what is a literature review in ap research

AP ® Research Handbook

Chapter 2 literature review.

List resources for conducting literature review. Show example of literature review with inline citations. Show ways to keep track of sources for bibliography.

• contains example literature reviews from political science, philosophy, and chemistry.

Consider using a reference management system like Mendeley to organize your sources as you conduct your literature review. In fact, Mendeley has a Literature Search function, so you can manage sources and conduct literature reviews at the same time. See the Bibliography Management Section for more information on managing sources.

Databases for Literature Reviews

• Browse by subjects in the humanities and sciences. This can be your starting point if you have not developed a research topic.
• Open-access journal articles in fields such as mathematics, statistics, economics, physics, quantitative biology, quantiative finance, and electrical engineering
• arXiv to BibTex : Outputs automated citations in BibTeX and other formats by typing the arXiv number of the article. For instance, just type in 1905.03758 into the search engine if the article is labeled arXiv: 1905.03758.
• Alternatively, use Mendeley Web Importer to import article into Mendeley Desktop for automated citation outputs.
• Download Mendeley Desktop and register for a free account. Mendeley Desktop syncs with your online Mendeley account, but the literature search is currently only available in the desktop version.
• Mendeley is primarly a reference managements software, so you can organize your citations as you conduct your literature review.
• Search engine with the world’s largest collectin of open-access research papers.
• For batch searches of metadata and full texts, you may consider requesting a free API key to use the Core API .
• Search for content, authors, collections, and journals in the advanced search , where you have the option to search by discipline or key word.
• Search for articles in clincial sciences, biochemistry, public health, physical chemistry, and materials engineering.
• Search open-access journals and dissertations. Note that dissertations can vary in quality, since they have not gone through peer review.
• AP Research students should have access to a free EBSCO account from the AP Capstone program.
• Many of the social science articles are free access.
• Search for articles related to to education research.
• The search engine includes the open to search for full-text articles.
• Index of major computer science publications.
• Option to search for open-access articles.
• Search for journal articles, working papers, and conference papers in economics and business.
• You can sign up for a free MyJSTOR account to access up to six articles a month for free.
• This may be helpful for accessing articles that are not open access.

Tips for Accessing Paywalled Articles

• Search for the author’s website. Many researchers have draft manuscripts on their websites or research profiles on sites such as ResearchGate .
• Consult your school’s research librarian for other ways to access the article.
• Send the author an e-mail to request for a digital copy of the article. You should provide context in the e-mail request by including a brief description of your AP Research project and its relevance and connection to the author’s article.

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The Advanced Placement (AP) curriculum is administered by the College Board and serves as a standardized set of year-long high school classes that are roughly equivalent to one semester of college-level coursework. Although most students enroll in an actual course to prepare for their AP exams, many others will self-study for the exams without enrolling in the actual AP class.

AP classes are generally stand-alone subjects that easily translate to traditional college courses. Typically, they culminate in a standardized exam on which students are graded using a 5-point scale, which colleges and universities will use to determine credit or advanced standing. Starting in fall of 2014, though, this traditional AP course and exam format has begun to adapt in efforts by the College Board to reflect less stringent rote curriculum and a heavier emphasis on critical thinking skills.

The AP Capstone program is at the center of these changes, and its culmination course is AP Research. If you are interested in learning more about the AP Research Course and Assessment, and how they can prepare you for college-level work, read on for CollegeVine’s Ultimate Guide to the AP Research Course and Assessment.

About the Course and Assessment

The AP Research course is the second of two classes required for the AP Capstone™ Diploma . In order to enroll in this course you need to have completed the AP Seminar course during a previous year. Through that course, you will have learned to collect and analyze information with accuracy and precision, developed arguments based on facts, and effectively communicated your conclusions. During the AP Research course, you apply these skills on a larger platform. In the AP Research course, you can expect to learn and apply research methods and practices to address a real-world topic of your choosing, with the end result being the production and defense of a scholarly academic paper. Students who receive a score of 3 or higher on both the AP Seminar and AP Research courses earn an AP Seminar and Research Certificate™. Students who receive a score of 3 or higher on both courses and on four additional AP exams of their choosing receive the AP Capstone Diploma™.    

The AP Research course will guide you through the design, planning, and implementation of a year-long, research-based investigation to address a research question of interest to you. While working with an expert advisor, chosen by you with the help of your teacher, you will explore an academic topic, problem, or issue of your choosing and cultivate the skills and discipline necessary to conduct independent research and produce and defend a scholarly academic paper. Through explicit instruction in research methodology, ethical research practices, and documentation processes, you will develop a portfolio of scholarly work to frame your research paper and subsequent presentation of it.

Although the core content and skills remain standardized for every AP Research course, the implementation of this instruction may vary. Some AP Research courses may have a specific disciplinary focus wherein the course content is rooted in a specific subject, such as AP Research STEM Inquiries or AP Research Performing and Visual Arts. Similarly, other AP Research courses are offered in conjunction with a separate and specific AP class, such as AP Research and AP Biology wherein students are concurrently enrolled in both AP courses and content is presented in a cross-curricular approach. Alternatively, AP Research may be presented in the form of an internship wherein students who are already working with a discipline-specific expert adviser conduct independent studies and research of the student’s choosing while taking the AP Research class. Finally, some AP Research courses are delivered independently as a research methods class. In this style of class, students develop inquiry methods for the purpose of determining which method best fits their chosen topic of inquiry/research question, and each student then uses a selected method to complete his or her investigation.    

Only schools that currently offer the AP Capstone Diploma may offer the AP Research course. Because it is a part of a larger comprehensive, skills-based program, students may not self-study for the AP Research course or final paper. At this time, home-schooled students, home-school organizations, and online providers are not eligible to participate in AP Capstone.

Your performance in the AP Research course is assessed through two performance tasks. The first is the Academic Paper, which accounts for 75% of your total AP score. In this paper, you will present the findings of your yearlong research in 4,000-5,000 words. Although the official submission deadline for this task is April 30, the College Board strongly recommends that this portion of your assessment be completed by April 15 in order to allow enough time for the second of your performance tasks.

The second performance task is your Presentation and Oral Defense, which accounts for the remaining 25% of your total AP score. Using your research topic, your will prepare a 15-20 minute presentation in an appropriate format with appropriate accompanying media. Your defense will include fielding three to four questions from a panel consisting of your AP Research teacher and two additional panel members chosen at the discretion of your teacher.    

In 2016, fewer than 3,000 students submitted an AP Research project, but enrollment is projected to grow rapidly, since 12,000 students took the AP Seminar assessment in 2016 and most will presumably go on to submit an AP Research project in 2017. Scores from the 2016 AP Research projects reveal a high pass rate (score of three or higher) but a difficult rate of mastery. While 67.1% of students taking the assessments scored a three or higher, only 11.6% received the highest score of a five, while nearly 40% received a three. Only 2% of students submitting research projects received the lowest score of one.    

A full course description that can help to guide your planning and understanding of the knowledge required for the AP Research course and assessments can be found in the College Board course description .

Read on for tips for successfully completing the AP Research course.

How Should I Prepare for the AP Research Course?

As you undertake the AP Research course and performance tasks, you will be expected to conduct research, write a scholarly paper, and defend your work in a formal presentation.   Having already completed the AP Seminar course, these skills should be familiar to you. You should use your scores on the AP Seminar performance task to help guide your preparations for the AP Research performance tasks.

Carefully review your scores from AP Seminar. Make sure you understand where points were lost and why. It may be helpful to schedule a meeting with your AP Seminar teacher to review your work. Alternatively, your AP Research teacher may be willing to go over your AP Seminar projects with you. You might also ask a classmate to review your projects together to get a better idea of where points were earned and where points were lost. Use this review as a jumping point for your AP Research studies. You should go into the course with a good idea of where your strengths lie, and where you need to focus on improving.

A sample timeline for the AP Research course is available on page 36 of the course description . One detail worth noting is that the recommended timeline actually begins not in September with the start of the new school year, but instead begins in May with the completion of the AP Seminar course during the previous school year. It is then that you should begin to consider research topics, problems, or ideas. By September of the following school year, it is recommended that you have already finalized a research question and proposal, completed an annotated bibliography, and prepared to begin a preliminary inquiry proposal for peer review.    

What Content Will I Be Held Accountable For During the AP Research Course?

To be successful in the AP Research class, you will begin with learning to investigate relevant topics, compose insightful problem statements, and develop compelling research questions, with consideration of scope, to extend your thinking.   Your teacher will expect you to demonstrate perseverance through setting goals, managing time, and working independently on a long-term project. Specifically, you will prepare for your research project by:

• Identifying, applying, and implementing appropriate methods for research and data collection
• Accessing information using effective strategies
• Evaluating the relevance and credibility of information from sources and data
• Reading a bibliography for the purpose of understanding that it is a source for other research and for determining context, credibility, and scope
• Attributing knowledge and ideas accurately and ethically, using an appropriate citation style
• Evaluating strengths and weaknesses of others’ inquiries and studies

As in the AP Research course, you will continue to investigate real-world issues from multiple perspectives, gathering and analyzing information from various sources in order to develop credible and valid evidence- based arguments. You will accomplish this through instruction in the AP Research Big Ideas, also called the QUEST Framework. These include:

• Question and Explore: Questioning begins with an initial exploration of complex topics or issues. Perspectives and questions emerge that spark one’s curiosity, leading to an investigation that challenges and expands the boundaries of one’s current knowledge.
• Understand and Analyze Arguments: Understanding various perspectives requires contextualizing arguments and evaluating the authors’ claims and lines of reasoning.
• Evaluate Multiple Perspectives: Evaluating an issue involves considering and evaluating multiple perspectives, both individually and in comparison to one another.
• Synthesize Ideas: Synthesizing others’ ideas with one’s own may lead to new understandings and is the foundation of a well-reasoned argument that conveys one’s perspective.
• Team, Transform, and Transmit: Teaming allows one to combine personal strengths and talents with those of others to reach a common goal. Transformation and growth occur upon thoughtful reflection. Transmitting requires the adaptation of one’s message based on audience and context.

In addition, you will use four distinct reasoning processes as you approach your research. The reasoning processes are situating, choosing, defending , and connecting . When you situate ideas, you are aware of their context in your own perspective and the perspective of others, ensuring that biases do not lead to false assumptions. When you make choices about ideas and themes, you recognize that these choices will have both intended and unintentional consequences. As you defend your choices, you explain and justify them using a logical line of reasoning. Finally, when you connect ideas you see intersections within and/or across concepts, disciplines, and cultures.

For a glossary of research terms that you should become familiar with, see page 62 of the course description .

How Will I Know If I’m Doing Well in the AP Research Course?

Because your entire score for the AP Research course is determined by your research paper and presentation, which come at the very end of the course, it can be difficult to gauge your success until that point. Do yourself a favor and do not wait until your final scores come back to determine how successful you have been in the course.

As you undertake the AP Research course, there will be many opportunities for formative assessments throughout the semester. These assessments are used to give both you and your teacher an idea of the direction of instruction needed for you to master the skills required in the AP Research course. You should use these assessments to your advantage and capitalize on the feedback you receive through each. A list of possible activities used for these assessments can be found on page 41 of the course description .

Another way that you and your teacher will track your progress is through your Process and Reflection Portfolio (PREP). The PREP serves to document your development as you investigate your research questions, thereby providing evidence that you have demonstrated a sustained effort during the entire inquiry process. You will review your PREP periodically with your teacher, who will use it as a formative assessment to evaluate your progress.

Throughout the course, you will be assigned prompts and questions to respond to in your PREP. You will use this portfolio to document your research or artistic processes, communication with your expert adviser, and reflections on your thought processes. You should also write freely, journaling about your strengths and weaknesses with regard to implementing such processes and developing your arguments or aesthetic rationales. 

Your final PREP should include:

• Table of contents
• Completed and approved proposal form
• Specific pieces of work selected by the student to represent what he or she considers to be the best showcase for his or her work. (Examples might include: in-class (teacher-directed) free-writing about the inquiry process, resource list, annotated bibliography of any source important to the student’s work, photographs, charts, spreadsheets, and/or links to videos or other relevant visual research/project artifacts, draft versions of selected sections of the academic paper, or notes in preparation for presentation and oral defense.)
• Documentation of permission(s) received from primary sources, if required — for example, permission(s) from an IRB or other agreements with individuals, institutions, or organizations that provide primary and private data such as interviews, surveys, or investigations
• Documentation or log of the student’s interaction with expert adviser(s) and the role the expert adviser(s) played in the student’s learning and inquiry process (e.g., What areas of expertise did the expert adviser have that the student needed to draw from? Did the student get the help he or she needed — and if not, what did he or she do to ensure that the research process was successful? Which avenues of exploration did the expert adviser help the student to discover?)
• Questions asked to and feedback received from peer and adult reviewers both in the initial stages and at key points along the way
• Reflection on whether or not the feedback was accepted or rejected and why
• Attestation signed by the student which states, “I hereby affirm that the work contained in this Process and Reflection Portfolio is my own and that I have read and understand the AP Capstone TM Policy on Plagiarism and Falsification or Fabrication of Information”

It cannot be stressed enough how important it is to maintain strong communications with your teacher as you progress through the AP Research course. Not only is your teacher your best resource for learning new skills and knowledge, but also it is your teacher who will be responsible for grading your final performance tasks and as such, you should always have a strong understanding of how your work is being assessed and the ways in which you can improve it. Remember, your teacher wants you to succeed just as much as you do; work together as a team to optimize your chances.

How Should I Choose a Research Topic?

You will begin to consider research topics before the school year even starts. If your AP Research class is offered in conjunction with another course, such as those rooted in a specific subject or linked to another concurrent AP course, you will have some idea of the direction in which your research should head. Regardless of whether you know the precise subject matter of your topic, you should begin by asking yourself what you want to know, learn, or understand. The AP Research class provides a unique opportunity for you to guide your own learning in a direction that is genuinely interesting to you. You will find your work more engaging, exciting, and worthwhile if you choose a topic that you want to learn more about.

As you begin to consider research topics, you should:

• Develop a list of topics and high-level questions that spark your interest to engage in an individual research project
• Identify potential expert advisers to guide you in the planning and development of your research project (For tips on how to find a mentor, read CollegeVine’s “ How to Choose a Winning Science Fair Project Idea ”)
• Identify potential opportunities (if you are interested) to perform primary research with an expert adviser during the summer, via internships or summer research projects for high school students offered in the community and local higher education institutions
• Discuss research project planning skills and ideas with students who are currently taking or have already taken the AP Research course

You might also find inspiration from reading about past AP Research topics. One list of potential research questions can be found here and another can be found here . Keep in mind that these lists make great starting points and do a good job of getting you thinking about important subjects, but your research topic should ultimately be something that you develop independently as the result of careful introspection, discussions with your teacher and peers, and your own preliminary research.

Finally, keep in mind that if you pursue a research project that involves human subjects, your proposal will need to be reviewed and approved by an institutional review board (IRB) before experimentation begins. Talk with your teacher to decide if this is the right path for you before you get too involved in a project that may not be feasible.

Once you have decided on a research topic, complete an Inquiry Proposal Form. This will be distributed by your teacher and can also be found on page 55 of the course description .

How Do I Conduct My Research?

By the time you begin your AP Research course, you will have already learned many of the basics about research methods during your AP Seminar course. You should be comfortable collecting and analyzing information with accuracy and precision, developing arguments based on facts, and effectively communicating your point of view. These will be essential skills as you move forward in your AP Research project.

As you undertake your work, remember the skills you’ve already learned about research:

• Use strategies to aid your comprehension as you tackle difficult texts.
• Identify the author’s main idea and the methods that he or she uses to support it.
• Think about biases and whether other perspectives are acknowledged.
• Assess the strength of research, products, and arguments.
• Look for patterns and trends as you strive to make connections between multiple arguments.
• Think about what other issues, questions, or topics could be explored further.

You should be certain to keep track of all sources used in your research and cite them appropriately. The College Board has a strict policy against plagiarism. You can read more about its specifics on page 60 of the course description .

How Do I Write My Paper?

Before you begin writing your final paper, make sure to thoroughly read the Task Overview handout which will be distributed by your teacher. If you would like to see it beforehand, it can be found on page 56 of the course description . You should also review the outline of required paper sections on page 49 of the course description .

