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Karnofsky Performance Index

Karnofsky performance index is used to classify cancer patients as far as functional deficits are concerned.

The index is useful for compare therapies and prognosis.


Able to carry on normal activity and to work; no special care needed
Normal, no complaints; no evidence of disease
Able to carry out normal activities; mild signs/symptoms of disease
Normal activities with effort; some signs/symptoms of disease
Unable to work; able to live at home and care for personal needs; different amount of assistance needed
Care for self; unable to carry on normal activity or to do active work
Require occasional assistance but is able to care for his personal needs
Require considerable assistance and frequent medical care
Unable to care for itself; require equivalent of hospital care; disease may be rapid in progression
Disabled: require special care and assistance
Severy disabled: hospital care is indicated. Death not imminent
Very sick: hospital care necessary. Active supportive treatment necessary



Enneking Classification

Enneking classification is used for staging vertebral tumors. It indicates prognosis and suggests the type of surgical treatment.


Biology of the lesion
Biology sub-type
Compartmental confinement
  Benign Latent G0 T0 M0 Intracapsular excision
Benign Lesions Benign Active G0 T0 M0 Extracapsular excision
  Benign Aggressive G0 T1/2 M0/1 Wide marginal excision +/- adjuvant
  IA (Low grade) G1 T0 M0 Wide marginal excision & limb salvage
  IB G1 T1 M0 Radical amputation vs limb salvage
Malignant Lesions IIA (High grade) G2 T1 M0 Radical amputation or wide marginal excision + adjuvant
  IIB G2 T2 M0 As IIA treatment 
  III (Metastatic) G1/2 T0/1/2 M1 Aggressive resection + adjuvant or palliative

McCormick Classification

McCormick classification is used for the clinical or pre-op evaluation in patients suffering for intramedullary spinal tumors.


1 Neurologically normal. Mild focal deficit, mild spasticity or reflex abnormality. Normal gait.
2 Sensorimotor deficit of the involved limb. Mild/moderate gait disturbance. Severe pain or dysesthetic syndrome. Ambulates independently 
3 More severe neurological deficits. Require cane/brace for ambulation or significant bilateral upper extremity impairment. May not be functional independent.
4 Severe deficit. Require wheelchair or cane/brace with bilateral upper extremity impairment. Not independent.

SINS Score

SINS score is used to assess if a patient with spinal primary cancer/metastasis is amenable to surgery.


Junctional (Occiput-C2, C7-T2, T11-L1, L5-S1) 3
Mobile Spine (C3-C6, L2-L4) 2
Semi-rigid (T3-T10) 1
Rigid (S2-S5) 0

Pain relief with recumbency and/or

Pain with movement-loading of the spine

Yes 3
No (occasional) 1
Pain free lesion 0
Bone lesion  
Lytic 2
Mixed (lytic/blastic) 1
Blastic 0
Radiographic spinal alignment  
Subluxation/translation 4
De novo deformity (scoliosis, kyphosis) 2
Normal alignment 0
Vertebral body collapse  
>50% 3
<50% 2
No collapse with >50% body involvement 1
None of the above 0
Posterolateral involvement of the spinal elements  
Bilateral 3
Unilateral 1
None of the above 0


0-6 Stability
7-12 Indeterminate stability 
13-18 Instability (surgical consultation needed)


Note that in the case of multiple spine lesions, stability scores are not summed. 

Tokuhashi score

Tokuhashi score is used to assess prognosis in patients suffering for metastatic spinal tumor.


General Condition (Performance Status)  
Poor (10%-40%) 0
Moderate (50%-70%) 1
Good (80%-100%) 2
Number of extra spinal bone metastasis foci  
>3 0
1-2 1
0 2
Number of metastases in the vertebral bodies  
>3 0
1-2 1
0 2
Metastases to the major internal organs  
Unremovable 0
Removable 1
No metastases 2
Primary site of the cancer  
Lung, osteosarcoma, stomach, bladder, esophagus, pancreas 0
Liver, gallbladder, unidentified 1
Others 2
Kidney, uterus 3
Rectum 4
Thyroid, breast, prostate, carcinoid tumor 5
Complete (Frankel A,B) 0
Incomplete (Frankel C,D) 1
None (Frankel E) 2


Total Score
0-8 <6 months
9-11 >6 months
12-15 >1 year

Tomita Score

Tomita score evaluates three prognostic features (malignancy, visceral metastases, osseus metastases) for the assessment of surgical treatment in case of spinal metastases.


