AO Spine Knowledge Forum Tumor
A global clinical research group advancing spine oncology care worldwide
Practical tools for clinicians treating patients with spinal tumors

Clinical recommendations and systematic literature reviews
Global Spine Journal
Precision Medicine in Spine Oncology
January 1, 2025 – Vol. 15 Issue 1_suppl
Spine
October 15, 2016—Vol. 41(20S)
Focus Issue 2 in Spine Oncology Evidence-based Medicine Recommendations for Spine Oncology
Key articles which combine top evidence and expert opinions and offer clinicians evidence-based treatment recommendations for primary spinal tumors and metastatic spine disease. They cover new technologies in surgery, medicine, and radiation, and the importance of personalized precision medicine.

Classification systems
SINS
The Spinal Instability Neoplastic Score (SINS) is a classification tool for assessing tumor-related spinal instability. This tool facilitates appropriate surgical referral of patients with metastatic spine disease.
AO Spine Spinal lnstability Neoplastic Score (SINS) Graphical Table
Spine
October 15, 2016—Vol. 41(20S)
Focus Issue 2 in Spine Oncology Evidence-based Medicine Recommendations for Spine Oncology

Patient-reported outcomes
SOSGOQ2.0
The first spine oncology-specific patient-reported outcome (PRO) tool SOSGOQ2.0 allows you to define how your patients are improving and serves to improve their quality of life.
Use the SOSGOQ2.0 in combination with a generic instrument.

