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
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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.
KeywordsSpine 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, SpineHealth.com. 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.
- 1.Connelly LBW, Brooks P (2006) Cost-effectiveness of interventions for musculoskeletal conditions. In: Jamison DB, Measham AR et al (eds) Disease control priorities in developing countries, 2nd edn. World Bank, Washington DCGoogle Scholar
- 3.National Collaborating Centre for Primary Care (2009) National Institute for Health and Clinical Excellence: guidance, in low back pain: early management of persistent non-specific low back pain. Royal College of General Practitioners, LondonGoogle Scholar
- 7.Global Burden of Disease Study (2015) Collaborators (2016) Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 388(10053):1545–1602Google Scholar
- 13.Kung J, Miller RR, Mackowiak PA (2012) Failure of clinical practice guidelines to meet institute of medicine standards: two more decades of little, if any, progress. Arch Intern Med 2012:1–6Google Scholar
- 14.Global Spine Care Initiative. http://www.globalspinecareinitiative.org/ (cited 6 July 2016)
- 20.American Academy of Orthopaedic Surgeons. Spinal injections. 2013. http://orthoinfo.aaos.org/topic.cfm?topic=A00560 (cited 15 Dec 2016)
- 28.Daffner RH, Wippold FJ II, Angtuaco EJ, Appel M, Berger KL, Cornelius RS, Douglas AC, Fries IB, Hayes CW, Holly L, Mechtler LL, Prall JA, Rubin DA, Ward RJ, Waxman AD (2012) Expert Panels on Musculoskeletal and Neurologic Imaging, ACR Appropriateness Criteria® suspected spine trauma. American College of Radiology, RestonGoogle Scholar
- 29.American College of Occupational and Environmental Medicine (2016) Cervical and thoracic spine disorders. In: Hegmann KT (ed) Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers, 3rd edn. Reed Group Ltd, WestminsterGoogle Scholar
- 30.American College of Occupational and Environmental Medicine (2011) Low back disorders. In: Hegmann KT (ed) Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers, 3rd edn. ACOEM, Elk Grove VillageGoogle Scholar
- 31.Work Loss Data Institute (2013) Neck and upper back (acute and chronic) [withdrawn]. Work Loss Data Institute, EncinitasGoogle Scholar
- 32.Institute Work Loss Data, Institute Work Loss Data (2013) Low back—lumbar and thoracic (acute and chronic) [withdrawn]. Work Loss Data Institute, EncinitasGoogle Scholar
- 33.Chou RQ et al (2011) Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. [Erratum appears in Ann Intern Med. 2012 Jan 3;156(1 Pt 1):71], [Summary for patients in Ann Intern Med. 2011 Feb 1;154(3):I36]. Ann Intern Med 154(3):181–189CrossRefGoogle Scholar
- 34.North American Spine Society (2012) Diagnosis and treatment of lumbar disc herniation with radiculopathy. North American Spine Society, Burr RidgeGoogle Scholar
- 35.North American Spine Society (2014) Evidence-based clinical guidelines for multidisciplinary spine care. Diagnosis and treatment of adult isthmic spondylolisthesis. North American Spine Society, Burr RidgeGoogle Scholar
- 37.Chung SM, Wales PW, Dirks P, Shroff M, Singhal A, Grant V, Hancock BJ, Creery D, Atkinson J, St-Vil D, Crevier L, Yanchar N, Hayashi A, Mehta V, Carey T, Dhanani S, Siemens R, Singh S, Price D (2011) Trauma association of Canada Pediatric Subcommittee National Pediatric Cervical Spine Evaluation Pathway: consensus guidelines. J Trauma Injury Infect Crit Care 70(4):873–884CrossRefGoogle Scholar
- 38.Livingston C et al. (2011) Evidence-based clinical guidelines project Evaluation and management of low back pain: a clinical practice guideline based on the joint practice guideline of the American College of Physicians and the American Pain Society (diagnosis and treatment of low back pain). Office for Oregon Health Policy and Research, SalemGoogle Scholar
- 39.Newman JS, Angevine PD, Appel M, Arnold E, Bencardino JT, Fries IB, Hayes CW, Hochman MG, Holly LT, Jacobson JA, Math KR, Murphey MD, O’Toole JE, Rubin DA, Scharf SC, Small KM, Expert Panel on Musculoskeletal Imaging (2013) ACR Appropriateness Criteria® chronic neck pain. American College of Radiology (ACR), RestonGoogle Scholar
- 41.Philippine Academy of Rehabilitation Medicine (PARM) (2012) Clinical practice guidelines on the diagnosis and management of low back pain (CPG 2011). http://parm.com.ph/wp-content/uploads/2016/09/PARM-Low-Back-Pain-CPG-2011-1.pdf (26 March 2016)
- 42.Juanola Roura X et al (2015) Recommendations for the detection, study and referral of inflammatory low-back pain in primary care. Rheumatol Clin 11(2):90–98Google Scholar
- 43.AIM Specialty Health (2017) Clinical Appropriateness Guidelines: Advanced Imaging. Appropriate use criteria: imaging of the spine. AIM Specialty Health, Chicago IL, USA. https://aimspecialtyhealth.com/PDF/Guidelines/2017/Sept05/AIM_Guidelines_Spine.pdf (cited October 5, 2017)
- 50.Campbell E (1990) Physical examination, chapter 4. In: Hurst JW (ed) Clinical method: the history, physical and laboratory examinations. Butterworths, BostonGoogle Scholar
- 51.National Institutes of Health (2016) MedlinePlus. Diagnostic imaging. https://www.nlm.nih.gov/medlineplus/diagnosticimaging.html (cited 8 July 2016)
- 53.Agency for Health Care Policy and Research (1994) Acute low back problems in adults: assessment and treatment. Clin Pract Guidel Quick Ref Guide Clin 14:iii–iv, 1–25Google Scholar
- 55.Cedraschi C, Nordin M, Haldeman S, Randhawa K, Kopansky-Giles D, Johnson CD et al (2018) The Global Spine Care Initiative: a narrative review of psychological and social issues in back pain in low- and middle-income communities. Eur Spine J https://doi.org/10.1007/s00586-017-5434-7
- 56.New Zealand Guidelines Group (2004) Accident Compensation Corporation, New Zealand Acute Low Back Pain Guide: incorporating the guide to assessing psychosocial yellow flags in acute low back pain. New Zealand Guidelines Group, WellingtonGoogle Scholar
- 62.New Zealand Guidelines Group (2004) Accident Compensation Corporation. New Zealand Acute Low Back Pain Guide: incorporating the guide to assessing psychosocial yellow flags in acute low back painGoogle Scholar
- 66.United Nations Scientific Committee on the Effects of Atomic Radiation (2008) UNSCEAR 2008 report, vol 1. UNSCEAR, ViennaGoogle Scholar
- 67.World Health Organization (2010) Baseline country survey on medical devices. WHO, GenevaGoogle Scholar