Grade of malignancy  
Slow growth 1
Moderate growth 2
Rapid growth 4
Visceral metastases  
No metastases 0
Treatable 2
Untreatable 4
Bone metastases  
Solitary or isolated 1
Multiple 2


Total Score
Treatment goal
Surgical strategy
2-3 Long-term local control Wide or marginal excision
4-5 Middle-term local control Marginal or intralesional excision
6-7 Short-term palliation Palliative surgery
8-10 Terminal care Supportive care




Simpson Grade

SIMPSON classification is used to correlate the degree of surgical resection of meningiomas with 10 years recurrence risk.

Note that best strategy for the follow up in case of WHO I meningiomas with Simpson grades II or III is the implementation with MIB-1 marker.


Tumor resection
% Recurrence rate

Macroscopically complete removal of tumor;

Excision of its dural attachment and abnormal bone;

Include resection of venous sinus is involved.


Macroscopically complete removal of tumor and its visible extension;

Coagulation of its dural attachments



Macroscopically compete removal of the intradural tumor;

No resection/coagulation of its dural attachments or extradural parts

4 Partial removal leaving intradural tumor in situ 44
5 Simple decompression (with or without biopsy)  

Berger-Sanai Classification

Berger-Sanai classification is used to assess the position of a insular glioma with respect to foramina of Monro.


The foramina of Monro is at the junction of two lines:

Horizontal line - a bisection line along the Sylvian fissure (this line is horizontal in a sagittal plane);

Perpendicular line - a line perpendicular to the horizontal one, passing from the foramina of Monro.


These lines divides the area in four zones:

Zone I - anterior-superior

Zone II - posterior-superior

Zone III - posterior-inferior

Zone IV - anterior-inferior


Note that:

  • For tumor occupying more than one zone, all the zones have to be indicated;
  • A tumor occupying all the four zone is defined "giant".


CLASS score is used for the selection of patients suffering from meningiomas amenable to surgery

Note that CLASS is an acronym reminding that we must balance risks (comorbidity, location, age) and benefits (size, symptoms/signs) of surgery.


  -2 -1 0 1 2
Co-morbidity ASA3 ASA2 ASA1    
Location Complex Moderate Simple    
Age (years) >71 61-70 <60    
Size (cm)     <2 2.1-4 >4
Symptoms     Asymptomatic + ++
Others   Prior RT/Surgery   Radiographic progression  


Total Score Group
% Poor outcome (GOS 1-3) at 6 weeks
% Neurologic complications
% Medical complications
>1 1,8 7,3 1,8
0 or -1 3,9 15,6 6,5
<-2 16,2 24,3 10,8



Anatomical classification and surgical considerations: Primary spinal tumours. An overview. JH Davis MD. Sa Orthopaedic Journal Spring 2011, Vol 10, No 3.

Intramedullary ependymoma of the spinal cord. Paul C. McCormick, M.D.  Journal of Neurosurgery. 72:523-532, 1990

A Novel Classification System for Spinal Instability in Neoplastic Disease. Charles G. Fisher, MD. Spine, Volume 35, Number 22, pp E1221–E1229

Tokuhashi scoring system: a revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Tokuhashi Y. Spine 20015, 30 (19), 2186-2191.

Surgical Strategy for Spinal Metastases. Katsuro Tomita, MD, PhD. Spine, Volume 26, Number 3, pp 298 –306.

En-bloc resection of bone tumors of the thoracolumbar spine. Boriani S. MD, Spine, 1996, Volume 21, Number 16, 1927-1931.

The recurrence of intracranial meningiomas after surgical treatment. Simpson D. Journal Neurol. Neurosurg. Psychiat. 1957, 20, 22.

Insular glioma resection: assessment of patient morbidity, survival, and tumor progression. Nader SaNai, M.D. Journal of Neurosurgery 112:1–9, 2010

The novel “CLASS” algorithmic scale for patient selection in meningioma surgery. Joung H Lee Skull Base 2005; 15 - B-9-139




Giannantonio Spena, MD

Neurosurgeon Consultant
University of Brescia
"Spedali Civili" Hospital Brescia (Italy)
Scientific Team - UpSurgeOn


Giorgio Saraceno, MS

Medical Student
University of Brescia (Italy) 
Scientific Team UpSurgeOn