European Spine Journal 2018 (Sep); 27 (Suppl 6): 889–900 ~ FULL TEXT
Scott Haldeman, Claire D. Johnson, Roger Chou, Margareta Nordin, Pierre Côté, Eric L. Hurwitz, et al.
Department of Epidemiology,
School of Public Health,
University of California Los Angeles,
Los Angeles, CA, USA
PURPOSE:   The purpose of this report is to describe the development of a classification system that would apply to anyone with a spine-related concern and that can be used in an evidence-based spine care pathway.
METHODS:   Existing classification systems for spinal disorders were assembled. A seed document was developed through round-table discussions followed by a modified Delphi process. International and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate.
RESULTS:   Thirty-six experts from 15 countries participated. After the second round, there was 95% agreement of the proposed classification system. The six major classifications included: no or minimal symptoms (class 0); mild symptoms (i.e., neck or back pain) but no interference with activities (class I); moderate or severe symptoms with interference of activities (class II); spine-related neurological signs or symptoms (class III); severe bony spine deformity, trauma or pathology (class IV); and spine-related symptoms or destructive lesions associated with systemic pathology (class V). Subclasses for each major class included chronicity and severity when different interventions were anticipated or recommended.
CONCLUSIONS:   An international and interprofessional group developed a comprehensive classification system for all potential presentations of people who may seek care or advice at a spine care program. This classification can be used in the development of a spine care pathway, in clinical practice, and for research purposes. This classification needs to be tested for validity, reliability, and consistency among clinicians from different specialties and in different communities and cultures. These slides can be retrieved under Electronic Supplementary Material.
KEYWORDS:   Back pain; Critical pathways; Delphi technique; Neck pain; Spinal diseases
From the FULL TEXT Article:
Spine-related pain and symptoms are ubiquitous in societies
across the globe [1, 2]. People with spinal disorders
commonly present to clinicians and spine clinics with
neck, mid back, or low back pain. However, people may
also present with complaints that are more serious than
localized spine pain including deformity, inflammatory,
infectious, or neoplastic disorders. Furthermore, clinicians
who manage spinal disorders may be approached with concerns
about structural spine pathology found incidentally
in a diagnostic imaging study or with an observed deformity,
such as scoliosis. Family, friends, and employers may
rely on spine care providers and programs for information
and answers to questions about prevention or prognosis of
spinal disorders and related disability.
World Spine Care is a multinational, not-for-profit,
charitable organization founded in 2008 . It was
launched to fill the gap in the evidence-based treatment
of spinal conditions found in underserved areas around
the world. World Spine Care developed the Global Spine
Care Initiative (GSCI) to reduce the global burden of disease
and disability by bringing together leading health
care scientists and specialists, government agencies, and
other stakeholders to transform the delivery of spine care
worldwide but especially in underserved and low- and
middle-income countries. The mission of the GSCI is to
develop an evidence-informed, practical, and sustainable,
care pathway and spine health care model for communities
with various levels of resources around the world [4–6].
A successful care pathway requires the ability to categorize
individuals who present with concerns for triage
and management. To satisfy the GSCI mission, the classification
must address anyone presenting with a spine concern.
Therefore, it is not sufficient to consider a system
limited to one area of the spine, one pathological process,
non-specific spine pain, or only those people who may
be concerned about disability. The classification system
must include all possible patient presentations, including
common and uncommon spinal symptoms and diagnoses.
The system must be able to identify individuals whose
symptoms have strong psychological or social components
and those that are associated with systemic disorders or
comorbidities. In addition, the system must be adaptable
or responsive to different cultures and traditions and
be flexible to accommodate differing levels of available
resources. The purpose of this paper is to present a classification
system for spine-related concerns that would apply
to all persons with spine-related concerns and that can be
used in an evidence-based spine care pathway.
The GSCI Principal Investigator (SH) and Scientific Secretaries
(MN, RC, PC, EH) invited internationally recognized,
interprofessional authors, policy and opinion leaders, scientists,
and clinicians with expertise and interest in spinal disorders
to participate in the GSCI classification development
process. After the initial list of invitees was developed, the
experts were asked for additional participant recommendations.
During this initial process, GSCI Principal Investigators
focused on including representatives from a broad range
of disciplines and nations. Criteria for the classification system
were developed to meet the mission of the GSCI (see
Online Resource Figure 1 for criteria for the development of
the classification system for spine-related concerns).