Your paper must contain the following sections:

› Introduction

› Method, Process, or Approach

› Results, Product, or Findings

› Discussion, Analysis, and/or Evaluation

› Conclusion and Future Directions

› Bibliography

Before you begin writing, organize your ideas and findings into an outline using the sections listed above. Be sure to consider how you can connect and analyze the evidence in order to develop an argument and support a conclusion. Also think about if there are any alternate conclusions that could be supported by your evidence and how you can acknowledge and account for your own biases and assumptions. 

Begin your paper by introducing and contextualizing your research question or problem. Make sure to include your initial assumptions and/or hypothesis. Next, include a literature review of previous work in the field and various perspectives on your topic. Use the literature review to highlight the gap in the current field of knowledge to be addressed by your research project. Then, explain and justify your methodology, present your findings, evidence, or data, and interpret the significance of these findings. Discuss implications for further research or limitations of your existing project. Finally, reflect on the project, how it could impact its field, and any possible next steps. Your paper should conclude with a comprehensive bibliography including all of the sources used in your process.

Make sure to proofread and edit your paper yourself, have it proofread and edited by a friend, and then proofread and edit it again before you complete your final draft.

How Do I Prepare For My Oral Defense?

Once your paper is finished, you may be tempted to sit back and rest on your laurels. Although you’ve no doubt expended a tremendous about of energy in producing a final product you can be proud of, don’t forget that the work is not over yet. Your oral defense accounts for 25% of your total score so it should be taken seriously.

Your oral defense is a 15-20 minute presentation that uses appropriate media to present your findings to an oral defense panel. You may choose any appropriate format for your presentation, as long as the presentation reflects the depth of your research. If your academic paper was accompanied by an additional piece of scholarly work (e.g., performance, exhibit, product), you should arrange with your teacher for him or her, along with the panelists, to view the scholarly work prior to your presentation.

As you plan your presentation, consider how you can best appeal to your audience. Consider different mediums for your presentation, and how those mediums might affect your credibility as a presenter. You want to be engaging to your audience while still being taken seriously.

Following your presentation, you will field three or four questions from your panelists. These will include one question pertaining to your research or inquiry process, one question focused on your depth of understanding, and one question about your reflection throughout the inquiry process as evidenced in your PREP. The fourth question and any follow-up questions are at the discretion of the panel. A list of sample oral defense questions begins on page 52 of the course description . For a complete outline of the oral defense, see page 49 of the course description . 

How Will My Work Be Assessed?

Because this assessment is only available to students enrolled in the AP Capstone program, your teacher will register you for the assessment when you enroll in the course. You should confirm with your teacher that you are registered for the assessment no later than March 1. 

You will submit your final paper and complete your oral presentation no later than April 30, at which point your teacher will submit your work and scores through an AP Digital Portfolio. Your presentation will be scored by your teacher alone. Your paper will be scored by your teacher and validated by the College Board.

You may find the scoring rubric from the 2016 performance tasks available here . You may find a collection authentic student research papers and scoring explanations available here .

Preparing for any AP assessment can be a stressful process. Having a specific plan of attack and a firm grasp of how your work is assessed will help you to feel prepared and score well. Use CollegeVine’s Ultimate Guide to the AP Research Course and Assessment to help shape your understanding of the course and how to complete your performance tasks effectively. When submission day arrives, you should feel better prepared and informed about the work you have produced.

For more about information about APs, check out these CollegeVine posts:

• Can AP Tests Actually Save You Thousands of Dollars?

• Should I Take AP/IB/Honors Classes?

• How to Choose Which AP Courses and Exams to Take

• What If My School Doesn’t Offer AP or IB Courses?

• Are All APs Created Equal in Admissions?

Want access to expert college guidance — for free? When you create your free CollegeVine account, you will find out your real admissions chances, build a best-fit school list, learn how to improve your profile, and get your questions answered by experts and peers—all for free. Sign up for your CollegeVine account today to get a boost on your college journey.

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What is a Literature Review? How to Write It (with Examples)

A literature review is a critical analysis and synthesis of existing research on a particular topic. It provides an overview of the current state of knowledge, identifies gaps, and highlights key findings in the literature. 1 The purpose of a literature review is to situate your own research within the context of existing scholarship, demonstrating your understanding of the topic and showing how your work contributes to the ongoing conversation in the field. Learning how to write a literature review is a critical tool for successful research. Your ability to summarize and synthesize prior research pertaining to a certain topic demonstrates your grasp on the topic of study, and assists in the learning process. 

Table of Contents

• What is the purpose of literature review? 
• a. Habitat Loss and Species Extinction: 
• b. Range Shifts and Phenological Changes: 
• c. Ocean Acidification and Coral Reefs: 
• d. Adaptive Strategies and Conservation Efforts: 

How to write a good literature review 

• Choose a Topic and Define the Research Question: 
• Decide on the Scope of Your Review: 
• Select Databases for Searches: 
• Conduct Searches and Keep Track: 
• Review the Literature: 
• Organize and Write Your Literature Review: 
• How to write a literature review faster with Paperpal? 
• Frequently asked questions 

What is a literature review?

A well-conducted literature review demonstrates the researcher’s familiarity with the existing literature, establishes the context for their own research, and contributes to scholarly conversations on the topic. One of the purposes of a literature review is also to help researchers avoid duplicating previous work and ensure that their research is informed by and builds upon the existing body of knowledge.

What is the purpose of literature review?

A literature review serves several important purposes within academic and research contexts. Here are some key objectives and functions of a literature review: 2  

1. Contextualizing the Research Problem: The literature review provides a background and context for the research problem under investigation. It helps to situate the study within the existing body of knowledge. 

2. Identifying Gaps in Knowledge: By identifying gaps, contradictions, or areas requiring further research, the researcher can shape the research question and justify the significance of the study. This is crucial for ensuring that the new research contributes something novel to the field. 

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3. Understanding Theoretical and Conceptual Frameworks: Literature reviews help researchers gain an understanding of the theoretical and conceptual frameworks used in previous studies. This aids in the development of a theoretical framework for the current research. 

4. Providing Methodological Insights: Another purpose of literature reviews is that it allows researchers to learn about the methodologies employed in previous studies. This can help in choosing appropriate research methods for the current study and avoiding pitfalls that others may have encountered. 

5. Establishing Credibility: A well-conducted literature review demonstrates the researcher’s familiarity with existing scholarship, establishing their credibility and expertise in the field. It also helps in building a solid foundation for the new research. 

6. Informing Hypotheses or Research Questions: The literature review guides the formulation of hypotheses or research questions by highlighting relevant findings and areas of uncertainty in existing literature. 

Literature review example

Let’s delve deeper with a literature review example: Let’s say your literature review is about the impact of climate change on biodiversity. You might format your literature review into sections such as the effects of climate change on habitat loss and species extinction, phenological changes, and marine biodiversity. Each section would then summarize and analyze relevant studies in those areas, highlighting key findings and identifying gaps in the research. The review would conclude by emphasizing the need for further research on specific aspects of the relationship between climate change and biodiversity. The following literature review template provides a glimpse into the recommended literature review structure and content, demonstrating how research findings are organized around specific themes within a broader topic. 

Literature Review on Climate Change Impacts on Biodiversity:

Climate change is a global phenomenon with far-reaching consequences, including significant impacts on biodiversity. This literature review synthesizes key findings from various studies: 

a. Habitat Loss and Species Extinction:

Climate change-induced alterations in temperature and precipitation patterns contribute to habitat loss, affecting numerous species (Thomas et al., 2004). The review discusses how these changes increase the risk of extinction, particularly for species with specific habitat requirements. 

b. Range Shifts and Phenological Changes:

Observations of range shifts and changes in the timing of biological events (phenology) are documented in response to changing climatic conditions (Parmesan & Yohe, 2003). These shifts affect ecosystems and may lead to mismatches between species and their resources. 

c. Ocean Acidification and Coral Reefs:

The review explores the impact of climate change on marine biodiversity, emphasizing ocean acidification’s threat to coral reefs (Hoegh-Guldberg et al., 2007). Changes in pH levels negatively affect coral calcification, disrupting the delicate balance of marine ecosystems. 

d. Adaptive Strategies and Conservation Efforts:

Recognizing the urgency of the situation, the literature review discusses various adaptive strategies adopted by species and conservation efforts aimed at mitigating the impacts of climate change on biodiversity (Hannah et al., 2007). It emphasizes the importance of interdisciplinary approaches for effective conservation planning. 

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Writing a literature review involves summarizing and synthesizing existing research on a particular topic. A good literature review format should include the following elements. 

Introduction: The introduction sets the stage for your literature review, providing context and introducing the main focus of your review. 

• Opening Statement: Begin with a general statement about the broader topic and its significance in the field. 
• Scope and Purpose: Clearly define the scope of your literature review. Explain the specific research question or objective you aim to address. 
• Organizational Framework: Briefly outline the structure of your literature review, indicating how you will categorize and discuss the existing research. 
• Significance of the Study: Highlight why your literature review is important and how it contributes to the understanding of the chosen topic. 
• Thesis Statement: Conclude the introduction with a concise thesis statement that outlines the main argument or perspective you will develop in the body of the literature review. 

Body: The body of the literature review is where you provide a comprehensive analysis of existing literature, grouping studies based on themes, methodologies, or other relevant criteria. 

• Organize by Theme or Concept: Group studies that share common themes, concepts, or methodologies. Discuss each theme or concept in detail, summarizing key findings and identifying gaps or areas of disagreement. 
• Critical Analysis: Evaluate the strengths and weaknesses of each study. Discuss the methodologies used, the quality of evidence, and the overall contribution of each work to the understanding of the topic. 
• Synthesis of Findings: Synthesize the information from different studies to highlight trends, patterns, or areas of consensus in the literature. 
• Identification of Gaps: Discuss any gaps or limitations in the existing research and explain how your review contributes to filling these gaps. 
• Transition between Sections: Provide smooth transitions between different themes or concepts to maintain the flow of your literature review. 

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Conclusion: The conclusion of your literature review should summarize the main findings, highlight the contributions of the review, and suggest avenues for future research. 

• Summary of Key Findings: Recap the main findings from the literature and restate how they contribute to your research question or objective. 
• Contributions to the Field: Discuss the overall contribution of your literature review to the existing knowledge in the field. 
• Implications and Applications: Explore the practical implications of the findings and suggest how they might impact future research or practice. 
• Recommendations for Future Research: Identify areas that require further investigation and propose potential directions for future research in the field. 
• Final Thoughts: Conclude with a final reflection on the importance of your literature review and its relevance to the broader academic community. 

Conducting a literature review

Conducting a literature review is an essential step in research that involves reviewing and analyzing existing literature on a specific topic. It’s important to know how to do a literature review effectively, so here are the steps to follow: 1  

Choose a Topic and Define the Research Question:

• Select a topic that is relevant to your field of study. 
• Clearly define your research question or objective. Determine what specific aspect of the topic do you want to explore? 

Decide on the Scope of Your Review:

• Determine the timeframe for your literature review. Are you focusing on recent developments, or do you want a historical overview? 
• Consider the geographical scope. Is your review global, or are you focusing on a specific region? 
• Define the inclusion and exclusion criteria. What types of sources will you include? Are there specific types of studies or publications you will exclude? 

Select Databases for Searches:

• Identify relevant databases for your field. Examples include PubMed, IEEE Xplore, Scopus, Web of Science, and Google Scholar. 
• Consider searching in library catalogs, institutional repositories, and specialized databases related to your topic. 

Conduct Searches and Keep Track:

• Develop a systematic search strategy using keywords, Boolean operators (AND, OR, NOT), and other search techniques. 
• Record and document your search strategy for transparency and replicability. 
• Keep track of the articles, including publication details, abstracts, and links. Use citation management tools like EndNote, Zotero, or Mendeley to organize your references. 

Review the Literature:

• Evaluate the relevance and quality of each source. Consider the methodology, sample size, and results of studies. 
• Organize the literature by themes or key concepts. Identify patterns, trends, and gaps in the existing research. 
• Summarize key findings and arguments from each source. Compare and contrast different perspectives. 
• Identify areas where there is a consensus in the literature and where there are conflicting opinions. 
• Provide critical analysis and synthesis of the literature. What are the strengths and weaknesses of existing research? 

Organize and Write Your Literature Review:

• Literature review outline should be based on themes, chronological order, or methodological approaches. 
• Write a clear and coherent narrative that synthesizes the information gathered. 
• Use proper citations for each source and ensure consistency in your citation style (APA, MLA, Chicago, etc.). 
• Conclude your literature review by summarizing key findings, identifying gaps, and suggesting areas for future research. 

Whether you’re exploring a new research field or finding new angles to develop an existing topic, sifting through hundreds of papers can take more time than you have to spare. But what if you could find science-backed insights with verified citations in seconds? That’s the power of Paperpal’s new Research feature!  

How to write a literature review faster with Paperpal?

Paperpal, an AI writing assistant, integrates powerful academic search capabilities within its writing platform. With the Research feature, you get 100% factual insights, with citations backed by 250M+ verified research articles, directly within your writing interface with the option to save relevant references in your Citation Library. By eliminating the need to switch tabs to find answers to all your research questions, Paperpal saves time and helps you stay focused on your writing.   

Here’s how to use the Research feature:  

• Ask a question: Get started with a new document on paperpal.com. Click on the “Research” feature and type your question in plain English. Paperpal will scour over 250 million research articles, including conference papers and preprints, to provide you with accurate insights and citations. 
• Review and Save: Paperpal summarizes the information, while citing sources and listing relevant reads. You can quickly scan the results to identify relevant references and save these directly to your built-in citations library for later access. 
• Cite with Confidence: Paperpal makes it easy to incorporate relevant citations and references into your writing, ensuring your arguments are well-supported by credible sources. This translates to a polished, well-researched literature review. 

The literature review sample and detailed advice on writing and conducting a review will help you produce a well-structured report. But remember that a good literature review is an ongoing process, and it may be necessary to revisit and update it as your research progresses. By combining effortless research with an easy citation process, Paperpal Research streamlines the literature review process and empowers you to write faster and with more confidence. Try Paperpal Research now and see for yourself.  

Frequently asked questions

A literature review is a critical and comprehensive analysis of existing literature (published and unpublished works) on a specific topic or research question and provides a synthesis of the current state of knowledge in a particular field. A well-conducted literature review is crucial for researchers to build upon existing knowledge, avoid duplication of efforts, and contribute to the advancement of their field. It also helps researchers situate their work within a broader context and facilitates the development of a sound theoretical and conceptual framework for their studies.

Literature review is a crucial component of research writing, providing a solid background for a research paper’s investigation. The aim is to keep professionals up to date by providing an understanding of ongoing developments within a specific field, including research methods, and experimental techniques used in that field, and present that knowledge in the form of a written report. Also, the depth and breadth of the literature review emphasizes the credibility of the scholar in his or her field.  

Before writing a literature review, it’s essential to undertake several preparatory steps to ensure that your review is well-researched, organized, and focused. This includes choosing a topic of general interest to you and doing exploratory research on that topic, writing an annotated bibliography, and noting major points, especially those that relate to the position you have taken on the topic. 

Literature reviews and academic research papers are essential components of scholarly work but serve different purposes within the academic realm. 3 A literature review aims to provide a foundation for understanding the current state of research on a particular topic, identify gaps or controversies, and lay the groundwork for future research. Therefore, it draws heavily from existing academic sources, including books, journal articles, and other scholarly publications. In contrast, an academic research paper aims to present new knowledge, contribute to the academic discourse, and advance the understanding of a specific research question. Therefore, it involves a mix of existing literature (in the introduction and literature review sections) and original data or findings obtained through research methods. 

Literature reviews are essential components of academic and research papers, and various strategies can be employed to conduct them effectively. If you want to know how to write a literature review for a research paper, here are four common approaches that are often used by researchers.  Chronological Review: This strategy involves organizing the literature based on the chronological order of publication. It helps to trace the development of a topic over time, showing how ideas, theories, and research have evolved.  Thematic Review: Thematic reviews focus on identifying and analyzing themes or topics that cut across different studies. Instead of organizing the literature chronologically, it is grouped by key themes or concepts, allowing for a comprehensive exploration of various aspects of the topic.  Methodological Review: This strategy involves organizing the literature based on the research methods employed in different studies. It helps to highlight the strengths and weaknesses of various methodologies and allows the reader to evaluate the reliability and validity of the research findings.  Theoretical Review: A theoretical review examines the literature based on the theoretical frameworks used in different studies. This approach helps to identify the key theories that have been applied to the topic and assess their contributions to the understanding of the subject.  It’s important to note that these strategies are not mutually exclusive, and a literature review may combine elements of more than one approach. The choice of strategy depends on the research question, the nature of the literature available, and the goals of the review. Additionally, other strategies, such as integrative reviews or systematic reviews, may be employed depending on the specific requirements of the research.

