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Evidence reviews for investigations – management
Evidence review G
NICE Guideline, No. 234
Investigations - management
Review question
How effective are radiological imaging techniques in guiding the management of spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
Introduction
Radiological imaging has an important role in the delineation of disease and assessment of spinal stability: crucial to management decisions for people with metastatic spinal disease. This review aimed to summarize evidence on the effectiveness of different imaging techniques in guiding the management of spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression.
Summary of the protocol
See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
For further details see the review protocol in appendix A.
Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document (supplementary document 1).
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
Effectiveness evidence
Included studies
A systematic review of the literature was conducted but no studies were identified which were applicable to this review question.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
A combined literature search was done for this review and evidence report [F]. See evidence report [F] investigations - diagnosis Appendix J for the list of excluded studies from this search.
Summary of included studies
No studies were identified which were applicable to this review question (and so there are no evidence tables in Appendix D). No meta-analysis was conducted for this review (and so there are no forest plots in Appendix E).
Summary of the evidence
No studies were identified which were applicable to this review question (and so there are no GRADE tables in Appendix F).
Economic evidence
Included studies
A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.
A single economic search was undertaken for all topics included in the scope of this guideline. See supplement 2 for details.
Excluded studies
Economic studies not included in this review are listed, and reasons for their exclusion are provided in supplement 2.
Economic model
No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.
The committee's discussion and interpretation of the evidence
The outcomes that matter most
Quality of clinical decision making and usefulness for decision making were critical outcomes. This was to capture the extent to which different types of radiological imaging help in making appropriate decisions about management. Overall survival, and neurological and functional status were chosen as critical outcomes, because better management decisions should lead to better patient outcomes. Quality of life and pain were important outcomes because good management decisions should improve these outcomes, even when overall survival or neurological status are unaffected.
Test related adverse events was an important outcome because any benefits of radiological imaging must be balanced with potential harms due to testing. Requirement for supplemental imaging was an important outcome because test results can be equivocal or identify features requiring a different type of radiological imaging, leading to delays and uncertainty. Finally, accuracy of spinal stability predictions was chosen as an important outcome because this is a key factor in management decision making and influences which treatment options are appropriate.
The quality of the evidence
No studies were identified which were applicable to this review question so the committee based their recommendations on their expertise and experience.
Benefits and harms
The committee discussed a related recommendation from the previous version of the guideline and agreed to retain it but recognised that a person may have already had a CT scan in a prior diagnostic work up so they recommended multiplanar viewing or 3-plane reconstruction of recent CT images to assess spinal stability and plan vertebroplasty, kyphoplasty or spinal surgery. They noted that a 3-dimensional image of position and size of the affected area of the spine should be considered to plan the surgical technique that is needed to help stabilise or decompress the spine (see evidence review N for information on invasive interventions). This is part of surgical planning and is current practice.
They acknowledged that this is also directly related to another recommendation on using scoring systems for spinal stability (see evidence report K) which would require radiological imaging to inform the stability score and that a targeted CT scan would be the most appropriate technique. Such scores would also feed into surgical decision making. The retained recommendation therefore facilitates this to be done, too.
Despite the lack of evidence, the committee did not make a research recommendation. They agreed that this is one of the less controversial areas in the management of malignant spinal disease and instead prioritised research elsewhere.
Cost effectiveness and resource use
The systematic review of previous economic evidence identified no studies for this topic. The committee, based on their knowledge and experience, retained the recommendations from the previous version of the guideline because 3-plane imaging is needed to fully visualise the surgical target area. Therefore, there will be no additional resource impact beyond that of the previous recommendations.
Recommendations supported by this evidence review
This evidence review supports recommendations 1.5.10 in the NICE guideline.
