Table 1.

Summary Recommendations From Focus Issues in Spine Oncology for Primary Bone Tumors.

Focus Issue in Spine Oncology	Question	Recommendations	Strength of Recommendationa (Strong/Weak)	Quality of the Evidence (High/Moderate/Low/Very Low)
Benign primary bone tumor
Aggressive “benign” primary spine neoplasms: osteoblastoma, aneurysmal bone cyst, and giant cell tumor11 (2009)	What is the optimal treatment for osteoblastomas, ABC, and GCT?	(1) For aggressive osteoblastoma, we recommend en bloc resection when anatomically feasible. (2) For ABC, we recommend intralesional gross total resection because local recurrence is influenced by the completeness of resection. (3) For GCT, when feasible and based on predicted surgical morbidity (not sacrificing sacral neural function), en bloc resection is recommended.	Strong Strong Strong	Very low Very low Very low
Benign tumors of the spine: has new chemotherapy and interventional radiology changed the treatment paradigm18 (2016)	(1) What is the role of denosumab in the treatment of GCT? (2) What is the role of selective arterial embolization (SAE) in the treatment of ABC? (3) What is the role of thermal ablation in the treatment of spinal OO?	Denosumab is indicated for the treatment of inoperable GCT and as neoadjuvant therapy. SAE might be considered in the treatment of ABC. Percutaneous thermal ablation is indication for selected OO. Absence of intact cortex and close vicinity < 5 mm to neural element warrant precautions.	Strong Weak Strong	Very low Very low Very low
Malignant primary bone tumor
Feasibility and Safety of en bloc resection for primary spine tumors: a systematic review by the Spine Oncology Study Group5 (2009)	(1) What is the effect of incisional biopsy performed before definitive en bloc resection? 2) Should Enneking principles of en bloc resection of primary tumors be applied to the spine?	When there is a suspicion of primary spine tumor, the surgeon who performs the definitive surgery should ideally perform or direct the biopsy procedure. En bloc resection of primary spine tumors with disease-free margins is achievable if proper oncologic and surgical staging determines that it is feasible. These surgeries should be performed by experienced, multidisciplinary teams.	Strong Strong	Low Low
Challenges of local recurrence and cure in low grade malignant tumors of the spine37 (2009)	(1) What is the optimal surgical management for chordoma and chondrosarcoma? (2) What is the role of radiation as an adjuvant treatment, for chordoma and chondrosarcomas?	En bloc resection with wide or marginal margins (en bloc) is the optimal surgical treatment. Radiation therapy of at least 60 to 65 Gy equivalents is indicated as an adjuvant treatment when there has been incomplete resection or an intralesional margin.	Strong Weak	Moderate Low
Ewing and osteogenic sarcoma: evidence for multidisciplinary management60 (2009)	(1) What is the role of chemotherapy in the management for Ewing and osteogenic sarcoma of the spine? (2) Does the extent of surgical resection affect local control and long-term survival for Ewing and osteogenic sarcoma of the spine?	Neoadjuvant chemotherapy is recommended for management of both Ewing and osteogenic sarcoma. (A) En bloc surgical resection for Ewing sarcoma of the spine is recommended it provides improved local control, but not improved overall survival. (B) En bloc surgical resection for osteogenic sarcoma of the spine is recommended as it provides improved local control and potentially improved overall survival.	Strong Weak Strong	Moderate Very low Very low
Safety and local control of radiation therapy for chordoma of the spine and sacrum: a systematic review61 (2016)	What are the toxicity and local control rates for adjuvant postoperative radiotherapy for spinal and sacral chordoma?	The use of adjuvant high-dose conformal radiotherapy should be used for patients undergoing surgery for the treatment of de novo chordoma when surgical margins are concerning and all recurrent chordoma in the mobile spine and sacrum.	Strong	Low
HRQOL
Optimizing the adverse event and HRQOL profiles in the management of primary spine tumors53 (2016)	Considering the significant morbidity and potential loss of function primary spinal tumor surgery may ensue, does it result in acceptable quality of life for patients?	We recommend primary spinal tumor surgery be performed with a curative intent whenever possible, even at the expense of greater initial morbidity to optimize long-term HRQOL.	Strong	Very low

Abbreviations: ABC, aneurysmal bone cyst; GCT, giant cell tumor; OO, osteoid osteoma.

^a A strong recommendation allows clinicians to confidently apply an intervention “to all or almost all the patients in all or almost all the circumstances without thorough review of the underlying evidence and without a detailed discussion with the patient.”⁶² A consensus weak recommendation is an endorsement of the intervention, but the magnitude is less and circumstances altered compared with a strong recommendation.