European Spine Journal

, Volume 27, Supplement 6, pp 816–827 | Cite as

The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities

  • Margareta NordinEmail author
  • Kristi Randhawa
  • Paola Torres
  • Hainan Yu
  • Scott Haldeman
  • O’Dane Brady
  • Pierre Côté
  • Carlos Torres
  • Michael Modic
  • Rajani Mullerpatan
  • Christine Cedraschi
  • Roger Chou
  • Emre Acaroğlu
  • Eric L. Hurwitz
  • Nadège Lemeunier
  • Jean Dudler
  • Anne Taylor-Vaisey
  • Erkin Sönmez
Review Article



The purpose of this systematic literature review was to develop recommendations for the assessment of spine-related complaints in medically underserved areas with limited resources.


We conducted a systematic review and best evidence synthesis of guidelines on the assessment of spine-related complaints. Independent reviewers critically appraised eligible guidelines using the Appraisal of Guidelines for Research and Evaluation-II criteria. Low risk of bias clinical practice guidelines was used to develop recommendations. In accordance with the mandate of the Global Spinal Care Initiative (GSCI), recommendations were selected that could be applied to medically underserved areas and low- and middle-income countries by considering the limited access and costs of diagnostic technologies.


We screened 3069 citations; 20 guidelines were eligible for critical appraisal. We used 13 that had a low risk of bias that targeted neck and back pain.


When assessing patients with spine-related complaints in medically underserved areas and low- and middle-income countries, we recommend that clinicians should: (1) take a clinical history to determine signs or symptoms suggesting serious pathology (red flags) and psychological factors (yellow flags); (2) perform a physical examination (musculoskeletal and neurological); (3) do not routinely obtain diagnostic imaging; (4) obtain diagnostic imaging and/or laboratory tests when serious pathologies are suspected, and/or presence of progressive neurologic deficits, and/or disabling persistent pain; (5) do not perform electromyography or nerve conduction studies for diagnosis of intervertebral disc disease with radiculopathy; and (6) do not perform discography for the assessment of spinal disorders. This information can be used to inform the GSCI care pathway and model of care.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


Spine Review literature as topic Symptom assessment Diagnosis Clinical decision-making 



We thank Leslie Verville and Geoff Outerbridge for their contributions to this paper.


The Global Spine Care Initiative and this study were funded by grants from the Skoll Foundation and NCMIC Foundation. World Spine Care provided financial management for this project. The funders had no role in study design, analysis, or preparation of this paper.

Compliance with ethical standards

Conflict of interest

MN declares funding from Skoll Foundation and NCMIC Foundation through World Spine Care; Co-Chair, World Spine Care Research Committee. Palladian Health, Clinical Policy Advisory Board member. Book Royalties Wolters Kluwer and Springer. Honoraria for speaking at research method courses. KR declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. PT declares no COI. HY declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. SH declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. Clinical Policy Advisory Board and stock holder, Palladian Health. Advisory Board, Book Royalties, McGraw Hill. Travel expense reimbursement—CMCC Board. OB declares he is a consultant for: Pacira Pharmaceuticals, Inc. Palladian Health. Travel expenses: World Spine Care. Stipend: World Spine Care. PC is funded by a Canada Research Chair in Disability Prevention and Rehabilitation at the University of Ontario Institute of Technology, and declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. Canadian Institutes of Health Research Canada. Research Chair Ontario Ministry of Finance. Financial Services Commission of Ontario. Ontario Trillium Foundation, ELIB Mitac. Fond de Recherche and Sante du Quebec. CT declares no COI. MM declares no COI. RM declares no COI. CC declares no COI. RC declares funding from AHRQ to conduct systematic reviews on treatments for low back pain within last 2 years. Honoraria for speaking at numerous meetings of professional societies and non-profit groups on topics related to low back pain (no industry sponsored talks). EAc declares grants: Depuy Synthes Spine, Medtronic; Speaker’s bureau: AOSpine, Zimmer Biomet. EH declares he is a consultant for: RAND Corporation; EBSCO Information Services; Southern California University of Health Sciences; Western University of Health Sciences Data and Safety Monitoring Committee. Chair, Palmer Center for Chiropractic Research. Research Committee Co-chair, World Spine Care. NL declares no COI. JD declares no COI. ATV declares funding to UOIT from Skoll Foundation, NCMIC Foundation through World Spine Care. ES declares funding from Başkent University Research Fund.

Supplementary material

586_2017_5446_MOESM1_ESM.pdf (315 kb)
Supplementary material 1 (PDF 306 kb)
586_2017_5446_MOESM2_ESM.pptx (168 kb)
Supplementary material 2 (PPTX 167 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Orthopedic SurgeryNew York UniversityNew YorkUSA
  2. 2.Department of Environmental MedicineNew York UniversityNew YorkUSA
  3. 3.World Spine Care EuropeHolmfirthUK
  4. 4.Faculty of Health SciencesUniversity of Ontario Institute of TechnologyOshawaCanada
  5. 5.UOIT-CMCC Centre for Disability Prevention and RehabilitationTorontoCanada
  6. 6.Exercise Science Laboratory, School of Kinesiology, Faculty of MedicineUniversidad Finis TerraeSantiagoChile
  7. 7.Department of Epidemiology, School of Public HealthUniversity of California Los AngelesLos AngelesUSA
  8. 8.Department of NeurologyUniversity of California, IrvineIrvineUSA
  9. 9.World Spine CareSanta AnaUSA
  10. 10.World Spine CareTampaUSA
  11. 11.Department of Medical Imaging, The Ottawa HospitalUniversity of OttawaOttawaCanada
  12. 12.Cleveland Clinic, Lerner College of MedicineClevelandUSA
  13. 13.University Department of PhysiotherapyMahatma Gandhi Mission Institute of Health SciencesNavi MumbaiIndia
  14. 14.Division of General Medical RehabilitationMultidisciplinary Pain Centre, Geneva University HospitalsGenevaSwitzerland
  15. 15.Division of Clinical Pharmacology and ToxicologyMultidisciplinary Pain Centre, Geneva University HospitalsGenevaSwitzerland
  16. 16.Department of Medical Informatics and Clinical EpidemiologyOregon Health and Science UniversityPortlandUSA
  17. 17.Department of MedicineOregon Health & Science UniversityPortlandUSA
  18. 18.ARTES Spine CenterAnkaraTurkey
  19. 19.Office of Public Health Studies, University of HawaiiHonoluluUSA
  20. 20.Institut Franco-Européen de ChiropraxieToulouseFrance
  21. 21.Department of RheumatologyHFR Fribourg, Hospital CantonalFribourgSwitzerland
  22. 22.Department of Neurological SurgeryBaşkent University School of MedicineAnkaraTurkey

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