Review of spine classification systems
A search of the literature was performed and input from
the members of the GSCI was collected to identify classification
systems that could meet the criteria for the development
of the care pathway and implementable model of
care. The literature search revealed many papers classifying
the severity of specific spine pathologies such as vertebral
body fractures, scoliosis, disk herniation or degeneration
but failed to identify classification systems that would apply
more generally to people with spine-related symptoms or
concerns. Members of the GSCI then identified 10 extant
spinal disorders classification systems that were widely used
or proposed for clinical guideline or research considerations
and that addressed people presenting with spine-related
symptoms (Table 1) [7–17].
One of the most widely used classification systems to
differentiate spinal disorders by clinicians and payers in
high-resource countries is the International Classification
of Diseases (ICD) developed by World Health Organization
(WHO) . The ICD-10 lists over 300 diagnostic codes
which could apply to people who present with spinal symptoms
or diagnoses. The use of the ICD requires a specific,
often pathological diagnosis. Most of the ICD codes focus
on an exclusive biomedical approach to spinal disorders .
This classification, although helpful in tracking diagnoses,
does not apply well to implementation in a care pathway
since they include over 300 diagnostic codes and do not take
into account psychosocial factors.
The International Classification of Functioning, Disability
and Health (ICF) also developed by the WHO focuses
on function . The ICF describes function as “an umbrella
term for body functions, body structures, activities and participation.”
 The ICF is a general description of function
that, if used in isolation, does not discuss a pathological
diagnosis or intervention. To achieve this goal, it should
be linked to ICD codes. The ICF and ICD are important in
defining diagnoses and disability. However, these classification
systems are complex, detailed and are difficult to use
outside of a comprehensive high-resource health care setting
with extensive administrative resources.
Several task forces have been convened to address spine
conditions or symptoms, review the evidence for interventions,
and make classification recommendations. The Quebec
Task Force on Whiplash-Associated Disorders divided
neck pain into five groups . This classification, however,
only addressed whiplash injuries to the neck, mostly from
motor vehicle crashes. The Quebec Task Force on Spinal
Disorders recommended differentiating spine-related disorders
into groups based on symptoms, clinical, and neurological
findings . It focuses on symptoms and pathology
and requires the user to differentiate 11 classes, which
mostly relate to pathology. The Bone and Joint Decade Task
Force on Neck Pain and Its Associated Disorders used the
Quebec Whiplash Classification system as a foundation and
defined groups based on activity interference due to neck
pain and the presence or absence of radiculopathy . Serious
pathology was defined as group IV in this classification,
and conditions in this group were not addressed further. The
National Institute of Health Back Pain Standards (NIHBPS)
mirrors the criteria of the Neck Pain Task Force (NPTF)
focusing on symptoms and disability for low back pain
but, in addition, differentiated classes based on chronicity
and severity of impact or impairment .
The NPTF and
NIHBPS classification systems have been valuable in the
discussion of the evidence for effectiveness of interventions
and have led to more reasonable and logical approaches to
patients, especially those with incapacitating low back and
neck pain. These efforts have resulted in a greater focus on
interventions that are supported by available evidence. They
have stressed the importance of psychosocial factors and
the reduction of the use of interventions with little supporting
evidence. However, they address a limited number of
symptoms such as low back, neck pain, or whiplash-associated
symptoms. Therefore, they are not suitable for use
in a setting that applies to people with spine symptoms or
concerns irrespective of the nature of the symptom, spine
region, severity, chronicity, and potential pathologies that a
general spine care pathway needs to address.
Work-related disabilities were addressed in several classifications.
The South Australia Work Cover Corporation
Classification System was developed to determine legal
impairment and focuses primarily on differentiating patients
with non-specific pain from those with a pathological diagnosis
. The AMA Guide to the Evaluation of Permanent
Impairment, 5th edition is widely used in the USA as
a means of establishing compensation for spine-related disability
. This system is based on clinical findings (e.g.,
muscle spasm or range of motion), the presence of radiculopathy,
and loss of structural integrity. The 6th
edition of the AMA Guides has similar goals but focuses on symptoms and
impairment of activities caused by the symptoms . These
classification systems are used to determine legal impairment
and should only be applied when a patient reaches the
point of maximum medical improvement and therefore do
not apply to people who are seeking care.
After deliberation, the panelists felt that any classification
system should be compatible with survey instruments
such as those developed by the Global Alliance for Musculoskeletal
Health, so it would be relatively easy to translate
the results of surveys into the implementation of a care
pathway . The classification panel recognized that none
of the available and widely used classification systems presented
above can guide clinicians to care for people who
present with all possible forms of spine symptoms, concerns,
or pathologies. It became evident that the panel needed to
develop a comprehensive classification system to address all
spine care concerns before a care pathway could be considered.