The literature review format can vary depending on the specific publication guidelines. However, there are some common elements and structures that are often followed. Here is a general guideline for the format of a literature review:  Introduction:   Provide an overview of the topic.  Define the scope and purpose of the literature review.  State the research question or objective.  Body:   Organize the literature by themes, concepts, or chronology.  Critically analyze and evaluate each source.  Discuss the strengths and weaknesses of the studies.  Highlight any methodological limitations or biases.  Identify patterns, connections, or contradictions in the existing research.  Conclusion:   Summarize the key points discussed in the literature review.  Highlight the research gap.  Address the research question or objective stated in the introduction.  Highlight the contributions of the review and suggest directions for future research.

Both annotated bibliographies and literature reviews involve the examination of scholarly sources. While annotated bibliographies focus on individual sources with brief annotations, literature reviews provide a more in-depth, integrated, and comprehensive analysis of existing literature on a specific topic. The key differences are as follows: 

References 

• Denney, A. S., & Tewksbury, R. (2013). How to write a literature review.  Journal of criminal justice education ,  24 (2), 218-234. 
• Pan, M. L. (2016).  Preparing literature reviews: Qualitative and quantitative approaches . Taylor & Francis. 
• Cantero, C. (2019). How to write a literature review.  San José State University Writing Center . 

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• University of Texas Libraries

Literature Reviews

• What is a literature review?
• Steps in the Literature Review Process
• Define your research question
• Determine inclusion and exclusion criteria
• Choose databases and search
• Review Results
• Synthesize Results
• Analyze Results
• Librarian Support

What is a Literature Review?

A literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important past and current research and practices. It provides background and context, and shows how your research will contribute to the field. 

A literature review should: 

• Provide a comprehensive and updated review of the literature;
• Explain why this review has taken place;
• Articulate a position or hypothesis;
• Acknowledge and account for conflicting and corroborating points of view

From  S age Research Methods

Purpose of a Literature Review

A literature review can be written as an introduction to a study to:

• Demonstrate how a study fills a gap in research
• Compare a study with other research that's been done

Or it can be a separate work (a research article on its own) which:

• Organizes or describes a topic
• Describes variables within a particular issue/problem

Limitations of a Literature Review

Some of the limitations of a literature review are:

• It's a snapshot in time. Unlike other reviews, this one has beginning, a middle and an end. There may be future developments that could make your work less relevant.
• It may be too focused. Some niche studies may miss the bigger picture.
• It can be difficult to be comprehensive. There is no way to make sure all the literature on a topic was considered.
• It is easy to be biased if you stick to top tier journals. There may be other places where people are publishing exemplary research. Look to open access publications and conferences to reflect a more inclusive collection. Also, make sure to include opposing views (and not just supporting evidence).

Source: Grant, Maria J., and Andrew Booth. “A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies.” Health Information & Libraries Journal, vol. 26, no. 2, June 2009, pp. 91–108. Wiley Online Library, doi:10.1111/j.1471-1842.2009.00848.x.

Meryl Brodsky : Communication and Information Studies

Hannah Chapman Tripp : Biology, Neuroscience

Carolyn Cunningham : Human Development & Family Sciences, Psychology, Sociology

Larayne Dallas : Engineering

Janelle Hedstrom : Special Education, Curriculum & Instruction, Ed Leadership & Policy ​

Susan Macicak : Linguistics

Imelda Vetter : Dell Medical School

For help in other subject areas, please see the guide to library specialists by subject .

Periodically, UT Libraries runs a workshop covering the basics and library support for literature reviews. While we try to offer these once per academic year, we find providing the recording to be helpful to community members who have missed the session. Following is the most recent recording of the workshop, Conducting a Literature Review. To view the recording, a UT login is required.

• October 26, 2022 recording
• Last Updated: Oct 26, 2022 2:49 PM
• URL: https://guides.lib.utexas.edu/literaturereviews

Method of Research--Research Process

• Explore Web Resources
• Reference Books
• Scholarly Articles
• Set up a Research Account!
• Article Log
• Keywords and Subject Terms
• Trunication and Wild Card Symbols
• Evaluating Information
• Primary and Secondary Sources
• Academic, Popular, and Trade Publications
• Scholarly and Peer-Reviewed Journals
• Grey Literature
• Finding Scales, Measurements and Assessments
• Annotated Bibliography
• Literature Review
• Library Guide

AP 7th Edition Headings

You'll want to use headings to structure your lit review. The APA 7th Additions specifies five levels of headings, in descending levels of emphasis (i. e. level 1 headings are the most important and level 5 headings the least).  The number of headings you use will depend on the length and complexity of your paper, but in any case, make sure to begin with a level 1 heading and proceed sequentially to level 2, then level 3, etc.

The introduction to your paper does not begin with a heading of any kind. Note that there cannot be single level 3, 4, or 5 headings. That is, you must have more than one heading at each of those levels.

Level 1 Headings Are Centered, Title Case and Bold With No Closing Period

Start a new, indented paragraph on the next line after Level 1 headings.

Level 2 Headings Are Flush Left (Not Centered and Not Indented) and Are Title Case and Bold With No Closing Period

Start a new, indented paragraph on the next line after Level 2 headings.

Level 3 Headings Are Flush Left (Not Centered and Not Indented) and Are Title Case, Bold, and Italicized, With No Closing Period

Start a new, indented paragraph on the next line after Level 3 headings.

               Level 4 Headings are Indented Left , Title Case and Bold With a Closing Period. Continue writing the paragraph on the same line after Level 4 headings.

          Level 5 Headings are Indented Left , Title Case , Bold, and Italicized With a Closing Period .  Continue writing the paragraph on the same line after Level 5 headings.

Template for APA 7th Edition Papers

• APA 7th Edition Template Here's a handy template for writing papers conforming to the APA 7th Edition, created by our own Prof. William Doverspike. This is a great resource to use when formatting your research papers.

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AP® English Literature

The best ap® english literature review guide for 2024.

• The Albert Team
• Last Updated On: January 29, 2024

Scoring a 5 on the AP® English Literature and Composition exam is no easy task. In 2019, for example, only 6.2% of students earned a 5 on the test. While this statistic may be discouraging at first glance, it does indicate that a perfect score is possible for those willing to do extra preparation and practice. In 2022, nearly 17% of test-takers earned a 5 – a big improvement!

It may take some hard work, but it’s possible to ace this exam! We’re here to help.

In this comprehensive review, we’ll unpack the exam’s basic format, analyze the common structures and shapes of AP® Literature questions, provide useful tips and strategies for scoring a 5, and offer a variety of helpful additional resources and study tools.

Let’s get to it!

What We Review

How is the AP® English Literature and Composition Exam formatted? 

The AP® English Literature and Composition exam is divided into two sections: multiple-choice and free-response. 

The multiple-choice section is broken into five chunks equipped with 8-13 questions each, totaling 55 questions. You will be asked to analyze excerpts from diverse literary texts, including prose fiction, drama, or poetry. Moreover, there will always be at least 2 prose fiction passages and 2 poems in this section of the exam. The fifth text can be either. 

The multiple-choice section has a time limit of 1 hour, and it counts as 45% of your overall exam score. 

Section 2 of the exam, often informally called the “essay section,” contains 3 free-response prompts which demand literary analysis of a given poem, a passage of prose fiction, or an excerpt from a play. 

The first two prompts will provide a passage or a poem requiring analysis, while the third and final prompt will ask you to engage with a concept, issue, or element in a literary work that you are expected to have encountered during the school year. A list of appropriate works is provided for the third prompt. 

You have 2 hours to complete Section 2, which comprises 55% of your final exam score.

Return to the Table of Contents

How Long is the AP® English Literature and Composition Exam?

The AP® English Literature and Composition exam is 3 hours long. Students will have 1 hour to complete the multiple-choice section (55 questions) and 2 hours to complete the free-response section (3 questions). 

Since you must answer 55 questions in 60 minutes on the multiple-choice portion of the exam, you should pace yourself at about 1 minute per question and about 12 minutes per passage. 

Likewise, since the free response section is timed at 120 minutes, you should aim to complete each essay in 40 minutes or under.

Time yourself when you practice, and don’t get caught up trying to answer a question that you totally do not know the answer to. Don’t rush through the test, but don’t take too much time.

How Many Questions Does the AP® English Literature and Composition Exam Have? 

Section i: multiple-choice.

• 5 passages, 55 questions total: 8-13 questions per passage
• Passages include 2 Prose, 2 Poems, and 1 of either

Section II: Free-Response

• 1 literary analysis of a given poem
• 1 literary analysis of a given passage of prose fiction
• 1 literary argument

What Topics are Covered on the AP® English Literature and Composition Exam? 

Perhaps the best way to begin thinking about the topics covered on the exam is through a holistic approach. Overall, the test assesses the six big ideas covered within the AP® English Literature and Composition course itself: 

• Figurative Language
• Literary Argumentation

These components comprise the whole exam, and you will be tested specifically on material from these broad concepts. 

Now, let’s return to its formatting. Remember, the exam is divided into multiple choice and free response, each carrying its own set of demands and topics.

Section I: Multiple Choice

Since the AP® English Literature and Composition exam is a skills-based test, there’s no way to know what specific passages or topics might appear on the official exam. Rather, CollegeBoard uses a variety of excerpts from literary texts, including prose, poetry, and drama. 

The passages often range from the 16th to the 21st century, and the authors and literary works change yearly. So it is imperative that you sharpen your critical reading skills and hone your ability to engage with the forms, styles, and content of a diverse range of literature. 

However, we have some good news. We do know how the multiple choice section is organized and weighted. It is divided into three broad units: short fiction, poetry, and longer fiction or drama, with each unit carrying its own weighted percentage. The chart below outlines this weighting:

Moreover, the multiple choice portion of the exam can be further broken down into 7 assessed skills:

Remember, the multiple-choice section will include five sets of 8 to 13 questions per set, so be prepared to encounter many if not all of these skill sets per passage. But it is safe to say that you should review certain skill categories more thoroughly than others on account of how frequently they appear on the exam. 

Below we’ve compiled a descending list of priorities for you to consider. 

• Skill Category 4 : Explain the function of the narrator or speaker
• Skill Category 1 : Explain the function of character
• Skill Category 3 : Explain the function of plot and structure
• Skill Category 5 : Explain the function of word choice, imagery, and symbols
• Skill Category 7 : Develop textually substantiated arguments about interpretations of part or all of a text
• Skill Category 6 : Explain the function of comparison
• Skill Category 2 . Explain the function of setting

Section 4, “Explain the function of the narrator or speaker,” should be studied the most since it holds a substantial amount of weight in determining your score. Skill category 2, as you see above, accounts for a small percentage of the exam so we recommend you don’t spend hours upon hours brushing up on the function of the setting. Don’t blow it off, though!

Section II: Free Response

Like the multiple choice section, the free response portion is also skills-based. We cannot predict what specific passages or poems will make it onto the test, but we do know the type(s) of essays you will be required to write:

• 1 Poetry Analysis: After reading a poem of 100 to 300 words, you will respond to a prompt based on the poem with a well-developed essay. Your essay, of course, must offer a defensible interpretation, make adequate use of textual evidence, engage critically with cited evidence, and use appropriate grammar and punctuation when communicating its argument. These requirements are present throughout all three free-response essays. 
• 1 Prose Fiction Analysis: This part of the free response section will provide a passage of prose fiction (500 to 700 words) and, like the poetry analysis, ask you to respond to a prompt through writing a well-developed essay. Your argument must adhere to the rigor and clarity outlined above in the poetry analysis description.
• 1 Literary Argument Essay: Here, you will be given an open-ended topic and be asked to write an evidence-based argumentative essay in response to the topic. There will be a quote or small passage to read, a corresponding prompt, and an extensive list of literary works you may use when developing your argument. While you do not have to use a work from this list, you must select a work of literary merit. Avoid choosing fantasy novels or works designed more for pure entertainment. It needs to be a work of “deep” literature.

What Do the AP® English Literature and Composition Exam Questions Look Like?

Multiple choice examples:.

The Course and Exam Description (CED) for AP® Lit provides 10 practice questions that address prose fiction and 9 practice questions that address poetry.

Below, we’ll look at examples of each question type and cover the skills and essential knowledge they address. First, we will examine the multiple-choice questions involving prose fiction:

Skill: 5.B Explain the function of specific words and phrases in a text.

Essential Knowledge: FIG-1.M Descriptive words, such as adjectives and adverbs, qualify or modify the things they describe and affect readers’ interaction with the text.

Skill: 4.C Identify and describe details, diction, or syntax in a text that reveal a narrator’s or speaker’s perspective.

Essential Knowledge: NAR-1.R Information included and/or not included in a text conveys the perspective of characters, narrators, and/or speakers.

Skill: 3.C Explain the function of structure in a text.

Essential Knowledge: STR-1.F A text’s structure affects readers’ reactions and expectations by presenting the relationships among the ideas of the text via their relative positions and their placement within the text as a whole

Now that we’ve taken a look at samples of multiple-choice questions involving prose fiction, let’s turn our attention toward questions that address poetry. 

Skill 7.B: Develop a thesis statement that conveys a defensible claim about an interpretation of literature and that may establish a line of reasoning. 

Essential Knowledge: LAN-1.D A thesis statement expresses an interpretation of a literary text, and requires a defense, through use of textual evidence and a line of reasoning, both of which are explained in an essay through commentary.

Skill 4.C: Identify and describe details, diction, or syntax in a text that reveal a narrator’s or speaker’s perspective.

Essential Knowledge: NAR-1.X Multiple, and even contrasting, perspectives can occur within a single text and contribute to the complexity of the text.

Skill: 5.D Identify and explain the function of an image or imagery.

Essential Knowledge: FIG-1.O Descriptive words, such as adjectives and adverbs, contribute to sensory imagery.

As you see, these questions force you to engage with literature more critically and technically. CollegeBoard’s main objective is to shape you into a budding literary critic capable of producing college-level work, so they consistently ask questions that look like those above. 

To develop your skills to a level that would be acceptable by a university, then, the test-makers over at CollegeBoard often craft questions involving analysis of literary devices, character perspective, figurative language, and more. The individual skills assessed by these questions are designed to take your thinking to a much higher level.

Free Response Examples: 

The Course and Exam Description (CED) for AP® Lit also provides samples of free response questions. Let’s begin by taking a look at a sample of a poetry-based free response prompt.

Poetry Analysis

Skills: 4.C, 7.A, 7.B, 7.C, 7.D, 7.E

Note how the prompt is somewhat vague and open-ended. While it does ask you to hone in on a specific topic within the poem—aging—through discussion of the writer’s use of poetic elements and techniques, it also does not specify which of those elements and techniques should be discussed:

• Then, in a well-written essay, analyze how Emerson uses poetic elements and techniques to convey the speaker’s complex perspective on aging.

So, it is imperative that you come to this exam with a deep and clear understanding of literary devices and motifs such as parallelism, imagery, irony, etc.

If you struggle with literary and rhetorical terms, check out our guide on essential AP® Literature Rhetorical Terms !

In a bit, we’ll provide some additional resources to help you build your knowledge of these literary tools.

Prose Fiction Analysis

Skills: 1.A, 7.A, 7.B, 7.C, 7.D, 7.E

The prompt requires you to read the excerpt and construct a well-developed literary analysis in response. Like the poetry prompt, note how this prompt is somewhat vague and open-ended. Again, it points you in a direction but leaves it up to you on how you’re going to get there:

• Then, in a well-written essay, analyze how Kincaid uses literary elements and techniques  to portray the complexity of the narrator’s new situation.

Therefore, it is imperative that you come to the test prepared with knowledge of literary elements and techniques.

Literary Argument 

Skills: 1.E, 2.C, 7.A, 7.B, 7.C, 7.D, 7.E

Unlike the other two essays, this prompt contains neither a prose excerpt nor a poem. Rather, it provides a brief quote and then asks you to expand on its central concept and, in our case, the notion of home. 

