European Spine Journal

, Volume 27, Supplement 6, pp 879–888 | Cite as

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

  • Emre AcaroğluEmail author
  • Tiro Mmopelwa
  • Selcen Yüksel
  • Selim Ayhan
  • Margareta Nordin
  • Kristi Randhawa
  • Scott Haldeman
Original Article



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.

Graphical Abstract

These slides can be retrieved under Electronic Supplementary Material.


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


Compliance with ethical standards


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

EAc declares grants: Depuy Synthes Spine, Medtronic; speaker’s bureau: AOSpine, Zimmer Biomet. TM declares fellowship grant-Medtronics. SY declares no COI. SA declares no COI. 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. 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.

Supplementary material

586_2017_5332_MOESM1_ESM.pdf (164 kb)
Supplementary material 1 (PDF 164 kb)
586_2017_5332_MOESM2_ESM.pptx (172 kb)
Supplementary material 2 (PPTX 173 kb)


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Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.ARTES Spine CenterAnkaraTurkey
  2. 2.ARTES Spine Centre Ankara, Life Gaborone HospitalGaboroneBotswana
  3. 3.Department of BiostatisticsAnkara Yildirim Beyazit University Medical SchoolAnkaraTurkey
  4. 4.Department of Orthopedic Surgery and Environmental MedicineNew York UniversityNew YorkUSA
  5. 5.World Spine Care EuropeHolmfirthUK
  6. 6.University of Ontario Institute of Technology (UOIT)-Canadian Memorial Chiropractic College (CMCC) Centre for Disability Prevention and RehabilitationTorontoCanada
  7. 7.Department of Epidemiology, School of Public HealthUniversity of California Los AngelesSanta AnaUSA
  8. 8.Department of NeurologyUniversity of California, Irvine and President, World Spine CareSanta AnaUSA

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