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Eur Spine J. 2018 Sep;27(Suppl 6):879-888. doi: 10.1007/s00586-017-5332-z. Epub 2017 Oct 16.

The Global Spine Care Initiative: a consensus process to develop and validate a stratification scheme for surgical care of spinal disorders as a guide for improved resource utilization in low- and middle-income communities.

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ARTES Spine Center, Ankara, Turkey.
ARTES Spine Centre Ankara, Life Gaborone Hospital, Gaborone, Botswana.
Department of Biostatistics, Ankara Yildirim Beyazit University Medical School, Ankara, Turkey.
ARTES Spine Center, Ankara, Turkey.
Department of Orthopedic Surgery and Environmental Medicine, New York University, New York, NY, USA.
World Spine Care Europe, Holmfirth, UK.
University of Ontario Institute of Technology (UOIT)-Canadian Memorial Chiropractic College (CMCC) Centre for Disability Prevention and Rehabilitation, Toronto, ON, Canada.
Department of Epidemiology, School of Public Health, University of California Los Angeles, Santa Ana, CA, USA.
Department of Neurology, University of California, Irvine and President, World Spine Care, Santa Ana, CA, USA.



The purpose of this study was to develop a stratification scheme for surgical spinal care to serve as a framework for referrals and distribution of patients with spinal disorders.


We used a modified Delphi process. A literature search identified experts for the consensus panel and the panel was expanded by inviting spine surgeons known to be global opinion leaders. After creating a seed document of five hierarchical levels of surgical care, a four-step modified Delphi process (question validation, collection of factors, evaluation of factors, re-evaluation of factors) was performed.


Of 78 invited experts, 19 participated in round 1, and of the 19, 14 participated in 2, and 12 in 3 and 4. Consensus was fairly heterogeneous for levels of care 2-4 (moderate resources). Only simple assessment methods based on the clinical skills of the medical personnel were considered feasible and safe in low-resource settings. Diagnosis, staging, and treatment were deemed feasible and safe in a specialized spine center. Accurate diagnostic workup was deemed feasible and safe for lower levels of care complexity (from level 3 upwards) compared to non-invasive procedures (level 4) and the full range of invasive procedures (level 5).


This study introduces a five-level stratification scheme for the surgical care of spinal disorders. This stratification may provide input into the Global Spine Care Initiative care pathway that will be applied in medically underserved areas and low- and middle-income countries. These slides can be retrieved under Electronic Supplementary Material.


Delivery of health care; General surgery; Health care facilities, manpower, and services; Operative; Spine; Surgical procedures


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