Patient questionnaire
PEPSO
The patient expectations questionnaire regarding treatment outcomes in spinal oncology assists clinicians understand what patients anticipate regarding their treatment outcomes, such as pain relief and recovery, to improve patient satisfaction and care quality.
Educational offerings and resources for spine professionals interested in spinal oncology
AO Spine offers gold-standard courses and resources in the field of spine oncology for surgeons at different stages of their career. The AO’s publishing and knowledge sharing platforms will further help boost their impact and improve the care of spine oncology patients.
- The AO Surgery Reference Deformity modules on primary and metastatic tumors
- Upcoming AO Spine courses
- Guest Blog posts on spine tumors
- AO Videos (members access only)
Ongoing research projects
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* RELIEVE : Research on effectiveness of surgery and radiotherapy in relieving mechanical and radicular pain in patients with vertebral metastasis – a multicenter international prospective observational study
Principal Investigator:
Ilya Laufer
Co-Principal Investigator:
Ori Barzilai
Goals:
To assess the effectiveness of surgery and radiotherapy in relieving pain for patients with metastatic spine disease. The proportions of responders and non-responders based on pain relief from the worst baseline index pain (the worst of one kind or multiple kinds of pain, if the patient has experienced multiple kinds of index pain at baseline) after surgery and/or radiotherapy will be described.
The AO Spine Cancer-Related Pain Classification will be used to categorize neoplastic spinal pain by etiology.
Secondary objectives include factors predicting pain relief and the relationship between pain and other patient-reported outcomes.
ClinicalTrials.gov Identifier: NCT06746103
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AO Spine Cancer-related Pain Classification
Principal Investigators:
Ori Barzilai, Ilya Laufer
Goals:
To develop a core set of spine tumor pain descriptors and a mechanism-driven classification system for spine tumor pain assessment and focused pain experience measurement to guide treatment decisions.
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METASTRA Horizon Europe Collaboration Grant
Principal Investigators:
Consortium of 15 partners including AO Spine. Coordinated by ALMA MATER STUDIORUM - UNIVERSITA DI BOLOGNA
Goals:
To improve fracture prevention in patients with vertebral metastases by developing computational models that assess fracture risk. These models will be integrated into a Decision Support System (DSS) to help clinicians tailor treatments based on individual risk.
The project will also create new guidelines for patient stratification and treatment selection.
ClinicalTrials.gov Identifier: NCT06910618
Additional information:
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* MTRON: Metastatic Tumor Research and Outcomes Network—A Multicenter Prospective Registry for the Management and Outcomes of Metastatic Spine Tumors
A multicenter prospective registry for the management and outcomes of metastatic spine tumors
Principal Investigator:
Charles Fisher
Co-Principal Investigators:
Arjun Sahgal, Ilya Laufer
Goals:
To establish a network of spine oncology centers dedicated to prospective multicenter international research of patients diagnosed with metastatic tumors of the spine and will include a comprehensive prospective clinical database which will serve as a shared research platform.
The association of clinical, diagnostic, and therapeutic variables with patient reported outcomes, morbidity data, local tumor control, and survival will be investigated.
ClinicalTrials.gov Identifier: NCT02830451
Research Output:
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*/** PTRON: Primary Tumor Research and Outcomes Network—A Multicenter Prospective Registry for the Management and Outcomes of Primary Tumors of the Spine
Principal Investigator:
Jeremy Reynolds
Co-Principal Investigators:
Nicolas Dea, Laurence Rhines
Goals:
To establish a network of spine oncology centers dedicated to prospective multicenter international research of patients diagnosed with primary spinal column and cord tumors and will include a comprehensive prospective clinical database which will serve as a shared research platform.
The association of clinical, diagnostic, and therapeutic variables with survival, local recurrence, morbidity data, and patient reported outcomes will be investigated.
ClinicalTrials.gov Identifier: NCT02790983
Research Output:
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*/** EPOSO: Epidemiology, Process, and Outcomes of Spine Oncology
Principal investigator:
Charles Fisher
Co-Principal investigator:
Ziya Gokaslan
Goals:
To prospectively collect patient, diagnostic and treatment variables along with disease-specific and generic health related quality of life (HRQOL) data on consecutively treated patients with metastatic spine tumors.
ClinicalTrials.gov Identifier: NCT01825161
Remark:
This project received co-funding from the Orthopaedic Research & Education Foundation (OREF) through a Spine Prospective Clinical Research Grant
Research Output:
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AO Spine Neoplastic Fracture Score
Principal investigator:
Aron Lazary
Co-Principal investigator:
Nicolas Dea
Goals:
To develop a novel scoring system to guide surgical treatment of patients with spinal metastases.
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2022 AO Spine Discovery and Innovation Award—Can personalized blood biomarkers detect residual disease in surgically treated chordoma?
Principal investigator:
Stephen Yip
Co-Principal investigators:
Raphaële Charest-Morin, Chetan Bettegowda, Nicolas Dea, Rory C. Goodwin
Goals:
- Investigated the ability of personalized biomarkers to detect circulating tumor DNA (ctDNA) in postoperative blood specimens of chordoma patients who had detectable ctDNA before surgery.
- Determined if there is a correlation between surgical margins (wide/marginal vs. Intralesional) and the persistence of postoperative ctDNA in these patients.
