spine stereotactic body radiotherapy: a multi-institutional analysis with a focus on radiation dose and the spinal instability neoplastic score.", "type" : "article-journal", "volume" : "31" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=7f40ba7f-9076-4697-b238-187b3bdf54d6" ] } ], "mendeley" : { "formattedCitation" : "35\u201337", "plainTextFormattedCitation" : "35\u201337", "previouslyFormattedCitation" : "35\u201337" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }3537 However, this study focused on the reliability of the global SINS score, which is the relevant feature for identifying patients eligible for surgery.
All patients underwent MRI and CT imaging. CT imaging is more accurate than radiography for depicting bone quality,ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1200/JCO.2004.08.181", "ISSN" : "0732-183X", "PMID" : "15254062", "abstract" : "Bone is the most common site to which breast cancer metastasizes. Imaging-by skeletal scintigraphy, plain radiography, computed tomography, or magnetic resonance imaging-is an essential part, and positron emission tomography or single-photon emission computed tomography have a potential of evaluating bone metastases, but no consensus exists as to the best modality for diagnosing the lesion and for assessing its response to treatment. Imaging bone metastases is problematic because the lesions can be osteolytic, osteoblastic, or mixed, and imaging modalities are based on either direct anatomic visualization of the bone or tumor or indirect measurements of bone or tumor metabolism. Although bone metastases can be treated, their response to treatment is considered \"unmeasurable\" according to existing response criteria. Therefore, the process by which oncologists and radiologists diagnose and monitor the response of bone metastases needs revision, and the current inability to assess the response of bone metastases excludes patients with breast cancer and bone disease from participating in clinical trials of new treatments for breast cancer. In this review of the MEDLINE literature, we discuss the pros and cons of each modality for diagnosing bone metastases and for assessing their response to treatment and we present a practical approach for diagnosis and assessment of bone metastasis.", "author" : [ { "dropping-particle" : "", "family" : "Hamaoka", "given" : "Tsuyoshi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Madewell", "given" : "John E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Podoloff", "given" : "Donald A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hortobagyi", "given" : "Gabriel N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ueno", "given" : "Naoto T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical oncology : official journal of the American Society of Clinical Oncology", "id" : "ITEM-1", "issue" : "14", "issued" : { "date-parts" : [ [ "2004", "7", "15" ] ] }, "page" : "2942-53", "title" : "Bone imaging in metastatic breast cancer.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=b3f98471-e82c-4296-9f16-157a6fbed41f" ] } ], "mendeley" : { "formattedCitation" : "38", "plainTextFormattedCitation" : "38", "previouslyFormattedCitation" : "38" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }38 and agreement in the SINS score might have been different if the latter had been used.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.spinee.2013.08.044", "ISSN" : "1878-1632", "PMID" : "24275615", "abstract" : "BACKGROUND: Metastatic vertebral instability has not yet been clearly defined in the literature; there still exists a paucity of reliable criteria to assess the risk of vertebral collapse.\n\nPURPOSE: We performed an independent interobserver and intraobserver agreement evaluation of the Spine Instability Neoplastic Score (SINS) and correlated the score with selected clinical cases and the treatment they received.\n\nSTUDY DESIGN: Independent reliability study for the newly created SINS.\n\nPATIENT SAMPLE: Thirty patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected from the orthopedic surgery and radiotherapy department's databases.\n\nOUTCOME MEASURES: Patients were rated and classified for spinal stability using SINS. Intraclass correlation coefficient (ICC) and Fleiss's kappa measures were occupied for reliability analysis.\n\nMETHODS: Patients who underwent either radiotherapy alone or surgery followed by radiotherapy were randomly selected and classified for spinal stability using the SINS by orthopedic surgeons and nonorthopedic oncology specialists. ICC and Fleiss's kappa were calculated for inter- and intraobserver agreement. A comparative analysis of SINS and the actual management was also conducted.\n\nRESULTS: Interobserver ICC reliability for the SINS was 0.79; \u03ba values for location, pain, bone quality, alignment, vertebral body collapse, and posterolateral involvement were 0.81, 0.58, 0.21, 0.45, 0.42, and 0.29 respectively. Intraobserver ICC for the SINS scores was 0.96; ICC values for the same components were 0.98, 0.98, 0.87, 0.88, 0.92, and 0.86, respectively. Potentially unstable lesions (SINS score\u22657) were operated on in 62.5%.