It then provides a list of works that would suit your analysis. You are to select one work from the list or choose another work of literary merit and analyze it in the context of the prompt. Again, note how much of the analysis is up to you. The prompt points you in a direction and then leaves you on your own to select how you’re going to get there. 

Therefore, it is imperative that you have not only a solid understanding of literary terms and concepts but also a diverse and deep history of reading. We will direct you toward some additional resources that will strengthen your knowledge below but start by consulting our Ultimate AP® English Literature Reading List to get started!

And if you’re not an avid reader, do not fret! You can guarantee the AP® English Literature and Composition course itself will cover at least one of the books on the list. You will likely be familiar with at least 2-3 of the texts just from taking the course. And if all else fails, you may select your own work of literary merit to discuss!

Free Response Rubric Breakdowns

In previous years, the AP® Lit essays were scored using holistic rubrics on a scale of 0-9. However, after the 2019 exam, the evaluation changed to a new analytic rubric which runs on a scale of 0-6. 

Switching to an analytic rubric from a holistic one can be difficult, especially if you’ve already taken another AP® English class or prepared using the holistic version. But, unlike the holistic rubric, the analytic model tells you exactly what to include in your essay to earn maximum points. 

Consider the new analytic rubric a How-To Guide, designed to earn you a 6 on each essay. And, unlike the AP® Lang exam, all three AP® Lit essays are graded essentially through the same rubric.

Below, we’ll spend some time breaking down the elements of the new rubric. First, let’s take a look at the Thesis row.

Row A: Thesis (0-1 Points)

A well-developed thesis statement is crucial to making your overall argument effective and convincing. Unsurprisingly, the Thesis row on the rubric is essentially all or nothing; you either earn the point or you don’t.

Let’s break down the wording on the rubric to further understand the significance of the thesis point.

It’s important to note what the rubric warns against: 

• No thesis at all
• The thesis only restates the prompt
• The thesis merely summarizes 
• The thesis does not respond to the prompt 

Doing any of these will miss the mark, and a weak thesis often leads to a weak essay. Rather, the rubric emphasizes that you: 

• Respond to the prompt with a thesis that presents a defensible interpretation of the poem, prose passage, or selected work.

Easier said than done, we know. But notice the key phrase, “defensible interpretation.” The basis of your argument, the rubric insists, is entirely up to you as long as you adequately defend and your point. This means you must be ready to dig into the text, cite textual evidence, and analyze your findings sophisticatedly and persuasively. Your thesis, then, must contain a claim. 

If thesis statements are particularly troubling to you, we recommend tuning into CollegeBoard’s official online workshop . It’s helpful, really. 

Below are two examples of thesis statements from the 2019 exam:

• This thesis statement thoroughly considers both the positive and negative consequences of idealism and explains how this portrayal illuminates the meaning of the work as a whole.
• This thesis statement fails to identify a character and confusingly identifies the government’s repressive efforts as presenting a “fabricated view of an Ideal world.” It ultimately makes no claim and overly generalizes.

Row B: Evidence and Commentary (0-4 Points)

Think of evidence and commentary as the meat of your essay. This is where you will really dig into your argument, cite the text, and make specific claims and arguments.

As mentioned, this portion of the rubric works on a scale of 0-4:

As you see, earning all four points requires direct and specific textual citation and thorough, deep analysis throughout your entire essay. Cite evidence that fits your main argument, do not simply cite for the sake of citation. Always avoid paraphrasing (except on the third free-response question where paraphrasing is acceptable). Do not simply cite text and then give a basic summary. Dig deep and analyze. 

If you struggle with analyzing evidence and developing commentary, check out one of our many practice models ! 

Row C Sophistication (0-1 Points)

Similar to the Thesis row, the Sophistication evaluation is also all or nothing — you either earn the point or you don’t. 

However, earning the sophistication point is not as cut and dry as earning the thesis point. You can’t really pinpoint or locate sophistication in the way you can a thesis statement. If it’s there, it’s everywhere; if not, it’s nowhere. 

So to unpack this complex idea, let’s return to the rubric. 

The rubric states that essays that earn the point “demonstrate sophistication of thought and/or develop a complex literary argument.” 

To be more precise, this means that your essay does these four things: 

• Identifies and explores complexities or tensions within the poem, prose passage, or selected work. 
• Situates your overall interpretation within a broader, more universal context. 
• Accounts for alternative interpretations of the poem, prose passage, or selected work. 
• Employs a style that is consistently vivid and persuasive.

Conversely, then, you will not earn the point if your essay:

• Contains sweeping generalizations
• Only hints at other positions or interpretations
• Uses overly complex sentences or language that doesn’t add anything to the argument

Above all, sophistication cannot be reduced to a checkbox. You can’t really add it here or there. It must pervade the entire essay for you to earn the point. It’s a difficult task, but it can be done with a little practice and perseverance. 

For additional tips on writing well-developed analyses, check out our guide on how to tackle prose passages !

What Can You Bring to the AP® English Literature and Composition Exam?

If you’re taking the  digital  exam, you must use a laptop computer (Mac, Windows, or school-managed Chromebook). Because the full-length digital AP® Exams require typewritten free responses, the exams can’t be taken on smartphones. For more details,  here is the full digital AP® exam specifications  from College Board.

If you’re traveling to a testing location to take an in-person exam, make sure to arrive early. If you’re testing digitally from home, be sure all of your digital login details are confirmed beforehand.

Given the sheer importance and seriousness surrounding AP® exams, the College Board has imposed very strict rules and regulations regarding what you can and cannot bring into your testing room (if you’re testing in-person at a school). Not adhering to these rules can lead to score invalidation and even room-wide exam cancellation, so it’s important to know what you can and cannot bring with you on testing day!

What You Should Bring to Your AP® English Literature Exam

If you’re taking the paper AP® English Literature exam in-person at school, you should bring:

• At least 2 sharpened No. 2 pencils for completing the multiple choice section
• At least 2 pens with black or blue ink only. These are used to complete certain areas of your exam booklet covers and to write your free-response questions. CollegeBoard is very clear that pens should be black or blue ink only, so do not show up with your favorite neon gel pen!
• You are allowed to wear a watch as long as it does not have internet access, does not beep or make any other noise, and does not have an alarm. It should be a standard analog or digital watch, nothing fancy!
• If you do not attend the school where you are taking an exam, you must bring a government issued or school issued photo ID.
• If you receive any testing accommodations , be sure that you bring your College Board SSD Accommodations Letter.

What You Should NOT Bring to Your AP® English Literature Exam

If you’re taking the paper AP® English Literature exam in-person at school, you should NOT bring:

• Electronic devices. Phones, smartwatches, tablets, and/or any other electronic devices are expressly prohibited both in the exam room and break areas. Seriously, do not bring these into the testing room. You could invalidate the entire room’s scores.
• Books, dictionaries, highlighters, or notes 
• Mechanical pencils, colored pencils, or pens that do not have black/blue ink. Sometimes the lead used in mechanical pencils cannot be read when run through the scantron reader, so it is best to just avoid them altogether. 
• Your own scratch paper
• Reference guides
• Watches that beep or have alarms
• Food or drink

This list is not exhaustive. Be sure to double-check with your teacher or testing site to make sure that you are not bringing any additional prohibited items.

How to Study for AP® English Literature and Composition: 7 Steps

Start with a diagnostic test to see where you stand. Ask your teacher if they can assign you one of our full-length practice tests as a starting point. Your multiple choice will be graded for you, and you can self-score your free response essays using the College Board’s scoring guidelines. If you would prefer to take a pencil and paper test, Princeton Review or Barron’s are two reputable places to start. Be sure to record your score.

Once you’ve completed and scored your diagnostic test, it’s time to analyze the results and create a study plan. 

• If you used Albert, you’ll notice that each question is labeled with the skill that it assesses. If any skills stand out as something you’re consistently getting wrong, those concepts should be a big part of your study plan. 
• If you used Princeton Review, Barron’s, or another paper test, do your best to sort your incorrect answers into the skill buckets from Albert’s AP® English Literature and Composition Standards Practice .

The tables below sort each set of skills into groups based on their Enduring Understandings and Big Ideas.

Big Idea: Character 

ENDURING UNDERSTANDING: Characters in literature allow readers to study and explore a range of values, beliefs, assumptions, biases, and cultural norms represented by those characters.

Big Idea: Setting

ENDURING UNDERSTANDING: Setting and the details associated with it not only depict a time and place, but also convey values associated with that setting.

Big Idea: Structure

ENDURING UNDERSTANDING: The arrangement of the parts and sections of a text, the relationship of the parts to each other, and the sequence in which the text reveals information are all structural choices made by a writer that contribute to the reader’s interpretation of a text.

Big Idea: Narration

ENDURING UNDERSTANDING: A narrator’s or speaker’s perspective controls the details and emphases that affect how readers experience and interpret a text.

Big Idea: Figurative Language

ENDURING UNDERSTANDING: Comparisons, representations, and associations shift meaning from the literal to the figurative and invite readers to interpret a text.

Big Idea: Literary Argumentation 

ENDURING UNDERSTANDING: Readers establish and communicate their interpretations of literature through arguments supported by textual evidence.

Once your list of practice questions is complete, check out our Ultimate List AP® English Literature Tips for some pointers.

Now that you’ve developed a study plan for the multiple choice section, it’s time to tackle the FRQs. You should have self-scored your essays using CollegeBoard’s scoring guidelines . If you notice that there is one particular prompt you struggled with, use Albert’s AP® Lit FRQ Approach Guide to help hone your skills!

Check out Albert’s AP® Lit FRQ prompts for more practice!

If you didn’t struggle with a particular prompt as much as you did a particular part of the rubric, try to figure out what went wrong. Does your thesis restate the prompt instead of proposing your own position? Did you generalize too much? Did you remember to provide evidence but forget to augment it with commentary and analysis? Maybe your word choice wasn’t varied enough to earn the sophistication point.

Whatever element you struggled with, have a look at our comprehensive page dedicated to AP® Lit for some expert advice!

Once you’ve developed an effective study plan using the links and practice above, and you’ve identified the skills which need more practice, it’s time to set your plan in motion. Check and mark your calendar. How many days, weeks, or months do you have until your exam? Pace your studying according to this time-frame. Pro-tip: If you only have a few weeks or days to go, prioritize the skills that you scored the lowest on. 

About halfway through your study schedule, plan to take a second practice test to check your progress. You can either have your teacher assign another full-length Albert practice test or use one of the additional practice tests included in whatever AP® English Literature and Composition review book you purchased. Use these results to inform the rest of your study schedule. Are there skills that you improved on or scored lower on this time? Adjust accordingly, and use our tips in the next section to guide you.

AP® English Literature and Composition Review: 15 Must Know Study Tips

5 AP® English Literature and Composition Study Tips for Home

1.  read as much as possible..

And read widely. Read everything from epic poetry and Victorian novels to New Yorker articles and album reviews to Buzzfeed-style listicles. Read a combination of high and lowbrow texts to make your knowledge more worldly and syncretic.

Make a schedule for personal reading time and stick to it. Reading widely, of course, has incalculable benefits that will not only help you score a 5 on the test but also strengthen your academic performance across the board. 

Reading will help you develop a more impressive vocabulary and a better understanding of varied sentence structure and syntax. The more you read, the better equipped you will be to score a 5 on this exam.

2. Become familiar with the Western Canon.

The Western canon, often referred to simply as “The Canon,” is the body of high-culture literature, music, philosophy, and works of art that is highly valued in the West, i.e., the poems, prose passages, and drama selections that you will mostly see on the AP® Lit exam. 

The canon contains the “classics,” so to speak, and it includes everything from Homer to Junot Diaz. Cultivating a basic understanding of these texts and their authors will not only familiarize you with the history and development of the English tradition but also strengthen your understanding of the so-called “conversation of literature,” the innumerable and complex ways that authors and their works speak to each other and interact. We recommend reading at least the first chapter of Harold Bloom’s book on the subject to get a basic understanding. 

We also insist that you familiarize yourself with the various problems that the perseverance of such a canon produces. During the 80s and 90s, a canon war of sorts took place among English departments, with progressives aiming to dismantle the canon on the grounds that it neglects many African-American, female, queer, and impoverished writers in favor of spotlighting “dead white males.” 

This friction between advocates and opponents of the canon is extremely important to the history and status quo of literary criticism, and understanding this battle will deeply enrich your understanding of literature and increase your chances of scoring a 5 on the exam.

3. Read Thomas Foster’s How To Read Literature Like a Professor .

This book is a lively and entertaining introduction to the tools frequently used in literary criticism, including symbolism, theme, context, irony, and more. It is an excellent way to begin thinking deeply about literature, and it offers clear examples of close-reading.

It also discusses a wide variety of works that will help familiarize you with the canon. It’s very accessible too. Buy it, read it, mark it up, and keep it by your side throughout class. It’s a great tool. 

4. Make flashcards.

You will need to have a strong understanding of different literary devices, authors, works, and rhetorical techniques, and you don’t want to waste time scrambling for definitions on the day of the exam. 

Make yourself some flashcards with the most common literary devices, authors, works, and rhetorical techniques, and carve out at least 30 minutes per day to review. If you’d prefer to use an online resource, make some flashcards over at Quizlet ! 

5. Form study groups!

The beauty of reading literature is that it often produces different and conflicting responses in people, so discussing literature with your friends is a good way to explore new and diverse perspectives. 

What you bring to a text, for instance, may be completely different from what your friend or peer brings. Discussion is a great way to comprehend and investigate difficult works. And it’s also pretty fun!

5 AP® English Literature and Composition Multiple Choice Study Tips

1. practice, practice..

Practice answering multiple choice questions as often as you can. AP® English Literature and Composition multiple choice questions will address either fiction, poetry, or drama, and they will ask you to identify and analyze various literary devices, techniques, and motifs. So study these very devices. If you find yourself totally stuck, consult our guide on how to tackle the multiple choice section . 

2. Sharpen your close-reading skills.

The true key to acing the multiple choice section of this exam is staying engaged with the passages provided to you and actively reading. That means staying alert through the passages, marking them up, and engaging with them directly, not passively skimming them.

Find a method of active reading that works best for you. Some like to mark up the passage extensively, while others prefer to just read the passage twice and take notes here and there. Select which method works for you and go with it. However, do not just choose the easy or lazy way out. You’ll regret it later when you receive your scores. 

3. Look over the questions before reading the passage.

This is often a semi-controversial piece of advice because it doesn’t work for all readers. But it can be helpful if you’re someone who gets easily distracted when reading old prose passages or difficult poetry! 

If you find your mind wandering when reading AP® Lit passages, glancing at the questions beforehand can give your brain a purpose to focus on and a point of entry into the passage. It’s always easiest to begin searching when you know what you’re looking for.

4. Use process of elimination.

Often, an AP® Lit multiple choice question will have one or two answer choices that can be crossed off pretty quickly. So try and narrow your choices down to two possible answers, and then choose the best one. 

If this strategy isn’t working on a particularly difficult question or it seems to hold you up longer than you’d like, it’s perfectly okay to circle it, skip it, and come back to it at the end. Do not get hung up on eliminating choices. Rather, use this strategy to make your reading more efficient and quicker. 

5. It doesn’t hurt to guess.

Obviously, while guessing on every single question isn’t a good strategy and will lead to a 1 on the exam, an educated guess on particularly difficult questions that you truly don’t know how to answer can help. You are scored only on the number of correct answers you give, not the number of questions you answer, so it makes sense to guess on questions that you seriously have no idea how to answer.  

5 AP® English Literature and Composition FRQ Study Tips

1. practice your writing skills by answering questions from collegeboard’s archive of past exam questions or explore our free response practice modules ..

Typically, the same skills are assessed from year to year, so practicing with released exams is a great way to brush up on your analysis skills, and our review practice allows you to pinpoint skills you may need help with.

2. Explore and use the rubric!

The best part about the updated AP® English Literature and Composition revised rubrics and scoring guidelines is that it’s very clear to discern which elements are needed to earn full credit for your essay. Granted, it can be tough to include each element—especially that tricky sophistication section—but the rubric’s outline offers a clear and concise portrait of the perfect essay .