The classification must include any person who might
present to a spine program. The panel recognized that in
some low-resource communities there may be presentations
other than primary neck or low back pain, which may not be
adequately addressed in the classic evidence-based guidelines
that were established in high-income settings. In many
global spine care programs, people may have concerns about
minor irritating symptoms, prevention, and risk factors, but
also pain that is in multiple spine regions, neurological
symptoms and deformities, in addition to serious systemic
pathology. Thus, the classification system must be created
to address all presentations.
Several meetings were held to refine the classification system.
An initial draft that incorporated applicable principles
of existing classification systems was presented to the GSCI
workgroup. The participants wanted the classification to be
compatible with other spine classification systems, relatively
simple to use, and applicable to first-contact, health care specialties
or professions. Refinements of the document were
made through 4 round-table group discussions and multiple
meetings among the executive and members of the classification
panel. This process yielded an initial seed classification
system (see Online Resource Figure 2).
Modified Delphi process
A modified Delphi process was performed to gain further
input on the classification system and to obtain consensus
from an interprofessional, international panel of spine care
clinicians, researchers, and other stakeholders [21–23]. The
modified Delphi process was selected because it allowed
all participants to have an equal voice in the discussion
and reduced the potential for bias or intimidation by senior
researchers [21–23]. Throughout the process, comments
were blinded so that the participants’ identities were not tied
to comments when being reviewed by the principal investigators
(SH, CJ). Comments were opened by the principal
investigators only after all participants had responded. The
participants gave informed consent that the GSCI research
papers would be published with information including participant
names, information from surveys/emails, and relevant
conflict of interest information for purposes of transparency.
Participants were given the right to refuse or withdraw
without penalty at any time. This project was approved by
National University of Health Sciences Institutional Review
Board (#H-1503). All participants were informed about the
nature of the study and the modified Delphi process and gave
written consent by completing the electronic questionnaire.
Surveys were distributed using an online survey program
(SurveyMonkey Inc, SurveyMonkey.com, San Mateo, California,
The seed document was provided as the starting document.
The first Delphi survey asked participants for their
level of agreement on the overall classification, on each
individual class, and gave the respondent the opportunity to
provide comments. The first survey also included questions
about demographics and their views and beliefs about health
care. The first Delphi survey responses were collected and
were matched to the relevant class. Each comment was considered
and addressed by the GSCI Principal Investigators
(SH, CJ) and the Executive Team (RC, PC, EH, MN) in a
response report, which included recommended changes in
the initial proposal with explanations and clarifications to
address comments and concerns. Examples of patient presentations
for each class were provided to clarify use of the
classification (see supplemental file Appendix A).
All 43 participants from the first survey were invited
to participate in the second round and were given the full
response report in advance. The second Delphi survey asked
participants to state their overall agreement, agreement
with minor changes, or disagreement with the updated draft
and to include any comments about the updated classification
system. Consensus for the second survey was defined
a priori as 80% agreement. The responses and comments
were collected from the second survey. Since there was high
agreement (95% of participants supported the updated classification),
a third survey was not undertaken. Based upon
feedback from the second survey, minor changes were made
to the classification system, which included corrections to
grammar and congruence. Following this, all participants
were asked to review the manuscript draft, provide additional
input, and invited to join as coauthors. (see Online
Resource Figure 3 for the steps in the consensus process.)
Invitations for the first modified Delphi survey were sent to
59 participants. Of the 59 invited, 14 (24%) did not reply or
indicated that they did not wish to participate. Participants
represented a wide variety of health and research disciplines
and represented 15 countries (Australia, Botswana, Cameroon,
Canada, Chile, Denmark, France, India, Iran, Kenya,
Morocco, Norway, Switzerland, Turkey, and USA).
In the first survey, several participants pointed out areas
where they suggested a modification or expressed concerns.
Concerns were addressed by modification to the seed document
or with a response by the principal investigator. All
comments were shared with all participants. The following
is a summary of the primary concerns and explanations for
modifications resulting from both survey rounds.
Summary of comments, responses, and modifications for each class
Class 0 = no or minimal spine symptoms, may have risk factors
In the second Delphi survey, a few participants questioned
the purpose of this class. One person felt that a new classification
system was not necessary and 2 expressed concern
about the potential for over-medicalizing minor discomfort.
Some spine care providers do not see people who
have minimal pain, especially medical specialists who
manage people with chronic and disabling pain. Clinicians
in general practice see people with minor symptoms
or concerns who either may seek advice for prevention or
may be seeking care for another complaint. It was recommended
that any model of care should include guidance on
current evidence as defined in the GSCI papers concerning
prevention including risk factors, comorbidities, and the
importance of psychosocial concerns that could lead to
Primary and secondary prevention
measures, whether applied at a population or individual
level, could potentially reduce further the burden of
spine disorders when applied to the specific needs of any
given community [28, 30]. These goals are consistent with
WHO global strategy on integrated people-centered health
services 2016–2026 that state “Reorienting the model of
care … requires investment in holistic and comprehensive
care, including health promotion and ill-health prevention
strategies that support people’s health and well-being.”
