The Global Spine Care Initiative: a summary of guidelines on invasive interventions for the management of persistent and disabling spinal pain in low- and middle-income communities



The purpose of this study was to synthesize recommendations on the use of common elective surgical and interventional procedures for individuals with persistent and disabling non-radicular/axial with or without myelopathy, radicular back pain, cervical myelopathy, symptomatic spinal stenosis, and fractures due to osteoporosis. This review was to inform a clinical care pathway on the patient presentations where surgical interventions could reasonably be considered.


We synthesized recommendations from six evidence-based clinical practice guidelines and one appropriate use criteria guidance for the surgical and interventional management of persistent and disabling spine pain.


Lower priority surgery/conditions include fusion for lumbar/non-radicular neck pain and higher priority surgery/conditions include discectomy/decompressive surgery for cervical or lumbar radiculopathy, cervical myelopathy, and lumbar spinal stenosis. Epidural steroid injections are less expensive than most surgeries with fewer harms; however, benefits are small and short lived. Vertebroplasty should be considered over kyphoplasty as an option for patients with severe pain and disability due to osteoporotic vertebral compression fracture.


Elective surgery and interventional procedures could be limited in medically underserved areas and low- and middle-income countries due to a lack of resources and surgeons and thus surgical and interventional procedures should be prioritized within these settings. There are non-invasive alternatives that produce similar outcomes and are a recommended option where surgical procedures are not available.

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Corresponding author

Correspondence to Emre Acaroğlu.

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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.

Conflict of interest

EA declares Grants: Depuy Synthes Spine, Medtronic; speaker’s bureau: AOSpine, Zimmer Biomet. 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. 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). 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. TM declares Fellowship Grant—Medtronics. 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.

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Acaroğlu, E., Nordin, M., Randhawa, K. et al. The Global Spine Care Initiative: a summary of guidelines on invasive interventions for the management of persistent and disabling spinal pain in low- and middle-income communities. Eur Spine J 27, 870–878 (2018).

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  • Spine
  • Orthopedics
  • General surgery
  • Back pain
  • Neck pain