Be sure to construct your thesis statement into a clear and definable interpretation. Provide specific evidence and compelling commentary that supports your thesis. If you check these boxes, then you will have a much greater chance of developing a clear and defensible interpretation. 

3. Pay attention to the task verbs employed in your free response prompts .

Task verbs are verbs that essentially indicate what it is you should do in your free response. The three common task verbs include: 

• Analyze: Examine methodically and in detail the structure of the topic of the question for purposes of interpretation and explanation.
• Choose: Select a literary work from among provided choices.
• Read: Look at or view printed directions and provided passages.

4. Have a solid understanding of literary devices.

Most of the FRQ’s require you to not only specifically identify a passage’s array of literary and rhetorical devices but also analyze and unpack how those devices construct mood, meaning, tone, and more. Study up, read the aforementioned Foster book , and take a look at our list of 15 Essential Rhetorical Terms to Know For AP® English Literature . 

5. Fine-tune your thesis statement.

Your thesis statement is arguably the most important sentence in your essay. It informs the reader of your central argument and summarizes your interpretation, and it sets the tone for the rest of your essay. It is imperative that you master the tricky art of the thesis statement before taking your exam. 

Many university writing centers offer online education on thesis statements that can prove extremely beneficial. Consult UNC Chapel Hill’s thesis statement handout for extra help!

The AP® English Literature and Composition Exam: 5 Test Day Tips to Remember

Be sure you put at least something in your stomach before taking the exam, even if it might be in knots from nerves. You don’t need to eat a deluxe breakfast of pancakes, eggs, bacon, biscuits, etc. (unless that’s your routine), but you do need to eat at least something . Your brain and your body need the energy. If you’re hungry during the exam, it might be harder for you to focus, leading to a lower score or an incomplete exam.

2. Make sure you know the location of your testing site before taking the test.

You do not want to be scrambling and running around the school trying to find your testing room on the day of the exam. Know your room number and know how to get there. There’s truly nothing worse than running around your school trying to find a room when a hugely-important test is underway. 

If you’re getting a ride from a parent or friend, be sure they know the address beforehand. If you’re taking public transit, check the schedule. If you are taking your exam at your own school, don’t get too comfortable. Be sure you know the room number! This is something small but impactful that you can do to reduce your stress the morning of your exam.

3. Prepare everything you need the night before.

Waking up and scrambling to choose an outfit, find pencils, or make breakfast will just stress you out and put you in a negative headspace. Plan your outfit the night before to reduce stress and have an easy breakfast ready to go.

Being prepared saves time and cuts back unnecessary stress. 

And wear something comfortable. You don’t want to be adjusting your outfit throughout the test. It’ll just be distracting. 

4. Bring mints or gum with you.

The rules say that you can’t have food or drink in the testing room, but mints and/or gum are usually allowed unless it’s against your testing site’s own rules. If you find yourself getting distracted, pop a mint or a stick of gum in your mouth! This can help to keep you more awake and focused.

5. Remember to breathe and just relax.

Seriously, just breathe. If you’ve followed the rest of the tips in this post, listened to your teacher, read up on your literary devices, and done your homework, then you’re well-prepared for this exam. Trust yourself. Know that you have done all you can do to prepare and don’t cram the morning of the exam. Last-minute studying helps no one, and it often just leads to stress!

AP® English Literature and Composition Review Notes and Practice Test Resources

Ap® collegeboard’s official youtube channel.

This YouTube channel provides tons of tips, advice, and strategies for tackling the AP® English Literature and Composition exam. It offers online seminars and classes on a diverse range of Lit-related topics such as plot structure, unpacking symbolism, and crafting strong commentary. The best thing about it is that real-life teachers lead the classes, so they feel very personalized.

If you’re a more visual learner who thrives on video content, then this channel is perfect for you!

How-to Guide for Literary Analysis Essays

While we 100% do not condone using Sparknotes textual summaries to get your way through AP® English Literature, we do recommend taking a look at some of their guides and workshops and using them as supplementary resources. This how-to guide offers a 7-step method of approaching literary analysis that might help you get the ball rolling if you’re totally stuck.

This guide is perfect for anyone needing to brush up on their writing skills or anyone needing to find a solid step-by-step approach to writing the free response questions.

AP® English Literature Jeopardy Game

This online Jeopardy game is not only tons of fun but also super helpful in developing your memory and strengthening your understanding of basic literary elements and devices. It contains categories involving poetry terms, general Lit, syntax, style, and figurative language. It’s a great way to review basic terms for the exam, and you can play with up to ten people through its make-your-team feature.  

This is a perfect review for anyone looking to quickly review literary terms in a fun way.

Ms. Effie’s Lifesavers

If you’re a seasoned AP® English teacher, Ms. Effie (Sandra Effinger) probably needs no introduction! Ms. Effie’s Lifesavers website has helped many AP® Lang and AP® Lit teachers plan effective and thoroughly aligned lessons and assignments. Sandra was an AP® Reader for many years, so she knows her stuff. She has tons of free content on her page, as well as a Dropbox full of AP® English goodies for anyone who makes a donation via her PayPal. You’ll find resources for both AP® Language and AP® Literature here. 

Ms. Effie’s webpage is perfect for all students. Really, it has material that would benefit those looking for quick reviews, deeper analysis of free response questions, or help with multiple choice questions.

Summary: The Best AP® English Literature and Composition Review Guide

Remember, the structure of the AP® Lang exam is as follows:

Because AP® English Literature and Composition is a skills-based course, there’s no way to know what specific passages, poems, authors, or concepts might make it onto the official exam. But, we do know exactly which skills will be assessed with which passages, so it’s best to center your studying around brushing up on those skills!

Use the provided charts to help you understand which skills you should focus on, and use Albert’s AP® English Literature and Composition Course Guide to brush up on your understanding of each skill and its corresponding essential knowledge.

Start with a diagnostic test, either on Albert or with a pencil and paper test via Princeton Review or Barron’s . Once you’ve completed and scored your diagnostic, follow our 7 steps on how to create an AP® English Literature and Composition study plan. 

And remember: start reading now! The more you read, the more equipped you will be to ace this exam. Review the Western Canon, study your literary terms, and begin critically engaging with writers!

Practice answering multiple choice questions on Albert and free-response questions from The College Board’s archive of past exam questions. 

If you’ve followed the rest of the tips in this post, listened to your teacher, and done your homework, you’re well-prepared for this exam. Trust that you have done all you can do to prepare and don’t cram the morning of. Last-minute studying helps no one!

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Rapid literature review: definition and methodology

Beata smela.

a Assignity, Cracow, Poland

Mondher Toumi

b Public Health Department, Aix-Marseille University, Marseille, France

Karolina Świerk

Clement francois, małgorzata biernikiewicz.

c Studio Slowa, Wroclaw, Poland

Emilie Clay

d Clever-Access, Paris, France

Laurent Boyer

Introduction: A rapid literature review (RLR) is an alternative to systematic literature review (SLR) that can speed up the analysis of newly published data. The objective was to identify and summarize available information regarding different approaches to defining RLR and the methodology applied to the conduct of such reviews.

Methods: The Medline and EMBASE databases, as well as the grey literature, were searched using the set of keywords and their combination related to the targeted and rapid review, as well as design, approach, and methodology. Of the 3,898 records retrieved, 12 articles were included.

Results: Specific definition of RLRs has only been developed in 2021. In terms of methodology, the RLR should be completed within shorter timeframes using simplified procedures in comparison to SLRs, while maintaining a similar level of transparency and minimizing bias. Inherent components of the RLR process should be a clear research question, search protocol, simplified process of study selection, data extraction, and quality assurance.

Conclusions: There is a lack of consensus on the formal definition of the RLR and the best approaches to perform it. The evidence-based supporting methods are evolving, and more work is needed to define the most robust approaches.

Introduction

A systematic literature review (SLR) summarizes the results of all available studies on a specific topic and provides a high level of evidence. Authors of the SLR have to follow an advanced plan that covers defining a priori information regarding the research question, sources they are going to search, inclusion criteria applied to choose studies answering the research question, and information regarding how they are going to summarize findings [ 1 ].

The rigor and transparency of SLRs make them the most reliable form of literature review [ 2 ], providing a comprehensive, objective summary of the evidence for a given topic [ 3 , 4 ]. On the other hand, the SLR process is usually very time-consuming and requires a lot of human resources. Taking into account a high increase of newly published data and a growing need to analyze information in the fastest possible way, rapid literature reviews (RLRs) often replace standard SLRs.

There are several guidelines on the methodology of RLRs [ 5–11 ]; however, only recently, one publication from 2021 attempted to construct a unified definition [ 11 ]. Generally, by RLRs, researchers understand evidence synthesis during which some of the components of the systematic approach are being used to facilitate answering a focused research question; however, scope restrictions and a narrower search strategy help to make the project manageable in a shorter time and to get the key conclusions faster [ 4 ].

The objective of this research was to collect and summarize available information on different approaches to the definition and methodology of RLRs. An RLR has been run to capture publications providing data that fit the project objective.

To find publications reporting information on the methodology of RLRs, searches were run in the Medline and EMBASE databases in November 2022. The following keywords were searched for in titles and abstracts: ‘targeted adj2 review’ OR ‘focused adj2 review’ OR ‘rapid adj2 review’, and ‘methodology’ OR ‘design’ OR ‘scheme’ OR ‘approach’. The grey literature was identified using Google Scholar with keywords including ‘targeted review methodology’ OR ‘focused review methodology’ OR ‘rapid review methodology’. Only publications in English were included, and the date of publication was restricted to year 2016 onward in order to identify the most up-to-date literature. The reference lists of each included article were searched manually to obtain the potentially eligible articles. Titles and abstracts of the retrieved records were first screened to exclude articles that were evidently irrelevant. The full texts of potentially relevant papers were further reviewed to examine their eligibility.

A pre-defined Excel grid was developed to extract the following information related to the methodology of RLR from guidelines:

• Definition,
• Research question and searches,
• Studies selection,
• Data extraction and quality assessment,
• Additional information.

There was no restriction on the study types to be analyzed; any study reporting on the methodology of RLRs could be included: reviews, practice guidelines, commentaries, and expert opinions on RLR relevant to healthcare policymakers or practitioners. The data extraction and evidence summary were conducted by one analyst and further examined by a senior analyst to ensure that relevant information was not omitted. Disagreements were resolved by discussion and consensus.

Studies selection

A total of 3,898 records (3,864 articles from a database search and 34 grey literature from Google Scholar) were retrieved. After removing duplicates, titles and abstracts of 3,813 articles were uploaded and screened. The full texts of 43 articles were analyzed resulting in 12 articles selected for this review, including 7 guidelines [ 5–11 ] on the methodology of RLRs, together with 2 papers summarizing the results of the Delphi consensus on the topic [ 12 , 13 ], and 3 publications analyzing and assessing different approaches to RLRs [ 4 , 14 , 15 ].

Overall, seven guidelines were identified: from the World Health Organization (WHO) [ 5 ], National Collaborating Centre for Methods and Tools (NCCMT) [ 7 ], the UK government [ 8 ], the Oxford Centre for Evidence Based Medicine [ 9 ], the Cochrane group [ 6 , 11 ], and one multi-national review [ 10 ]. Among the papers that did not describe the guidelines, Gordon et al. [ 4 ] proposed 12 tips for conducting a rapid review in the right settings and discussed why these reviews may be more beneficial in some circumstances. The objective of work conducted by Tricco et al. [ 13 ] and Pandor et al. [ 12 ] was to collect and compare perceptions of rapid reviews from stakeholders, including researchers, policymakers, industry, journal editors, and healthcare providers, and to reach a consensus outlining the domains to consider when deciding on approaches for RLRs. Haby et al. [ 14 ] run a rapid review of systematic reviews and primary studies to find out the best way to conduct an RLR in health policy and practice. In Tricco et al. (2022) [ 15 ], JBI position statement for RLRs is presented.

From all the seven identified guidelines information regarding definitions the authors used for RLRs, approach to the PICOS criteria and search strategy development, studies selection, data extractions, quality assessment, and reporting were extracted.

Cochrane Rapid Reviews Methods Group developed methods guidance based on scoping review of the underlying evidence, primary methods studies conducted, as well as surveys sent to Cochrane representative and discussion among those with expertise [ 11 ]. They analyzed over 300 RLRs or RLR method papers and based on the methodology of those studies, constructed a broad definition RLR, one that meets a minimum set of requirements identified in the thematic analysis: ‘ A rapid review is a form of knowledge synthesis that accelerates the process of conducting a traditional systematic review through streamlining or omitting a variety of methods to produce evidence in a resource-efficient manner .’ This interpretation aligns with more than 50% of RLRs identified in this study. The authors additionally provided several other definitions, depending on specific situations or requirements (e.g., when RLR is produced on stakeholder’s request). It was additionally underlined that RLRs should be driven by the need of timely evidence for decision-making purposes [ 11 ].

Rapid reviews vary in their objective, format, and methods used for evidence synthesis. This is a quite new area, and still no agreement on optimal methods can be found [ 5 ]. All of the definitions are highlighting that RLRs are completed within shorter timeframes than SLRs, and also lack of time is one of the main reasons they are conducted. It has been suggested that most rapid reviews are conducted within 12 weeks; however, some of the resources suggest time between a few weeks to no more than 6 months [ 5 , 6 ]. Some of the definitions are highlighting that RLRs follow the SLR process, but certain phases of the process are simplified or omitted to retrieve information in a time-saving way [ 6 , 7 ]. Different mechanisms are used to enhance the timeliness of reviews. They can be used independently or concurrently: increasing the intensity of work by intensifying the efforts of multiple analysts by parallelization of tasks, using review shortcuts whereby one or more systematic review steps may be reduced, automatizing review steps by using new technologies [ 5 ]. The UK government report [ 8 ] referred to two different RLRs: in the form of quick scoping reviews (QSR) or rapid evidence assessments (REA). While being less resource and time-consuming compared to standard SLRs, QSRs and REAs are designed to be similarly transparent and to minimize bias. QSRs can be applied to rather open-ended questions, e.g., ‘what do we know about something’ but both, QSRs and REAs, provide an understanding of the volume and characteristics of evidence on a specific topic, allowing answering questions by maximizing the use of existing data, and providing a clear picture of the adequacy of existing evidence [ 8 ].

Research questions and searches

The guidelines suggest creating a clear research question and search protocol at the beginning of the project. Additionally, to not duplicate RLRs, the Cochrane Rapid Reviews Methods Group encourages all people working on RLRs to consider registering their search protocol with PROSPERO, the international prospective register of reviews; however, so far they are not formally registered in most cases [ 5 , 6 ]. They also recommend involving key stakeholders (review users) to set and refine the review question, criteria, and outcomes, as well as consulting them through the entire process [ 11 ].

Regarding research questions, it is better to structure them in a neutral way rather than focus on a specific direction for the outcome. By doing so, the researcher is in a better position to identify all the relevant evidence [ 7 ]. Authors can add a second, supportive research question when needed [ 8 ]. It is encouraged to limit the number of interventions, comparators and outcomes, to focus on the ones that are most important for decision-making [ 11 ]. Useful could be also reviewing additional materials, e.g., SLRs on the topic, as well as conducting a quick literature search to better understand the topic before starting with RLRs [ 7 ]. In SLRs researchers usually do not need to care a lot about time spent on creating PICOS, they need to make sure that the scope is broad enough, and they cannot use many restrictions. When working on RLRs, a reviewer may spend more or less time defining each of the components of the study question, and the main step is making sure that PICOS addresses the needs of those who requested the rapid review, and at the same time, it is feasible within the required time frame [ 7 ]. Search protocol should contain an outline of how the following review steps are to be carried out, including selected search keywords and a full strategy, a list of data sources, precise inclusion and exclusion criteria, a strategy for data extraction and critical appraisal, and a plan of how the information will be synthesized [ 8 ].

