Margareta Nordin, 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

October 2018, Volume 27, Issue 6, pp 816 - 827 Review Article Read Full Article 10.1007/s00586-017-5446-3

First Online: 28 February 2018


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.[Figure not available: see fulltext.]

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