Research Output:
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2022 AO Spine Discovery and Innovation Award—Externally Validating Thirteen Survival Models and Predicting Quality of Life in Metastatic Spine Disease
Principal investigator:
Joost Rutges
Co-Principal investigators:
Daniel Tobert, Joseph Schwab, Jorrit-Jan Verlaan, Harmen Kuijten
Goals:
- Externally validated 10 survival predication models for metastatic spine disease using data from a recent cohort of patients treated with surgery and/or radiotherapy between 2016 and 2021
- Predicted the quality of life (QOL) after treatment using data from prospectively collected QOL questionnaires
- Identified additional prognostic factors using the NOMS framework to improve survival and QOL predictions for new and updated models
- Assessed the optimal trade-off between gains in QOL and extending survival
Research Outputs:
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2024 AO Spine Knowledge Forum Associate Research Award—Exploring Peer-to-Peer Support in Spinal Surgery, Lived Experience from Two
Principal investigator:
Raphaële Charest-Morin
Co-Principal investigators:
Jeremy Reynolds, Gerard Mawhinney
Goals:
To explore lived experiences of people diagnosed with a primary bone tumor using a peer-to-peer support program (spinal Buddy Program (BP)).
The study aims to:
- Implement the BP at two different health centers (Oxford and Vancouver), including necessary training and documentation.
- Evaluate the BP’s impact on patient satisfaction and expectations before and after surgery using both quantitative and qualitative methods.
- Investigate cultural and institutional differences between the two centers.
* This AO Spine-sponsored study is executed with support from the AO Innovation Translation Center (AO ITC) Clinical Evidence.
** Award-winning project
Completed research projects
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SINS: Spinal Instability Neoplastic Score—Interdisciplinary Validity and Reliability of the Spinal Instability Neoplastic Score (SINS) in Radiologists and Radiation Oncologists
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** PT Retro: Predictors of Mortality and Morbidity in the Surgical Management of Primary Tumors of the Spine—A Multicenter Retrospective Cohort Study with A Cross-sectional Survival Check
Principal investigator:
Charles Fisher
Co-Principal investigators:
Ziya Gokaslan, Sigurd Berven, Mark Bilsky, Patrick Boland, Stefano Boriani, Dean Chou, Mark Dekutoski, Alexander Disch, Michael Fehlings, Nasir Quraishi, Alessandro Luzzati, Laurence Rhines, Peter Varga, Richard Williams
Goals:
Determined what variables (clinical, diagnostic, therapeutic, or demographic) are associated with local recurrence and survival within defined groups of primary malignant and benign bone and soft tissue spine tumors:
- Overall analysis—analysis of the complete collection (>1500 tumors)
- Histopathology type analysis—analysis of each tumor histopathology type (13 identified) were individually analysed by assigned project members
ClinicalTrials.gov Identifier: NCT01643174
Research Outputs:
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FFPE Chordoma (an extension of PT Retro): An Analysis of the Role of the Single Nucleotide Polymorphism rs2305089 in Retrospectively Collected Chordomas
Principal investigator:
Chetan Bettegowda
Co-Principal investigators:
Stephen Yip, Aron Lazary, Ziya Gokaslan, Charles Fisher, Peter Varga, Stefano Boriani, Marco Gambarotti, Laurence Rhines, Billy Wang, Alexander Lazar
Goals:
Aimed to determine the role that the SNP rs2305089 has in the prognosis of chordoma patients by evaluating whether there is a relationship between the status of the SNP and various clinical outcomes/measures (eg, survival, local recurrence, response to radiation therapy, response to chemotherapy, link to metastasis, demographics)
Research Outputs:
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TERT (an extension of PT Retro): An Analysis of the Role of the TERT Promoter Mutations in Retrospectively Collected Primary Spinal Column Tumors
Principal investigator:
Chetan Bettegowda
Co-Principal investigators:
Ziya Gokaslan, Stephen Yip, Aron Lazary, Charles Fisher, Peter Varga, Stefano Boriani, Marco Gambarotti, Laurence Rhines, Billy Wang, Alexander Lazar, Michael Fehlings, Gelareh Zadeh, Alessandro Luzzati, Mark Dekutoski, Michelle Clarke
Goals:
Determined the rates of TERT promoter mutation (mutation of the promoter of the telomerase gene [23348506,23348503]) and its prognostic significance in primary spinal column tumors, namely spinal chordomas
Research Outputs:
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Mets and PT Systematic Reviews: Systematic Reviews About the Outcomes of Surgical Treatment of Metastases to the Spine and Primary Tumors of the Spine
Principal investigator:
Charles Fisher
Co-Principal investigators:
Michelle Clarke, Daniel Sciubba, Daryl Fourney
Goals:
- Performed a systematic review of the literature for prognostic factors specific to:
- surgical treatment of prostate metastases to the spine
- surgical treatment of breast metastases to the spine
- surgical treatment of renal cell metastases to the spine
- surgical treatment of lung metastases to the spine
- symptomatic vertebral hemangioma
- Performed a systematic review of the literature for the management of malignant primary tumors of the spine
Research Outputs:
- Performed a systematic review of the literature for prognostic factors specific to:
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Focus Issue II in Spine Oncology—Evidence-based Medicine Recommendations for Spine Oncology
Principal investigator:
Charles Fisher
Goals:
Produced a spine oncology Focus Issue which synthesizes the best available evidence and expert opinion in the management of primary spinal column tumors and metastatic spine disease to provide clinicians with evidence-based treatment recommendations
Research Outputs:
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2019 AO Spine Discovery and Innovation Award—Stabilize or Not to Stabilize: Biomechanics-based Guidelines in Case of Indeterminate Spinal Instability Neoplastic Score (SINS)
Principal investigator:
Marco Palanca
Co-Principal investigators:
Luca Cristofolini
Goals:
Through biomechanical evaluation, they assist surgeons in better identifying cases needing spine stabilization in patients with spinal metastasis classified as "indeterminate" by the SINS
Specific aims included:
- Characterizing metastatic tissues and their interface with healthy vertebrae.
- Identifying the effects of metastatic lesions on spine stability to create clear guidelines for indeterminate SINS cases.
- Clarifying how metastasis size, location, and involvement of cortical and pedicular areas affect mechanical strength through biomechanical tests.
Research Outputs:
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2019 AO Spine Discovery and Innovation Award—Exploration and Clinical Application of New Indicators for Prognosis Evaluation of Solitary Plasmacytoma of Bone
Principal investigator:
Hanqiang Ouyang
Co-Principal investigators:
Liang Jiang, Shaomin Yang
Goals:
Using high-throughput sequencing technology, they conducted a genome-wide association analysis to study gene mutations related to early progression of solitary plasmacytoma of bone to multiple myeloma
Research Outputs:
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2019 AO Spine Discovery Innovation Award—Determining Efficacy and Toxicity of Magnetically Guided Nanoparticles for Intramedullary Spinal Cord Tumors (IMSCTs)
Principal investigator:
Ankit I. Mehta
Goals:
Aims to evaluate doxorubicin-loaded magnetic nanoparticles (MNP-DOX) for IMSCTs compared to systemic and intrathecal chemotherapy in an orthotopic xenograft tumor model
Research Outputs:
The project was unexpectedly discontinued
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SOSUS: Development of a Spine Oncology Specific Utility Score (SOSUS) for the SOSGOQ
Principal investigator:
Nicolas Dea
Co-Principal investigators:
Charles Fisher, Anne Versteeg, Arjun Sahgal, Markian Pahuta
Goals:
Developed a method to convert the Spine Oncology Study Group Outcomes Questionnaire v2.0 (SOSGOQ2.0) to utilities, enabling the calculating of quality-adjusted life years (QALYs) for economic analysis.
Research Outputs:
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RT in Chordoma: Effective Radiation Therapy Regimes for Spinal Chordoma
Principal investigator:
Nicolas Dea
Co-Principal investigators:
Jeremy Reynolds, John Shin, Charles Fisher
Goals:
Through an expert survey and systematic literature review, the variability in current treatment protocols for managing newly diagnosed chordoma of the mobile spine and sacrum were investigated.
Research Outputs:
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PEPSO: Patient Expectations and Perceptions in Spinal Oncology—Patient Expectations and Perceptions Regarding Treatment Decisions and Received Treatment for Symptomatic Spinal Metastases: A Qualitative Study
Principal investigator:
H.M. Verkooijen
Co-Principal investigators:
Anne Versteeg, Charles Fisher
Goals:
Obtained an in-depth understanding of patient expectations of outcomes related to surgical and/or radiotherapy treatments for spinal metastases and created a patients’ expectations questionnaire for clinical use in patients with spinal metastases
Research Outputs:
Questionnaire—Radiation Therapy
Additional Information:
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Optimal Care Pathway and Treatment Guideline for Primary Tumors of the Spine
Principal investigator:
Raphaële Charest-Morin
Co-Principal investigators:
Nicholas Dea, Arjun Sahgal, Ilya Laufer
Goals:
Aims to define the optimal care pathway for patients with primary spinal column tumors
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2022 AO Spine Knowledge Forum Associated Research Award—Effect of the Intervertebral Disc (IVD) Conditions on the Risk of Vertebral fracture in Metastatic Patients
Principal investigator:
Marco Palanca
Co-Principal investigators:
Luca Cristofolini, Enrico Dall’Ara
Goal:
The different failure pattern experienced by metastatic vertebrae with respect to the different disc degeneration levels were evaluated based on imaging and biomechanical testing
Research Outputs:
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MetsFrailty: An International Survey Regarding Frailty in Spinal Metastatic Disease
Principal investigator:
Michael Weber
Co-Principal investigators:
Miltiadis Georgiopoulos, Raphaële Charest-Morin, Rory C. Goodwin
Goal:
The perceptions, opinions, and practices of spine surgeons about frailty regarding spinal metastatic disease were assessed through an AO Spine-wide survey and what spine surgeons consider to be relevant preoperative factors and postoperative outcomes were identified.
Research Outputs:
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Precision Medicine in Spinal Oncology: An Overview from the AO Spine Knowledge Forum Tumor
Principal investigators:
Laurence Rhines, Arjun Sahgal
Goal:
Produced a spine oncology Focus Issue which highlights key tools and techniques, such as the Spinal Instability Neoplastic Score (SINS) and stereotactic body radiotherapy (SBRT), and emphasizes the importance of personalized medicine, molecular prognostication, and new technologies to optimize patient care.
Research Outputs:
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KF Tumor Needs Assessment
Principal investigators:
Ilya Laufer, Matthew Goodwin
Goals:
The practice patterns and knowledge gaps of AO members managing spine tumor patients were assessed to identify the questions and decisions AO members find challenging when caring for patients with spinal tumors. This evaluation also determined the effectiveness of knowledge translation for the instruments and recommendations already developed by the KF Tumor
Research Outputs:
* This AO Spine-sponsored study is executed with support from the AO Innovation Translation Center (AO ITC) Clinical Evidence.
** Award-winning project
AO Spine KF Tumor Steering Committee