In terms of searches running, in most cases, an exhaustive process will not be feasible. Researchers should make sure that the search is effective and efficient to produce results in a timely manner. Cochrane Rapid Reviews Methods Group recommends involving an information specialist and conducting peer review of at least one search strategy [ 11 ]. According to the rapid review guidebook by McMaster University [ 7 ], it is important that RLRs, especially those that support policy and program decisions, are being fed by the results of a body of literature, rather than single studies, when possible. It would result in more generalizable findings applied at the level of a population and serve more realistic findings for program decisions [ 7 ]. It is important to document the search strategy, together with a record of the date and any date limits of the search, so that it can easily be run again, modified, or updated. Furthermore, the information on the individual databases included in platform services should always be reported, as this depends on organizations’ subscriptions and must be included for transparency and repeatability [ 7 , 8 ]. Good solution for RLRs is narrowing the scope or searching a limited number of databases and other sources [ 7 ]. Often, the authors use the PubMed/MEDLINE, Cochrane Library, and Embase databases. In most reviews, two or more databases are searched, and common limits are language (usually restricted to English), date, study design, and geographical area. Some RLRs include searching of grey literature; however, contact with authors is rather uncommon [ 5 , 8 ]. According to the flexible framework for restricted systematic review published by the University of Oxford, the search should be run in at least one major scientific database such as PubMed, and one other source, e.g., Google Scholar [ 9 ]. Grey literature and unpublished evidence may be particularly needed and important for intervention questions. It is related to the fact that studies that do not report the effects of interventions are less likely to be published [ 8 ]. If there is any type of evidence that will not be considered by the RLRs, e.g., reviews or theoretical and conceptual studies, it should also be stated in the protocol together with justification [ 8 ]. Additionally, authors of a practical guide published by WHO suggest using a staged search to identify existing SLRs at the beginning, and then focusing on studies with other designs [ 5 ]. If a low number of citations have been retrieved, it is acceptable to expand searches, remove some of the limits, and add additional databases and sources [ 7 ].

Searching for RLRs is an iterative process, and revising the approach is usually needed [ 7 ]. Changes should be confirmed with stakeholders and should be tracked and reflected in the final report [ 5 ].

The next step in the rapid review is the selection of studies consisting of two phases: screening of titles and abstracts, and analysis of full texts. Prior to screening initiation, it is recommended to conduct a pilot exercise using the same 30–50 abstracts and 5–10 full-texts for the entire screening team in order to calibrate and test the review form [ 11 ]. In contrast to SLRs, it can be done by one reviewer with or without verification by a second one. If verification is performed, usually the second reviewer checks only a subset of records and compares them. Cochrane Group, in contrast, recommends a stricter approach: at least 20% of references should be double-screened at titles and abstracts stage, and while the rest of the references may be screened by one reviewer, the excluded items need to be re-examined by second reviewer; similar approach is used in full-text screening [ 11 ]. This helps to ensure that bias was reduced and that the PICOS criteria are applied in a relevant way [ 5 , 8 , 9 , 11 ]. During the analysis of titles and abstracts, there is no need to report reasons for exclusion; however, they should be tracked for all excluded full texts [ 7 ].

Data extraction and quality assessment

According to the WHO guide, the most common method for data extraction in RLRs is extraction done by a single reviewer with or without partial verification. The authors point out that a reasonable approach is to use a second reviewer to check a random sample of at least 10% of the extractions for accuracy. Dual performance is more necessary for the extraction of quantitative results than for descriptive study information. In contrast, Cochrane group recommends that second reviewer should check the correctness and completeness of all data [ 11 ]. When possible, extractions should be limited to key characteristics and outcomes of the study. The same approach to data extraction is also suggested for a quality assessment process within rapid reviews [ 5 , 9 , 11 ]. Authors of the guidebook from McMaster University highlight that data extraction should be done ideally by two reviewers independently and consensus on the discrepancies should always be reached [ 7 ]. The final decision on the approach to this important step of review should depend on the available time and should also reflect the complexity of the research question [ 9 ].

For screening, analysis of full texts, extractions, and quality assessments, researchers can use information technologies to support them by making these review steps more efficient [ 5 ].

Before data reporting, a reviewer should prepare a document with key message headings, executive summary, background related to the topic and status of the current knowledge, project question, synthesis of findings, conclusions, and recommendations. According to the McMaster University guidebook, a report should be structured in a 1:2:20 format, that is, one page for key messages, two pages for an executive summary, and a full report of up to 20 pages [ 7 ]. All the limitations of the RLRs should be analyzed, and conclusions should be drawn with caution [ 5 ]. The quality of the accumulated evidence and the strength of recommendations can be assessed using, e.g., the GRADE system [ 5 ]. When working on references quoting, researchers should remember to use a primary source, not secondary references [ 7 ]. It would be worth considering the support of some software tools to automate reporting steps. Additionally, any standardization of the process and the usage of templates can support report development and enhance the transparency of the review [ 5 ].

Ideally, all the review steps should be completed during RLRs; however, often some steps may need skipping or will not be completed as thoroughly as should because of time constraints. It is always crucial to decide which steps may be skipped, and which are the key ones, depending on the project [ 7 ]. Guidelines suggest that it may be helpful to invite researchers with experience in the operations of SLRs to participate in the rapid review development [ 5 , 9 ]. As some of the steps will be completed by one reviewer only, it is important to provide them with relevant training at the beginning of the process, as well as during the review, to minimize the risk of mistakes [ 5 ].

Additional information

Depending on the policy goal and available resources and deadlines, methodology of the RLRs may be modified. Wilson et al. [ 10 ] provided extensive guidelines for performing RLR within days (e.g., to inform urgent internal policy discussions and/or management decisions), weeks (e.g., to inform public debates), or months (e.g., to inform policy development cycles that have a longer timeline, but that cannot wait for a traditional full systematic review). These approaches vary in terms of data synthesis, types of considered evidence and project management considerations.

In shortest timeframes, focused questions and subquestions should be formulated, typically to conduct a policy analysis; the report should consist of tables along with a brief narrative summary. Evidence from SLRs is often considered, as well as key informant interviews may be conducted to identify additional literature and insights about the topic, while primary studies and other types of evidence are not typically feasible due to time restrictions. The review would be best conducted with 1–2 reviewers sharing the work, enabling rapid iterations of the review. As for RLRs with longer timeline (weeks), these may use a mix of policy, systems and political analysis. Structure of the review would be similar to shorter RLRs – tabular with short narrative summary, as the timeline does not allow for comprehensive synthesis of data. Besides SLRs, primary studies and other evidence may be feasible in this timeframe, if obtained using the targeted searches in the most relevant databases. The review team should be larger, and standardized procedures for reviewing of the results and data extraction should be applied. In contrast to previous timeframe, merit review process may be feasible. For both timeframes, brief consultations with small transdisciplinary team should be conducted at the beginning and in the final stage of the review to discuss important matters.

For RLRs spanning several months, more comprehensive methodology may be adapted in terms of data synthesis and types of evidence. However, authors advise that review may be best conducted with a small review team in order to allow for more in-depth interpretation and iteration.

Studies analyzing methodology

There have been two interesting publications summarizing the results of Delphi consensus on the RLR methodology identified and included in this review [ 12 , 13 ].

Tricco et al. [ 13 ] first conducted an international survey and scoping review to collect information on the possible approaches to the running of rapid reviews, based on which, they employed a modified Delphi method that included inputs from 113 stakeholders to explore the most optimized approach. Among the six most frequent rapid review approaches (not all detailed here) being evaluated, the approach that combines inclusion of published literature only, a search of more than one database and limitations by date and language, study selection by one analyst, data extraction, and quality assessment by one analyst and one verifier, was perceived as the most feasible approach (72%, 81/113 responses) with the potentially lowest risk of bias (12%, 12/103). The approach ranked as the first one when considering timelines assumes updating of the search from a previously published review, no additional limits on search, studies selection and data extraction done by one reviewer, and no quality assessment. Finally, based on the publication, the most comprehensive RLRs can be made by moving on with the following rules: searching more than one database and grey literature and using date restriction, and assigning one reviewer working on screening, data extraction, and risk of bias assessment ( Table 1 ). Pandor et al. [ 12 ] introduced a decision tool for SelecTing Approaches for Rapid Reviews (STARR) that were produced through the Delphi consensus of international experts through an iterative and rigorous process. Participants were asked to assess the importance of predefined items in four domains related to the rapid review process: interaction with commissioners, understanding the evidence base, data extraction and synthesis methods, and reporting of rapid review methods. All items assigned to four domains achieved > 70% of consensus, and in that way, the first consensus-driven tool has been created that supports authors of RLRs in planning and deciding on approaches.

Six most frequent approaches to RLRs (adapted from Tricco et al. [ 13 ]).

Haby et al. [ 14 ] run searches of 11 databases and two websites and developed a comprehensive overview of the methodology of RLRs. With five SLRs and one RCT being finally included, they identified the following approaches used in RLRs to make them faster than full SLRs: limiting the number and scope of questions, searching fewer databases, limited searching of grey literature, restrictions on language and date (e.g., English only, most recent publications), updating the existing SLRs, eliminating or limiting hand searches of reference lists, noniterative search strategies, eliminating consultation with experts, limiting dual study selection, data extraction and quality assessment, minimal data synthesis with short concise conclusions or recommendations. All the SLRs included in this review were consistent in stating that no agreed definition of rapid reviews is available, and there is still no final agreement on the best methodological rules to be followed.

Gordon et al. [ 4 ] explained the advantages of performing a focused review and provided 12 tips for its conduction. They define focused reviews as ‘a form of knowledge synthesis in which the components of the systematic process are applied to facilitate the analysis of a focused research question’. The first tip presented by the authors is related to deciding if a focused review is a right solution for the considered project. RLRs will suit emerging topics, approaches, or assessments where early synthesis can support doctors, policymakers, etc., but also can direct future research. The second, third, and fourth tips highlight the importance of running preliminary searches and considering narrowing the results by using reasonable constraints taking into account the local context, problems, efficiency perspectives, and available time. Further tips include creating a team of experienced reviewers working on the RLRs, thinking about the target journal from the beginning of work on the rapid review, registering the search protocol on the PROSPERO registry, and the need for contacting authors of papers when data available in publications are missing or incongruent. The last three tips are related to the choice of evidence synthesis method, using the visual presentation of data, and considering and describing all the limitations of the focused review.

Finally, a new publication by Tricco et al. from 2022, describing JBI position statement [ 15 ] underlined that for the time being, there is no specific tool for critical appraisal of the RLR’s methodological quality. Instead, reviewers may use available tools to assess the risk of bias or quality of SLRs, like ROBIS, the JBI critical appraisal tools, or the assessment of multiple systematic reviews (AMSTAR).

Inconsistency in the definitions and methodologies of RLR

Although RLR was broadly perceived as an approach to quicken the conduct of conventional SLR, there is a lack of consensus on the formal definition of the RLR, so as to the best approaches to perform it. Only in 2021, a study proposing unified definition was published; however, it is important to note that the most accurate definition was only matching slightly over 50% of papers analysed by the authors, which underlines the lack of homogeneity in the field [ 11 ]. The evidence-based supporting methods are evolving, and more evidence is needed to define the most robust approaches [ 5 ].

Diverse terms are used to describe the RLR, including ‘rapid review’, focused systematic review’, ‘quick scoping reviews’, and ‘rapid evidence assessments’. Although the general principles of conducting RLR are to accelerate the whole process, complexity was seen in the methodologies used for RLRs, as reflected in this study. Also, inconsistencies related to the scope of the questions, search strategies, inclusion criteria, study screening, full-text review, quality assessment, and evidence presentation were implied. All these factors may hamper decision-making about optimal methodologies for conducting rapid reviews, and as a result, the efficiency of RLR might be decreased. Additionally, researchers may tend to report the methodology of their reviews without a sufficient level of detail, making it difficult to appraise the quality and robustness of their work.

Advantages and weaknesses of RLR

Although RLR used simplified approaches for evidence synthesis compared with SLR, the methodologies for RLR should be replicable, rigorous, and transparent to the greatest extent [ 16 ]. When time and resources are limited, RLR could be a practical and efficient tool to provide the summary of evidence that is critical for making rapid clinical or policy-related decisions [ 5 ]. Focusing on specific questions that are of controversy or special interest could be powerful in reaffirming whether the existing recommendation statements are still appropriate [ 17 ].

The weakness of RLR should also be borne in mind, and the trade-off of using RLR should be carefully considered regarding the thoroughness of the search, breadth of a research question, and depth of analysis [ 18 ]. If allowed, SLR is preferred over RLR considering that some relevant studies might be omitted with narrowed search strategies and simplified screening process [ 14 ]. Additionally, omitting the quality assessment of included studies could result in an increased risk of bias, making the comprehensiveness of RLR compromised [ 13 ]. Furthermore, in situations that require high accuracy, for example, where a small relative difference in an intervention has great impacts, for the purpose of drafting clinical guidelines, or making licensing decisions, a comprehensive SLR may remain the priority [ 19 ]. Therefore, clear communications with policymakers are recommended to reach an agreement on whether an RLR is justified and whether the methodologies of RLR are acceptable to address the unanswered questions [ 18 ].

Disclosure statement

No potential conflict of interest was reported by the author(s).

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Title: text generation: a systematic literature review of tasks, evaluation, and challenges.

Abstract: Text generation has become more accessible than ever, and the increasing interest in these systems, especially those using large language models, has spurred an increasing number of related publications. We provide a systematic literature review comprising 244 selected papers between 2017 and 2024. This review categorizes works in text generation into five main tasks: open-ended text generation, summarization, translation, paraphrasing, and question answering. For each task, we review their relevant characteristics, sub-tasks, and specific challenges (e.g., missing datasets for multi-document summarization, coherence in story generation, and complex reasoning for question answering). Additionally, we assess current approaches for evaluating text generation systems and ascertain problems with current metrics. Our investigation shows nine prominent challenges common to all tasks and sub-tasks in recent text generation publications: bias, reasoning, hallucinations, misuse, privacy, interpretability, transparency, datasets, and computing. We provide a detailed analysis of these challenges, their potential solutions, and which gaps still require further engagement from the community. This systematic literature review targets two main audiences: early career researchers in natural language processing looking for an overview of the field and promising research directions, as well as experienced researchers seeking a detailed view of tasks, evaluation methodologies, open challenges, and recent mitigation strategies.

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Book Review: Twin brothers, one religious, one not, go on a wild and wacky road trip through South

This cover image released by Central Avenue shows “Goyhood” by Reuven Fenton. (Central Avenue via AP)

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In the beginning was… a lie. One day a rabbi knocked on the door of a woman with a Jewish-sounding last name in a small town in Georgia to recruit new members for his synagogue. When he asks if she knows of any Jews in the area, Ida Mae Belkin admits to being one herself. This comes as a shock to her 12-year-old twins Marty and David, who grew up believing in not much more than the national pastime of TV and fast food.

Fast forward some 20 years and Marty, who has become a religious scholar at a Brooklyn yeshiva and goes by the more Jewish-sounding name of Mayer, finds out via Ida Mae’s suicide note that she lied and he and David are not in fact Jewish. That means his marriage to devoutly Orthodox Sarah is effectively null and void since she never would have consented to marry someone outside the faith.

What to do? Clearly, the only solution is to convert to Judaism “on the down-low,” as Mayer’s pot-smoking rascal of a brother puts it, and in the meantime, take a road trip through the Deep South to, well, relax. So begins Reuven Fenton’s quirky debut novel, “Goyhood,” which takes the classic literary theme of the journey — think Homer’s “Odyssey” or Jack Kerouac’s “On the Road” — and gives it a decidedly unorthodox twist.

Over the course of their journey, the brothers will adopt a one-eyed dog, almost get blown up in a fireworks store and eventually scatter Ida Mae’s ashes in the Great Smoky Mountains. David’s good friend Charlayne, an Instagram influencer with issues of her own, wonders if their trip isn’t a kind of rumspringa, the Amish rite of passage when young people are encouraged to break the rules before joining the church.

At the beginning of their travels Mayer defines his newly discovered “goyhood” – that is, the condition of not being Jewish – as “the state of rebounding from one travesty to the next.” By the end, he has gained a glimmer of understanding about why the wife he adored was always so standoffish about sex.

Fenton, a longtime reporter for the New York Post whose previous book “Stolen Years” was a nonfiction study of 10 men and women wrongfully imprisoned, has written a big-hearted novel about the enduring importance of faith and family. While some of the plot twists are a little meshuga — the Yiddish word for crazy — overall, the book is a lot of fun.

