A STAR Is Born: A New Tool in EBSJ 2021

The Spine Treatment Appraisal Report

In 2021, EBSJ will introduce a new evidence-based summary tool to assist spine surgeons in their clinical decision making, the Spine Treatment Appraisal Report (STAR). The purpose of the STAR is to provide a concise summary and critical appraisal of recent studies of interest in the spine surgery literature, evaluating their strengths and limitations. In doing so, it is the desire of the editorial staff to provide a clinical resource that provides important, relevant, and timely information to aid a busy spine surgeon.

How Will Articles Be Chosen for Review?

Each quarter, journals publishing spine surgery clinical research will be searched. A list of therapeutic articles (those assessing spine surgery interventions) will be reviewed by the editorial staff. Two or 3 articles deemed to be clinically important will be selected for appraisal in the STAR. Randomized controlled trials, observational studies, and systematic reviews of either study type will be considered for inclusion. The STAR will be prepared by a team with training in clinical epidemiology and research methodology.

What Will the STAR Look Like?

The STAR will include a summary of the article and the following sections:

• Evaluation of the study’s methodological quality

• Visual abstract

• The clinical importance of the study topic

• The study characteristics (study question(s), patient population, intervention, comparator, outcomes)

• Important study results

• The effect the findings may have on clinical care

Evaluation of the Study’s Methodological Quality

The methodological quality will be evaluated generally following the Cochrane risk of bias (RoB) tools for assessing individual studies, and the AMSTAR 2 for systematic reviews:

• The Cochrane risk of bias tool (RoB 2) for randomized trials

• The Cochrane Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) for observational studies

• A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) for systematic reviews

Primary domains assessed for risk of bias for different study types:

Randomized trials	Cohort studies	Systematic reviews
Randomization Deviations from intended intervention Missing outcome data Measurement of outcome Selection of reported results	Confounding Selection of study participants Classification of interventions Deviations from intended interventions Missing outcome data Measurement of outcomes Selection of the reported result	Protocol registered or review methods established before start of review Comprehensive literature search List of and justification for excluded studies Risk of bias from individual studies that were included in the review Appropriateness of meta-analytical methods Consideration of risk of bias when interpreting/discussing results of the review Assessment of presence and likely impact of publication bias

The study’s methodological quality will be rated good, fair, or poor.

Rating	Description and criteria
Good	Least risk of bias, results generally considered valid Clear descriptions of the population, setting, interventions, and comparison groups Valid method for allocation of participants to treatment Low dropout rates and clear reporting of dropouts Appropriate means for preventing bias Appropriate measurement of outcomes
Fair	Susceptible to some bias, though not enough to necessarily invalidate the results May not meet all the criteria for a rating of good quality, but no flaw is likely to cause major bias May be missing information, making it difficult to assess limitations and potential problems Category is broad, and studies with this rating will vary in their strengths and weaknesses Results of some fair-quality studies are likely to be valid, while others may be only possibly valid
Poor	Significant flaws that imply biases of various types that may invalidate results “Fatal flaws” in design, analysis, or reporting Large amounts of missing information Discrepancies in reporting Serious problems in the delivery of the intervention Results at least as likely to reflect flaws in the study design or execution as the true difference between the compared interventions

It is the expectation that the STAR will allow readers to quickly and efficiently digest new relevant spine surgery studies and determine where the results fit in terms of study quality, clinical importance, and the potential effect on clinical care.