References – included studies
Effectiveness
A systematic review of the literature was conducted but no studies were identified which were applicable to this review question.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Appendices
Appendix A. Review protocol
Appendix B. Search strategy (clinical/economic)
Appendix C. Effectiveness evidence study selection
Appendix D. Evidence tables
Evidence tables for review question: How effective are radiological imaging techniques in guiding the management of spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
No evidence was identified which was applicable to this review question.
Appendix E. Forest plots
Forest plots for review question: How effective are radiological imaging techniques in guiding the management of spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
No meta-analysis was conducted for this review question and so there are no forest plots.
Appendix F. Modified GRADE tables
GRADE tables for review question: How effective are radiological imaging techniques in guiding the management of spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
No evidence was identified which was applicable to this review question.
Appendix G. Economic evidence study selection
Study selection for: How effective are radiological imaging techniques in guiding the management of spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
No economic evidence was identified which was applicable to this review question.
Appendix H. Economic evidence tables
Economic evidence tables for review question: How effective are radiological imaging techniques in guiding the management of spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
No evidence was identified which was applicable to this review question.
Appendix I. Economic model
Economic model for review question: How effective are radiological imaging techniques in guiding the management of spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
No economic analysis was conducted for this review question.
Appendix J. Excluded studies
Excluded studies for review question: How effective are radiological imaging techniques in guiding the management of spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
Excluded effectiveness studies
A combined literature search was done for this review and evidence report [F]. See evidence report [F] Investigations - diagnosis Appendix J for the list of excluded studies from this search.
Excluded economic studies
No economic evidence was identified for this review. See supplement 2 for further information.
Appendix K. Research recommendations – full details
Research recommendations for review question: How effective are radiological imaging techniques in guiding the management of spinal metastases, direct malignant infiltration of the spine or associated spinal cord compression?
No research recommendations were made for this review question.
Final version
Evidence reviews underpinning recommendation 1.5.10 in the NICE guideline
These evidence reviews were developed by NICE
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
- Review Evidence reviews for investigations – diagnosis: Spinal metastases and metastatic spinal cord compression: Evidence review F[ 2023]Review Evidence reviews for investigations – diagnosis: Spinal metastases and metastatic spinal cord compression: Evidence review F. 2023 Sep
- Review A systematic review of evidence on malignant spinal metastases: natural history and technologies for identifying patients at high risk of vertebral fracture and spinal cord compression.[Health Technol Assess. 2013]Review A systematic review of evidence on malignant spinal metastases: natural history and technologies for identifying patients at high risk of vertebral fracture and spinal cord compression.Sutcliffe P, Connock M, Shyangdan D, Court R, Kandala NB, Clarke A. Health Technol Assess. 2013 Sep; 17(42):1-274.
- CyberKnife stereotactic radiotherapy for spinal tumors: value of computed tomographic myelography in spinal cord delineation.[Neurosurgery. 2009]CyberKnife stereotactic radiotherapy for spinal tumors: value of computed tomographic myelography in spinal cord delineation.Thariat J, Castelli J, Chanalet S, Marcie S, Mammar H, Bondiau PY. Neurosurgery. 2009 Feb; 64(2 Suppl):A60-6.
- Spinal computed tomography and computed tomographic metrizamide myelography in the early diagnosis of metastatic disease.[J Clin Oncol. 1986]Spinal computed tomography and computed tomographic metrizamide myelography in the early diagnosis of metastatic disease.O'Rourke T, George CB, Redmond J 3rd, Davidson H, Cornett P, Fill WL, Spring DB, Sobel D, Dabe IB, Karl RD Jr. J Clin Oncol. 1986 Apr; 4(4):576-83.
- Spinal cord compression due to metastatic disease: diagnosis with MR imaging versus myelography.[Radiology. 1989]Spinal cord compression due to metastatic disease: diagnosis with MR imaging versus myelography.Carmody RF, Yang PJ, Seeley GW, Seeger JF, Unger EC, Johnson JE. Radiology. 1989 Oct; 173(1):225-9.
- Evidence reviews for investigations – managementEvidence reviews for investigations – management
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