AP book reviews: https://apnews.com/hub/book-reviews

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• Published: 24 May 2024

Vertebral hemangiomas: a review on diagnosis and management

• Kyle Kato 1 ,
• Nahom Teferi 2 ,
• Meron Challa 1 ,
• Kathryn Eschbacher 3 &
• Satoshi Yamaguchi 2  

Journal of Orthopaedic Surgery and Research volume  19 , Article number:  310 ( 2024 ) Cite this article

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Vertebral hemangiomas (VHs) are the most common benign tumors of the spinal column and are often encountered incidentally during routine spinal imaging.

A retrospective review of the inpatient and outpatient hospital records at our institution was performed for the diagnosis of VHs from January 2005 to September 2023. Search filters included “vertebral hemangioma,” "back pain,” “weakness,” “radiculopathy,” and “focal neurological deficits.” Radiographic evaluation of these patients included plain X-rays, CT, and MRI. Following confirmation of a diagnosis of VH, these images were used to generate the figures used in this manuscript. Moreover, an extensive literature search was conducted using PubMed for the literature review portion of the manuscript.

VHs are benign vascular proliferations that cause remodeling of bony trabeculae in the vertebral body of the spinal column. Horizontal trabeculae deteriorate leading to thickening of vertical trabeculae which causes a striated appearance on sagittal magnetic resonance imaging (MRI) and computed tomography (CT), “Corduroy sign,” and a punctuated appearance on axial imaging, “Polka dot sign.” These findings are seen in “typical vertebral hemangiomas” due to a low vascular-to-fat ratio of the lesion. Contrarily, atypical vertebral hemangiomas may or may not demonstrate the “Corduroy” or “Polka-dot” signs due to lower amounts of fat and a higher vascular component. Atypical vertebral hemangiomas often mimic other neoplastic pathologies, making diagnosis challenging. Although most VHs are asymptomatic, aggressive vertebral hemangiomas can present with neurologic sequelae such as myelopathy and radiculopathy due to nerve root and/or spinal cord compression. Asymptomatic vertebral hemangiomas do not require therapy, and there are many treatment options for vertebral hemangiomas causing pain, radiculopathy, and/or myelopathy. Surgery (corpectomy, laminectomy), percutaneous techniques (vertebroplasty, sclerotherapy, embolization), and radiotherapy can be used in combination or isolation as appropriate. Specific treatment options depend on the lesion's size/location and the extent of neural element compression. There is no consensus on the optimal treatment plan for symptomatic vertebral hemangioma patients, although management algorithms have been proposed.

While typical vertebral hemangioma diagnosis is relatively straightforward, the differential diagnosis is broad for atypical and aggressive lesions. There is an ongoing debate as to the best approach for managing symptomatic cases, however, surgical resection is often considered first line treatment for patients with neurologic deficit.

Introduction

Vertebral hemangiomas (VHs) are benign vascular lesions formed from vascular proliferation in bone marrow spaces that are limited by bony trabeculae [ 1 ]. VHs are quite common and are often incidental findings on spinal computed tomography (CT) and magnetic resonance imaging (MRI) of patients presenting with back or neck pain [ 2 , 3 ]. Previous, large autopsy series such as Schmorl (1926) and Junghanns (1932) found a VH prevalence of 11% in adult specimens [ 1 , 4 ]. However, the prevalence is believed to be higher as modern imaging techniques allow for better detection of small VHs that may not be easily diagnosed on autopsy specimens [ 5 ]. They can occur at any age but are most often seen in individuals in their 5th decade of life with a slight female preponderance [ 2 , 6 , 7 ]. Most VHs are found in the thoracic or lumbar spinal column and often involve the vertebral body, though they can extend to the pedicle, lamina, or spinous process, and may span multiple spinal segments [ 5 ].

The vast majority of VHs are asymptomatic, quiescent lesions [ 3 ]. Prior studies have stated less than 5% of VHs are symptomatic [ 8 , 9 ], although the 2023 study by Teferi et. al. demonstrated 35% of their 75 VH patients presented with symptoms including localized pain, numbness, and/or paresthesia [ 1 ]. 85% of symptomatic cases in this series were found to have VHs localized in the thoracic spine [ 1 ].

Among symptomatic VHs, up to 20–45% of cases may exhibit aggressive features including damage to surrounding bone and soft tissue or demonstrate rapid growth that extends beyond the vertebral body and invades the paravertebral and/or epidural space [ 1 , 5 , 10 , 11 ]. When “aggressive”, VHs may compress the spinal cord and nerve roots causing severe symptoms [ 1 , 5 ]. 45% of symptomatic VH patients present with neurologic deficits secondary to compressive lesions, bony expansion, disrupted blood flow, or vertebral body collapse while the remaining 55% present solely with back pain [ 8 , 12 , 13 , 14 , 15 ].

VHs are primarily diagnosed with radiographs, CT, and MRI, although other studies such as angiography, nuclear medicine studies, and positron emission—computed tomography (PET-CT) have been previously utilized to a lesser extent [ 1 , 15 , 16 , 17 , 18 , 19 ]. Radiologically, these lesions can be grouped into Typical, Atypical, and Aggressive subtypes (see radiological features). Histologically, VHs are composed of varying proportions of adipocytes, blood vessels, and interstitial edema which leads to thickening of vertical trabeculae in the affected vertebra [ 5 ]. This histopathology leads to the characteristic “polka-dot” sign on axial CT/MRI and “corduroy” sign on coronal and sagittal CT/MRI [ 5 , 20 ].

In terms of management, conservative treatment with observation and pain control are the mainstay of treatment for asymptomatic VH patients and those with mild-to-moderate pain respectively [ 21 ]. Surgical decompression is indicated for patients with neurologic deficits including compressive myelopathy or radiculopathy [ 22 ]. Other symptomatic patients have a wide variety of treatment options available including sclerotherapy, embolization, radiotherapy, and/or vertebroplasty [ 1 , 5 , 23 ]. The best approach in managing an individual patient with a symptomatic VH has not been elucidated and there have been different management algorithms suggested based on varying institutional experiences [ 1 , 5 , 24 , 25 ].

This article will review what is currently known regarding VHs. Diagnostic techniques and challenges will be highlighted as well as current treatment recommendations from the literature.

A retrospective review of the inpatient and outpatient hospital records at our institution was performed for the diagnosis of VHs from January 2005 to September 2023. Search filters included “vertebral hemangioma” "back pain,” “weakness,” “radiculopathy,” and “focal neurological deficits.” Radiographic evaluation of these patients included plain X-rays, CT, and MRI. Following confirmation of a diagnosis of VH, these images were used to generate the figures used in this manuscript. Moreover, an extensive literature search was conducted using PubMed for the literature review portion of the manuscript.

68 Articles were selected from our PubMed search. This article will review what is currently known about VHs. Diagnostic techniques and challenges will be highlighted as well as current treatment recommendations from the literature.

Histopathological features

VHs are benign tumors composed of various sized blood vessels, adipocytes, smooth muscle, fibrous tissue, hemosiderin, interstitial edema, and remodeled bone [ 5 , 7 , 26 , 27 ]. Macroscopically, they appear as soft, well-demarcated, dark red masses with intralesional, sclerotic boney trabeculae and scattered blood-filled cavities lending to a honeycomb appearance [ 5 , 6 , 7 ].

Microscopically, there are four subtypes of hemangiomas based on vascular composition: capillary, cavernous, arteriovenous (AV), and venous hemangiomas [ 28 ] (Fig.  1 ). Capillary hemangiomas are composed of small, capillary-sized blood vessels while cavernous hemangiomas present with collections of larger, dilated blood vessels [ 1 ]. AV hemangiomas are composed of interconnected arterial and venous networks while an abnormal collection of veins comprises venous hemangiomas [ 1 ]. VHs are predominately capillary and cavernous subtypes with thin-walled blood vessels surrounded by edematous stroma and boney trabeculae that permeate the bone marrow space [ 1 , 7 , 27 ]. In a sample of 64 surgically treated VHs cases, Pastushyn et al. reported 50% were capillary subtype, 28% were cavernous subtype, and 22% were mixed [ 29 ]. Occasionally, secondary reactive phenomena such as fibrous and/or adipose involution of bone marrow and remodeling of bone trabeculae may be seen [ 7 , 26 ]. Symptomatic VHs can be caused by all hemangioma subtypes, and there are no distinguishing features between subtypes on imaging [ 1 ]. However, cavernous and capillary subtypes are associated with favorable postsurgical outcomes [ 29 ].

Capillary hemangioma ( A and B ): A H&E 200× magnification showing proliferation of small caliber vessels within a fibrous stroma with surrounding bone, B CD34 immunohistochemical stain, 200× magnification highlighting small caliber vascular spaces. Cavernous hemangioma ( C and D ): C H&E 100× magnification showing proliferation of thin-walled, dilated, blood filled vascular channels, D H&E 200× magnification: Thin-walled, dilated vascular channels within a loose stroma with adjacent mature bone. Venous hemangioma ( E and F ): E H&E 100 ×  magnification showing abnormal proliferation of thick-walled vessels with dilated lumens. F H&E 100× magnification reveals tightly packed, thick-walled vessels with adjacent fragments of mature bone

Radiographic features

The histopathology of VHs gives rise to imaging features used to classify VHs as typical, atypical, or aggressive [ 13 ]. Typical and atypical MRI findings are correlated with the intralesional ratio of fat to vascular components [ 20 ]. Lesions with a high fat content are more likely to demonstrate features of typical VHs while those with a high vascular content (atypical VHs) tend to present without these findings [ 5 , 30 , 31 ]. Aggressive VHs have features including destruction of the cortex, invasion of the epidural and paravertebral spaces, and lesions extending beyond the vertebral body [ 13 , 15 , 20 ].

Laredo et al. demonstrated that VHs with a higher fatty content are generally quiescent lesions, while those with a higher vascular content are more likely to display “active” behavior and potentially evolve into compressive lesions [ 20 ]. Therefore, asymptomatic VHs can display both typical or atypical imaging findings while symptomatic lesions are more likely to present with atypical or aggressive findings [ 1 ]. Despite radiographically typical VHs being relatively easy to diagnose, atypical and aggressive VHs are much more challenging to recognize as they do not present with classic imaging findings and often mimic other pathologies such as multiple myeloma, metastatic bone lesions, and inflammatory conditions [ 5 , 30 , 31 ]. Compressive VHs often have coinciding radiologic and clinical classifications due to the correlation between aggressive behavior and compressive symptoms [ 5 ].

While MRI, CT, and radiographs are the primary imaging modalities used in the workup of VHs, other studies have also been used. Angiography will occasionally be performed to identify feeding/draining vessels and evaluate the blood supply to the spinal cord [ 5 ]. Multiphase technetium 99-methyl diphosphonate ( 99 Tc-MDP) bone scintigraphy may show increased tracer uptake in all phases (perfusion, blood pool, and delayed) due to technetium 99-labeled red blood cell accumulation in the tumors, which occurs in all hemangiomas [ 16 ]. PET-CT has been used to classify VHs as “hot” or “cold” lesions based on the degree of 18-FDG and 68-Ga DOTATATE uptake [ 17 , 18 , 19 ]. Although angiography is useful in clarifying the vascular network of aggressive VHs primarily, nuclear medicine studies offer a much more limited contribution to diagnosis when compared to CT and MRI [ 5 ].

Typical VHs

The collection of thin-walled, blood-filled spaces that comprise VHs cause resorption of horizontal trabeculae and reinforcement of vertical trabeculae, leading to a pattern of thickened vertical trabeculae interspersed with lower density bone of the nonexpanding vertebral body [ 15 , 31 , 32 ]. This composition is responsible for the “corduroy cloth” appearance seen in typical VHs on radiographic images [ 31 ].

On unenhanced axial CT images, typical VHs are characterized by a “polka dot” appearance, termed polka-dot sign. This is caused by small, punctate areas of high attenuation from hyperdense trabeculae surrounded by hypodense stroma [ 20 , 33 ] (Fig.  2 ). Like radiographs, sagittal and coronal CT images display the “corduroy” sign caused by thickened trabeculae in a field of hypodense bone (Fig.  2 ). There is no extraosseous extension of the hemangioma in typical VHs [ 5 ].

Sagittal ( A ) and axial ( B ) CT scans of a typical VH in an asymptomatic 50-year-old male demonstrating the “Corduroy” and “Polka-dot” signs respectively. Sagittal ( C ) and axial ( D ) T1-weighted MRIs of typical VHs are predominately hyperintense with areas of hypo-intensity due to thickening of vertical trabeculae. Sagittal ( E ) and axial ( F ) T2-weighted MRIs of typical VHs also appear as hyperintense lesions with areas of hypo-intensity that may demonstrate the “Corduroy” and “Polka-dot” signs as seen in CT images of typical VHs

Typical VHs tend to appear as hyperintense lesions on T1- and T2-weighted MRI sequences due to predominately fatty overgrowth with penetrating blood vessels [ 31 ] (Fig.  2 ). There are punctate areas of slight hypointensity within the lesion on axial T1-weighted MRI due to thickened vertical trabeculae which resembles the “polka-dot" sign [ 5 ] (Fig.  2 ). These trabeculae appear as linear striations on sagittal/coronal T1- and T2-weighted MRI [ 5 ] (Fig.  2 ). Fluid-sensitive sequences (i.e. short-tau inversion recovery or fat-saturated T2-weighted MRI) appear slightly hyperintense due to the vascular components of the lesion, and T1-weighted MRI with contrast demonstrates heterogenous enhancement of the lesion [ 3 ] (Fig.  3 ).

Contrast-enhanced T1 MRIs of a T8 VH in an asymptomatic fourteen-year-old female ( A ) and L3, L5 VHs in a thirty-one-year-old female with back pain ( B ), illustrating the heterogenous presentation of hemangiomas on post-contrast MRI

Atypical VHs

In contrast to typical VHs, atypical VHs tend to have a higher vascular component-to-fat ratio and may not demonstrate the classical imaging findings such as the “corduroy” and “polka-dot” signs [ 5 ]. This composition gives the lesion an iso- to hypointense appearance on T1-weighted MRI as well as a very high intensity appearance on T2-weighted and fluid-sensitive MRI [ 20 , 31 ] (Fig.  4 ). Atypical VHs often mimic primary bony malignancies or metastases and are more likely to demonstrate aggressive features, often making them difficult to diagnose [ 12 , 13 , 14 , 15 ].

Asymptomatic fifty-six-year-old male with a T9 atypical vertebral hemangioma that appears iso- to hypointense on axial T1 MRI ( A ) and hyperintense on axial T2 MRI ( B ). Atypical vertebral hemangiomas of the L3 and L5 vertebral bodies in a thirty-one-year-old female who presented with backpain. Sagittal T1 ( C ) and T2 ( D ) demonstrate hypo- and hyperintense lesions respectively

Aggressive VHs

Aggressive VHs routinely have atypical features on any imaging modality [ 1 , 5 ]. They may appear radiographically normal or show nonspecific findings such as osteoporosis, pedicle erosion, cortex expansion, vertebral collapse, or irregular vertical trabeculae associated with lytic areas of varying size [ 13 , 15 ] (Fig.  5 ).

Fifty-five-year-old female with an aggressive vertebral hemangioma of the L4 vertebral body with extension into the spinal canal. A Sagittal T1 MRI shows hypo-intensity of the entire vertebral body, although vertebral height is maintained. B Sagittal T2 MRI redemonstrates the lesion but appears hyperintense due to the vascularity of the hemangioma. Axial T1 ( C ) and T2 ( D ) MRI show involvement of the pedicles bilaterally and extension of the lesion into the anterior epidural space

CT findings are often nonspecific, including features such as extraosseous soft tissue expansion, cortical ballooning, or cortical lysis [ 34 , 35 ]. As with atypical VHs, the “corduroy” and “polka-dot” signs may not be readily visualized in aggressive or destructive lesions due to the higher vascular-to-fat ratio common in these hemangiomas [ 5 ]. However, it is important to be mindful of these signs because they can guide to the correct diagnosis. Other CT features that may assist in the diagnosis of inconspicuous VHs include extension of the lesion into the neural arch, involvement of the entire vertebral body, or an irregular honeycomb pattern due to serpentine vascular channels and fatty proliferation within the network of reorganizing bony trabeculae [ 20 ]. Vertebral fractures are rare due to the reinforcement of vertical trabeculae [ 1 ].