\n\nCONCLUSIONS: SINS seem to be a reproducible tool that could be used equally by multiple specialists to estimate metastatic vertebral stability; however, prospective clinical validation is still pending.", "author" : [ { "dropping-particle" : "", "family" : "Campos", "given" : "Mauricio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Urrutia", "given" : "Julio", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zamora", "given" : "Tom\u00e1s", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rom\u00e1n", "given" : "Javier", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Canessa", "given" : "Valentina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Borghero", "given" : "Yerko", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Palma", "given" : "Alejandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Molina", "given" : "Marcelo", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The spine journal : official journal of the North American Spine Society", "id" : "ITEM-1", "issue" : "8", "issued" : { "date-parts" : [ [ "2014", "8", "1" ] ] }, "page" : "1466-9", "title" : "The Spine Instability Neoplastic Score: an independent reliability and\u00a0reproducibility analysis.", "type" : "article-journal", "volume" : "14" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=017d00c3-32ef-452d-b531-31aedc498eb7" ] }, { "id" : "ITEM-2", "itemData" : { "ISSN" : "1980-5322", "PMID" : "23525318", "abstract" : "OBJECTIVES: To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties.\n\nMETHODS: Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient.\n\nRESULTS: Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases.\n\nCONCLUSIONS: This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.", "author" : [ { "dropping-particle" : "", "family" : "Teixeira", "given" : "William Gemio Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Coutinho", "given" : "Pedro Ricardo de Mesquita", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marchese", "given" : "Luiz Delboni", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Narazaki", "given" : "Douglas Kenji", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cristante", "given" : "Alexandre Foga\u00e7a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Teixeira", "given" : "Manoel Jacobsen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Barros Filho", "given" : "Tarc\u00edsio Eloy Pessoa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "de", "family" : "Camargo", "given" : "Olavo Pires", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinics (S\u00e3o Paulo, Brazil)", "id" : "ITEM-2", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "1" ] ] }, "page" : "213-8", "title" : "Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator.", "type" : "article-journal", "volume" : "68" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=61319ca4-3f56-4d6f-a2d3-289237a4707c" ] } ], "mendeley" : { "formattedCitation" : "10, 18", "manualFormatting" : "10,19", "plainTextFormattedCitation" : "10, 18", "previouslyFormattedCitation" : "10, 18" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }10,19 However, CT imaging is routinely used to assess spine metastatic disease within the SNHS and most Western countries. Readers were volunteers from each of the invited Hospital Departments, and were not randomly selected. Therefore, selection bias may exist; it is possible that physicians who agreed to participate in this study were those who were the most motivated or interested in spine metastatic disease.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1200/JOP.2014.001515", "ISSN" : "1935-469X", "PMID" : "25316024", "abstract" : "PURPOSE: Although quality improvement (QI) is an integral part of cancer care, there are few QI publications in the medical oncology literature. We examined the prevailing attitudes of medical oncologists toward QI and causes for the low QI publication rate in the medical oncology literature. METHODS: Using a modified Dillman method, we distributed a 13-question online survey to medical oncologists across Canada asking about their attitudes toward and involvement in QI and perceived barriers to publishing QI studies. RESULTS: We attained a 43% response rate (143 of 332). Of the responding oncologists, 97% (138) agreed that QI was an important aspect of their practice, although only 49% (70) had participated in QI in the past 5 years. Physicians with administrative responsibility were more likely than clinicians to be involved in QI (P = .008). Most QI participants focused on domains of safety (70%) and patient centeredness (67%). Among QI participants, 72% did not publish their findings, because of lack of time (34%), no identifiable journals (14%), and unfamiliarity with QI methodology (10%). Barriers for QI nonparticipants included uncertainty about how to get involved (45%), lack of time (18%), and limited institutional support or recognition (18%). QI participants had greater awareness of recent practice-changing QI publications compared with nonparticipants (P = .003). CONCLUSION: Canadian