Introduction to Focus Issue in Spine Oncology The Synthesis of Evidence and Expert Opinion for Best Practice Recommendation

Study Design. Narrative review. Objectives. To outline and explain the organizational evidence-based medicine (EBM) technique used in the articles for this focus issue and discuss the suitability of spine oncology to this technique. Summary of Background Data. EBM is research-derived evidence and patient preferences, applied in the context of clinical experience and expertise. In the past, most clinical recommendations were based solely on the scientific evidence with little or no regard for clinical expertise and patient preference. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) technique is based on a sequential assessment of the quality of evidence, followed by weighing benefits against risks, leading to a subsequent treatment recommendation, either strong or weak. Weak is still an endorsement of treatment but not for all patients. Methods. A literature review was conducted using MEDLINE addressing EBM and grades of recommendations. The GRADE Methodology was then discussed among clinical experts in oncology and methodologists to determine appropriateness for this focus issue. Results. The strength of recommendations based on evidence quality and clinical expertise was performed by an international group of spine oncology experts and methodologists using the GRADE methodology. Specifically, a systematic review followed by a modified Delphi technique was carried out to answer 2 specific questions on a range of topics in primary and secondary spine oncology. The strength of the recommendation is given priority over the quality of the evidence, thus differentiating the judgments regarding the quality of evidence from assessment of the strength of recommendations. This is critical as many questions in oncology lack high quality evidence due to low prevalence of the disease or complex research design issues, but clinical direction is still required. Conclusion. Key opinion leaders using the GRADE System made treatment recommendations based on systematically reviewed evidence, blended with clinical expertise and patient preference on critical, controversial questions in spine oncology.