The composition of aggressive VHs, with a hypervascular stroma and less fat, results in a hypointense lesion on T1-weighted MRI [ 20 , 31 ] (Fig.  5 ). Again, this may conceal the “corduroy” and “polka-dot” signs which remain amongst the most useful imaging findings in the diagnosis of VHs, particularly in cases where other findings are nonspecific [ 5 ]. These non-specific findings may include hyperintensity on T2-weighted MRI due to the vascular components of the lesion (Fig.  5 ), which is also seen in most neoplastic and inflammatory lesions [ 31 ]. Areas of hyperintensity on fluid-sensitive MRI and the presence of lipid-dense content within the lesion may be seen as well [ 31 , 36 ]. Other features suggestive of an aggressive VH include a maintained vertebral body height, a sharp margin with normal marrow, an intact cortex adjacent to a paraspinal mass, or enlarged paraspinal vessels, however these findings are also nonspecific and relatively uncommon [ 5 , 13 ]. Although highly unusual, there have been cases of aggressive VHs with extensive intraosseous fatty stroma and simultaneous extraosseous extension of the lesion, permitting a straightforward diagnosis [ 36 ].

Even though some aggressive VHs may be diagnosed on CT and MRI, challenging cases may warrant the use of more advanced imaging techniques for accurate diagnosis. Higher fluid content relative to cellular soft tissue gives hemangiomas a bright appearance on diffusion weighted imaging (DWI) with elevated apparent diffusion coefficient (ADC) values, distinguishing them from metastases [ 37 ]. Volume transfer constant (K trans ) and plasma volume, which reflect capillary permeability and vessel density respectively, are quantitative measures derived from dynamic contrast enhanced magnetic resonance imaging (DCE MRI) perfusion imaging that can also be used to differentiate VHs and metastases [ 38 ]. K trans and plasma volume are both low in VHs and elevated in metastatic lesions [ 38 ]. Furthermore, aggressive VHs may show a signal drop when comparing non-contrast T1-weighted MRI with and without fat suppression, as well as microscopic lipid content on chemical shift imaging [ 39 ]. Finally, characteristic findings of aggressive VHs in angiography include vertebral body arteriole dilation, multiple capillary phase blood pools, and complete vertebral body opacification [ 15 ].

Laredo et al. [ 15 ] proposed a six-point scoring system to assist in the diagnosis of aggressive VHs based on the more common features observed in radiographs and CT. One point was given for each of the following findings: a soft tissue mass, thoracic location between T3–T9, involvement of the entire vertebral body, an irregular honeycomb appearance, cortical expansion, and extension into the neural arch [ 15 ]. The authors suggest that aggressive VHs should be suspected when a patient presents with nerve root pain in association with three or more of these features [ 15 ]. However, additional studies are needed to determine the utility of this scoring system as the predictive power has not been determined [ 5 ].

Some VHs are difficult to diagnose because they can have nonspecific findings on radiographs, CT, and MRI, making characteristic findings such as the “corduroy” and “polka-dot” signs, when present, important diagnostic features. VHs may also coexist with other vertebral lesions, further complicating the diagnosis. In these cases, angiography can differentiate a VH from a nonvascular lesion [ 40 ]. Ultimately, a biopsy may be required for accurate diagnosis, especially when there is potential for a malignant lesion such as angiosarcoma or epithelioid hemangioendothelioma.

Clinical features

VHs are often noted incidentally on spinal imaging and are often observed in patients in their fifth to sixth decade of life. Studies have shown that vertebral hemangiomas exhibit a slight female preponderance, with a male-to-female ratio of 1:1.5. [ 6 ]. Clinically, most VHs are asymptomatic and quiescent lesions, which rarely demonstrate active behavior and become symptomatic [ 41 ]. VHs occur most frequently in the thoracic spine [ 42 ], followed by the lumbar spine and cervical spine; sacral involvement is very rare [ 43 ].

When symptomatic, VHs can present with localized back pain or result in neurologic symptoms that are attributable to spinal cord compression, nerve root compression, or both, leading to myelopathy and/or radiculopathy [ 1 ]. At least 4 mechanisms of spinal cord and nerve root compression have been suggested: (1) hypertrophy or ballooning of the posterior cortex of the vertebral body caused by the angioma, (2) extension of the angioma through the cortex into the epidural space, (3) compression fracture of the involved vertebra, and (4) epidural hematoma [ 44 ]. When aggressive and symptomatic with spinal cord compression, VHs tend to occur in the thoracic spine [ 42 ].

Boriani et al. classified VHs into 4 groups based on the presence of symptoms and radiographic findings [ 45 ]. These include: Type I—latent, mild bony destruction with no symptoms; Type II—active, bony destruction with pain; Type III—aggressive, asymptomatic lesion with epidural and/or soft-tissue extension; and Type IV—aggressive, neurologic deficit with epidural and/or soft tissue extension.

Management options

Most VHs are asymptomatic and do not require treatment [ 1 , 21 ]. Treatment is indicated in cases with back pain or neurological symptoms, including myelopathy and/or radiculopathy, often caused by neuronal compression or vertebral fracture [ 1 ]. Previously, surgery was the primary treatment option offered to these patients, which was associated with an increased risk of complications, particularly intraoperative bleeding [ 1 ]. New modalities such as vertebroplasty have since gained traction as adjuncts or alternatives to surgery [ 1 ]. Today, there are several management options available for the treatment of symptomatic VHs, including conservative medical therapy, surgery, percutaneous techniques, radiotherapy, or a combination of these modalities [ 1 , 46 ].

There is no consensus on the best treatment strategy, however recently Teferi et. al. proposed a treatment algorithm for VHs based on their institutional experience and literature review (Fig.  6 ) [ 1 ]. They recommend conservative management for typical, asymptomatic VHs, CT-guided biopsy and metastatic workup with PET-CT for radiographically atypical VHs, surgical intervention with or without adjuvant therapy in cases with epidural spinal cord compression or vertebral compression fracture, and radiotherapy for recurrent, asymptomatic VHs following surgery.

Algorithm for diagnosis and management of VHs proposed by Teferi et al. [ 1 ]

Surgical treatment of VHs is recommended in cases with rapid or progressive neurologic symptoms including compressive myelopathy or radiculopathy [ 47 ]. Baily et al. documented the first case of surgical management for VHs after they successfully resolved a patient’s paraplegia secondary to an aggressive VH [ 48 ]. Prior to the 1960s, the average neurological recovery rate was 73% (range, 43–85%) with a mortality rate of 11.7% [ 49 ]. This is consistent with a series published by Ghormley et al. in 1941 where 5 symptomatic VH patients were treated with decompressive laminectomy and postoperative radiotherapy. Although three patients achieved partial or complete resolution of neurologic deficits, the procedure resulted in the death of the remaining two patients secondary to significant blood loss [ 50 ]. There were very few cases of symptomatic VHs documented prior to the 1960s, with one literature review reporting only 64 instances of VHs with neurologic dysfunction [ 49 ]. More recent studies demonstrate improvement in surgical outcomes with neurological recovery reaching 100% and mortality as low as 0% [ 42 ].

The goal of surgery is to decompress neural elements and stabilize the spine [ 1 ]. Potential options include corpectomy, involving resection of a portion of the vertebral body containing the hemangioma, followed by anterior column reconstruction and/or laminectomy, which offers indirect decompression [ 1 ]. The selected approach depends on the size of the hemangioma and the extent of vertebral body and/or neural arch involvement due to potential weaknesses in the anterior column and the location of the epidural intrusion into the spinal canal [ 1 ]. For example, corpectomy and reconstruction could be performed in cases with ventral spinal cord compression while cases with dorsal compression could be treated with laminectomy [ 1 ].

Corpectomy has an increased risk of substantial intraoperative blood loss, up to 5 L in some cases, due to the hypervascular nature of VHs [ 1 , 51 ]. Acosta et al. reported an average blood loss of 2.1 L in their series of 10 aggressive VHs treated with corpectomy [ 51 ]. Conversely, laminectomy has a lower surgical burden and reduced risk of significant intraoperative blood loss [ 1 ]. Laminectomy blood loss can be further reduced by nearly 50% by performing vertebroplasty before laminectomy [ 8 ]. Preoperative embolization of VHs should also be considered to minimize intraoperative blood loss and reduce mortality [ 1 , 22 ].

Goldstein et al. demonstrated that en bloc resection may not be necessary, as intralesional resection produced equivalent long-term survival and prevention of recurrence in their series of 65 patients [ 47 ]. However, there have not been any large-scale studies comparing outcomes and recurrence rates of indirect decompression versus corpectomy [ 1 ].

The treatment algorithm proposed by Teferi et al. suggests dividing symptomatic VH patients with radiculopathy or neurological deficit into cohorts of epidural spinal cord compression (ESCC) versus vertebral body compression fracture to determine appropriate surgical intervention (Fig.  6 ) [ 1 ]. Patients with ESCC are encouraged to undergo preoperative embolization followed by laminectomy with or without fusion depending on spinal stability, or preoperative embolization followed by corpectomy and fusion if ESCC is accompanied by extensive anterior column compromise [ 1 ]. Conversely, the recommended treatment for symptomatic VHs secondary to vertebral body compression fracture is posterior laminectomy with decompression and fusion [ 1 ].

Whether through corpectomy or laminectomy, surgical management of VHs has a low recurrence rate [ 1 ]. Piper et al. reported complete remission in 84% of VHs treated surgically in their 2020 meta-analysis [ 52 ]. They also reported a severe complication rate, including pathological fracture, significant intraoperative blood loss, wound infection, and cerebrospinal fluid leak, of 3.5% [ 1 , 52 ].

Percutaneous techniques

Percutaneous techniques include vertebroplasty, sclerotherapy, and embolization which have been rising in popularity as treatment options for VHs in isolation or in combination with surgery [ 1 ].

Vertebroplasty is a minimally invasive procedure that improves the structural integrity of a vertebra by injecting an acrylic compound, such as polymethyl methacrylate (PMMA), into a lesion [ 1 ]. It was first utilized in the treatment of VHs by Galibert et al. in 1987 [ 53 ]. PMMA causes thrombosis and irreversible sclerosis of the hemangiomatous venous pool, shrinking the lesion and consolidating trabecular microfractures [ 1 ]. It allows for rapid recovery of mobility, enhances anterior column support, and provides vertebral stabilization, but does not induce new bone formation due to poor biological activity and absorbability [ 54 , 55 ]. Vertebroplasty is particularly effective in alleviating back pain in VH patients with intravertebral fractures by providing an immediate analgesic effect and has previously been recommended as stand-alone first line therapy for VHs with moderate to severe back pain without neurologic compromise [ 1 , 54 ]. It can also be used in combination with surgery to reduce intraoperative blood loss when given as a preoperative adjunct therapy [ 8 ]. The most common complication of vertebroplasty is extravasation of injected compound outside the vertebral body with rates of 20–35% [ 55 , 56 ]. However, some researchers suggest small amounts of extravasation should be considered a stopping point rather than a complication as the vast majority of cases are asymptomatic [ 55 , 56 ]. In a series of 673 vertebroplasty cases, Layton et al. reported extravasation in 25% of patients with only 1% developing clinical symptoms of new onset radiculopathy (5 patients) or symptomatic pulmonary embolism (1 patient) [ 56 ]. Their second most common complication was rib fracture related to lying prone on the fluoroscopy table during the procedure which occurred in 1% of cases (7 patients) [ 56 ].

Alternatively, sclerotherapy involves direct intralesional injection of ethanol under percutaneous CT-guidance which causes thrombosis and destruction of endothelium, resulting in devascularization, shrinkage of the lesion, and, consequently, decompression of the neural elements [ 46 ]. It was first described as a treatment for VHs in 1994 by Heiss et al. and is less common in the treatment of VHs [ 57 ]. CT angiography is a prerequisite to target the most hypervascular subsection of the lesion and ensure patients are candidates for the procedure without leakage of contrast media, which occurred in 25% of patients in a series of 18 cases [ 58 ]. There are reports of intraoperative sclerotherapy as an adjunct to surgery, but the sample sizes are similarly limited [ 59 , 60 ]. Complications of direct ethanol injection include neurologic deterioration (including Brown- Sequard syndrome), pathologic fractures, and VH recurrence [ 46 , 61 ].

The last option for percutaneous intervention is trans-arterial embolization of feeding vessels using particulate agents [ 1 ]. It has been used as a preoperative adjunct therapy with surgery to reduce blood loss as well as a primary treatment for VHs alone or in conjunction with vertebroplasty [ 41 , 62 , 63 , 64 ]. In a series of 26 patients, Premat et al. demonstrated embolization combined with vertebroplasty was safe and effective in treating pain associated with aggressive VHs but was less effective in resolving motor deficits [ 65 ]. The primary role for embolization in the treatment of compressive VHs is preoperative adjunct therapy to reduce the risk of procedural bleeding [ 62 ].

• Radiotherapy

Radiotherapy (XRT) is a noninvasive approach that can obliterate hemangiomas and relieve pain through vascular necrosis and/or anti-inflammatory effects [ 1 ]. It is a suitable option for VH patients with back pain and no neurologic deficits, or as postoperative adjunct therapy after suboptimal surgical decompression. Patients with neural element compromise often require prompt decompression to prevent irreversible injury that is more appropriately managed with surgery rather than the delayed response offered by XRT [ 1 , 21 , 66 ]. Neurological deficits may, in fact, be aggravated by XRT, as demonstrated in 20% of patients with aggressive VHs from a series of 29 cases by Jiang et al. [ 8 ]. Multiple studies have proclaimed a 60–80% success rate in eliminating symptoms from VHs using XRT, which increases to over 90% when including partial symptom relief [ 8 , 67 , 68 ]. This does include neurological deficits in some cases, but the response of these symptoms to XRT continues to vary [ 52 ]. A radiation dose of at least 34 Gy was recommended by Heyd et al. after their multicenter study identified significantly greater symptom relief and recurrence control compared to lower doses [ 67 ].

XRT is gaining popularity as a postoperative adjunct therapy intended to reduce local recurrence, especially in subtotal resections [ 8 , 52 , 67 ]. There is a 50% recurrence rate in partial resections without adjunct XRT [ 8 , 11 ]. The extent to which XRT can reduce recurrence has not been fully elucidated and has been suggested for future study [ 52 ]. However, these potential benefits must be weighed against the known adverse effects including nausea, fatigue, anorexia, ileus, radionecrosis, and specifically in spinal XRT, radiation myelitis [ 1 , 8 , 52 ].

VHs are often asymptomatic, incidental findings on routine spinal imaging that do not require treatment or follow-up imaging unless they become symptomatic. Most can be diagnosed with characteristic CT and MRI findings while atypical lesions may be difficult to differentiate from alternative diagnoses. Some authors suggest the utilization of emerging imaging techniques such as DWI or DCE MRI to differentiate atypical lesions from malignancies, which is a promising solution that requires further research. Other authors suggest observation with regular follow-up may be the best course of management for asymptomatic, atypical lesions while others still recommend biopsy for definitive diagnosis of atypical lesions. Regardless, there is a consensus that symptomatic lesions should be treated. Most authors recommend surgical decompression for treatment in patients with neurological deficits, but there is ongoing debate as to the optimal treatment for back pain alone. There are several treatment options which should be considered case-by-case given the properties of various lesions. Management algorithms have been suggested but additional research is required to identify the optimal treatment for the many different classifications of VHs.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Abbreviations

• Vertebral hemangioma

Computed tomography

Magnetic resonance imaging

Arteriovenous

Positron emission-computed tomography

Technetium 99-methyl diphosphonate

Diffusion weighted imaging

Apparent diffusion coefficient

Volume transfer constant

Dynamic contrast enhanced magnetic resonance imaging

Epidural spinal cord compression

Polymethyl methacrylate

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The University of Iowa Hospitals and Clinics provided funding for this research.

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Kyle Kato & Meron Challa

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KK performed a portion of the literature review and was a major contributor in writing the manuscript/generating figures. NT performed most of the literature review and was a major contributor in reviewing the manuscript. MC contributed to writing the manuscript. KE provided histological images for figures. SY was a major contributor in reviewing the manuscript. All authors read and approved the final manuscript.

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Kato, K., Teferi, N., Challa, M. et al. Vertebral hemangiomas: a review on diagnosis and management. J Orthop Surg Res 19 , 310 (2024). https://doi.org/10.1186/s13018-024-04799-5

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Received : 02 April 2024

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DOI : https://doi.org/10.1186/s13018-024-04799-5

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