medical oncologists face limitations to participating in and publishing QI initiatives because of lack of knowledge about ongoing initiatives, lack of time, and lack of resources to aid publication. Improving networking opportunities and prioritizing QI at the institutional level can address this need.", "author" : [ { "dropping-particle" : "", "family" : "Lim", "given" : "Charles", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cheung", "given" : "Matthew C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Franco", "given" : "Bryan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dharmakulaseelan", "given" : "Laavanya", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chong", "given" : "Evan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iyngarathasan", "given" : "Amesha", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Singh", "given" : "Simron", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of oncology practice / American Society of Clinical Oncology", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2014", "11", "14" ] ] }, "page" : "e408-14", "title" : "Quality improvement: an assessment of participation and attitudes of medical oncologists.", "type" : "article-journal", "volume" : "10" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=c9cc295b-a0f3-45a1-923d-c48483a83fea" ] } ], "mendeley" : { "formattedCitation" : "39", "plainTextFormattedCitation" : "39", "previouslyFormattedCitation" : "39" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }39 Should this be the case, agreement might be lower among other clinicians less familiar with spine metastatic disease, and it is impossible to completely rule out this possibility. Nevertheless, the number of participants was large, they came from different specialties and settings, and agreement was similar irrespective of the number of years of experience and across all types of hospitals.ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.2214/ajr.182.4.1820867", "ISSN" : "0361-803X", "PMID" : "15039154", "author" : [ { "dropping-particle" : "", "family" : "Obuchowski", "given" : "Nancy A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "AJR. American journal of roentgenology", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2004", "4" ] ] }, "page" : "867-9", "title" : "How many observers are needed in clinical studies of medical imaging?", "type" : "article-journal", "volume" : "182" }, "uris" : [ "http://www.mendeley.com/documents/?uuid=a2d05015-cb1a-4383-8178-163f1142cf38" ] } ], "mendeley" : { "formattedCitation" : "20", "plainTextFormattedCitation" : "20", "previouslyFormattedCitation" : "20" }, "properties" : { "noteIndex" : 0 }, "schema" : "https://github.com/citation-style-language/schema/raw/master/csl-citation.json" }20 All of the above suggests that results from this study are valid in routine clinical practice.
In conclusion, this study suggests that the agreement in the SINS score among radiologists, medical oncologists, radiation oncologists, orthopedic surgeons and neurosurgeons is moderate, and almost perfect when identifying the spine levels involved.
Figure legend
Appendix Fig. A1. An example of the information pack provided to readers for each patient.
Images corresponding to a 69 years old female, suffering from breast cancer, who reported continuous back pain without referred pain. She presented lung, liver and bone metastases. Please select the most unstable spine level and fill in the corresponding SINS scoring.
%C e r v i c a l %T h o r a c i c %L u m b a r % S a c r u m
S I N S _ _ _ _ _
R e f e r e n c e s
A D D I N M e n d e l e y B i b l i o g r a p h y C S L _ B I B L I O G R A P H Y 1 . C o l e m a n R E : C l i n i c a l f e a t u r e s o f m e t a s t a t i c b o n e d i s e a s e a n d r i s k o f s k e l e t a l m o r b i d i t y . C l i n C a n c e r R e s 1 2 : 6 2 4 3 s 6 2 4 9 s , 2 0 0 6
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39. Lim C, Cheung MC, Franco B, et al: Quality improvement: an assessment of participation and attitudes of medical oncologists. J Oncol Pract 10:e40814, 2014
Table 1. The SINS classification according to the Spine Oncology Study Group (SOSG).ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/BRS.0b013e3181e16ae2", "ISSN" : "1528-1159", "PMID" : "20562730", "abstract" : "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. 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LocationScore J u n c t i o n a l ( o c c i p u t - C 2 , C 7 - T 2 , T 1 1 - L 1 , L 5 - S 1 ) 3 M o b i l e s p i n e ( C 3 - C 6 , L 2 - L 4 ) 2 S e m i r i g i d ( T 3 - T 1 0 ) 1 R i g i d ( S 2 - S 5 ) 0 P a i n * Y e s 3 O c c a s i o n a l p a i n b u t n o t m e c h a n i c a l 1 P a i n - f r e e l e s i o n 0 B o n e l e s i o n L y t i c 2 M i x e d ( l y t i c / b l a s t i c ) 1 B l a s t i c 0 R a d i o g r a p h i c s p i n a l a l i g n m e n t S u b l u x a t i o n / t r a n s l a t i o n p r e s e n t 4 D e n o v o d e f o r m i t y ( k y p h o s i s / s c o l i o s i s ) 2 N o r m a l a l i g n m e n t 0 V e r t e b r a l b o d y c o l l a p s e > 5 0 % c o l l a p s e 3 <