Ilya Laufer
Chairperon
NYU Grossman School of Medicine
New York, NY, USA

Arjun Sahgal
Past Chairperson
Sunnybrook Health Sciences Center
Toronto, ON, Canada

Laurence Rhines
Past Chairperson
The University of Texas, MD Anderson Cancer Center
Houston, TX, USA

Nicolas Dea
University of British Columbia
Vancouver, BC, Canada

Alessandro Gasbarrini
IRCCS Istituto Ortopedico Rizzoli
Bologna, Italy

Jeremy Reynolds
Nuffield Orthopaedic Centre
Oxford, UK

Jorrit-Jan Verlaan
UMC Utrecht
Utrecht, The Netherlands

Cordula Netzer
Universitätsspital Basel
Basel, Switzerland

Ori Barzilai
Memorial Sloan-Kettering Cancer Center
New York, NY, USA
KF Tumor Advisory Board

Chetan Bettegowda
Johns Hopkins University School of Medicine
Baltimore, MD, USA

Stefano Boriani
IRCCS
Istituto Ortopedico Galeazzi
Milan, Italy
Co-Chairperson 2011–2014

Charles Fisher
University of British Columbia
Vancouver, BC, Canada
Chairperson 2014–2020

Ziya Gokaslan
The Warren Alpert Medical School of Brown University
Providence, RI, USA
Co-Chairperson/ Chairperson 2011–2014

Áron Lazáry
National Center for Spinal Disorders
Budapest, Hungary
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KF Tumor Associate Members
Adam Biczo, National Center for Spinal Disorders, Budapest, Hungary
Riccardo Cecchinato, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
Raphaële Charest-Morin, University of British Columbia, Vancouver, BC, Canada
Hanbo Chen, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
Dean Chou, Columbia University Irving Medical Center, New York, NY, USA
Michelle Clarke, Mayo Clinic, Department of Neurologic Surgery, Rochester, MN, USA
Brian Coimba, Universidad De Sao Paulo, Sao Paulo, Brazil
Marcin Czyz, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
Alexander Disch, Universitätsklinikum Cal Gustav Carus, Dresden, Germany
Wietse Eppinga, UMC Utrecht, Utrecht, the Netherlands
Gisberto Evangelisti, Istituto Ortopedico Rizzoli, Bologna, Italy
Michael Fehlings, University of Toronto, Toronto, ON, Canada
Michael Galgano, University of North Carolina, Department of Neurosurgery, Chapel Hill, NC, USA
Alvaro Silva Gonzalez, University of El Desarrollo, Santiago, Chile
Matthew Goodwin, Washington University, St. Louis, MO, USA
Rory Goodwin, Duke University, Durham, NC, USA Francis Hornicek, University of Miami, Miami, FL, USA
Francis Hornicek, University of Miami, Miami, FL, USA
Jeremy Kam, Monash Medical Centre, Melbourne, Victoria, Australia
Mohammed Karim, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
Naresh Kumar, National University Hospital, Singapore
Sheng-fu Larry Lo, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
Daniel Lubelski, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Alessandro Luzzati, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
Antonio Martin-Benlloch, Hospital Universitario Doctor Peset, Valencia, Spain
Ankit I. Mehta, University of Illinois at Chicago, Chicago, IL, USA
Addisu Mesfin, University of Rochester, Rochester, NY, USA
Jacques Müller-Broich, Orthopedic University Hospital Friedrichsheim, Frankfurt am Main, Germany
Tianyi Niu, Warren Alpert Medical School of Brown University, Providence, RI, USA
Christopher Newman, Memorial Sloan Kettering Cancer Center, New York, NY, USA
John O'Toole, Rush University Medical Center, Chicago, IL, USA
Markian Pahuta, Henry Ford Health System, Detroit, MI, USA
Shalin Patel, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
Shreyaskumar Patel, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
Kristin Redmond, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Joost Rutges, Erasmus MC, Rotterdam, the Netherlands
Markus Schultheiss, University of Ulm, Ulm, Germany
Joseph Schwab, Massachusetts General Hospital, Boston, MA, USA
Daniel Sciubba, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
John Shin, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Byron Stephens, Vanderbilt University, Nashville, TN, USA
Patricia Sullivan, Rhode Island Hospital/Brown University (part of Warren Alpert Medical School), Providence, RI, USA
Jonathan Tan, National University Hospital, Singapore, Singapore
Claudio E. Tatsui, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
Daniel Tobert, Massachusetts General Hospital, Boston, MA, USA
Peter Vajkoczy, Charite Universitätsmedizin, Berlin, Germany
Marie-Laure Vial, Project Manager
Michael Weber, McGill University, Montreal, QC, Canada
Feng Wei, Peking University Third Hospital, Beijing, China
Josh Yamada, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
Jonathan Yang, New York University School of Medecine, New York, NY, USA
Stephen Yip, University of British Columbia, Vancouver, BC Canada
Scott Zuckerman, Vanderbilt University Medical Center, Nashville, TN, USA
Other Knowledge Forums

“To truly advance care for spine oncology patients, we have developed an international network of spine oncology centers committed to collaborative prospective multicenter research.”
Charles Fisher, AO Spine Research Commission Chairperson