 For Class 0, we agreed that any of the classes could be
considered as an option and that the health care provider
may choose to use or not use any class depending on the
social, or environmental situation, level of resources, or
clinical setting in which they practice.
Class I = mild symptoms, no interference with function or activities of daily living, no neurologic deficits and Class II = moderate or severe symptoms, interference with function or activities of daily living, no neurologic
A few participants asked if there should be greater emphasis
on diagnosis for Classes I and II, such as degeneration,
discogenic pain, or muscle strain. Current evidence shows
that findings from clinical examination (e.g., local tenderness,
decreased range of motion) or radiographic imaging
(e.g., degenerative findings) are common in asymptomatic
people and do not have sufficient sensitivity and specificity
to impact a decision concerning recommended interventions
required in the development of a care pathway . Therefore,
specific diagnoses were not included in Class I or II.
Class III = neurological signs/symptoms originating from spinal pathology
Participants discussed if Class III should have diagnostic
subclasses that would accommodate diagnoses such as radiculopathy,
myelopathy, or cauda equina syndrome. Participants
agreed that this differentiation complicated the classification
and that imaging and interventions would not vary
markedly between these 3 diagnoses. However, interventions
are different for patients with acute and progressive neurological
deficits that may require emergency care or for those
with chronic, stable or unchanging neurological symptoms.
Therefore, the subcategories were modified to acute/mild,
acute/progressive, and chronic/stable.
Class IV = severe spinal bone deformity, trauma, or pathology
Some participants suggested the term “severe pathology”
should have a more precise definition. There was also concern
this class might be used by some people to justify
surgical interventions for findings on imaging that have
not been confirmed by the evidence to be a source of pain.
The consensus was that Class IV differentiates the growing
literature on the indications for spine surgery when welldefined
spinal structural pathology, such as when congenital
or developmental deformity, fracture, or disabling unstable
spondylolisthesis are present [24, 32]. It was agreed that it is
not the role of this classification system to define when surgical
intervention is indicated. Instead, the GSCI systematic
literature reviews and guidelines should be used to address
the indications for surgery or other interventions.
Class V = spine*related symptoms associated with systemic or destructive pathology
A few people questioned whether Class V was necessary.
The Quebec Task Force on Whiplash-Associated Disorders
 and the Bone and Joint Decade 2000–2010 Task Force on
Neck Pain and Its Associated Disorders  addressed this
issue by calling all red flags for serious systemic pathology
“Group IV” and elected not to make any recommendations
for this group of patients. Not having this class may be reasonable
in high-income settings where referral for advanced
medical specialty care is readily available. However, in communities
without these resources, spine care providers must
triage a wide array of problems and make referral decisions.
Therefore, the majority of participants agreed that guidance
on presentations found in Class V should be included in
a care pathway. This class helps to triage patients requiring
care for acute emergency or life-threatening pathologies
from those with chronic spine pathology that can be
managed on a non-emergent basis. The inclusion of spinal
symptoms originating from systemic, non-spinal tissues,
and organ systems was questioned by a few participants, but
the majority felt that this subclass was necessary to remind
clinicians that not all spine-related symptoms originate
from the spine and that these patients should be referred
GSCI spinal disorders classification
We took all the ratings and comments into consideration
and refined the classification by reducing the subclasses and
rearranging the higher classes. The revision process after the
first survey included the standardization of the taxonomy for
each class, and a legend was added to help clarify terms .
The order of classes was rearranged and simplified to assist
with use in the clinical setting. In the second survey, 95% of
participants agreed with this statement “Do you agree that
all possible presentations of a person to a spine clinician
or clinic could be included in this classification system?”
The final version of the GSCI classification is represented
in Table 2. For examples of each class, see Online Resource
The GSCI classification system for spine-related concerns
was then compared with the classes outlined in the review
of other classifications. The comparison confirmed that the
other broadly used classification systems could easily work
in conjunction with the proposed GSCI classification system
(see Online Resource Appendix B).
To our knowledge, this is the first interprofessional and international
attempt to provide a comprehensive classification
that reflects all potential presentations of people who may
seek care or advice from a health care provider for spinerelated
symptoms or concerns. The proposed classification
system may be easily taught to clinicians and stakeholders,
such as through visual educational tools (e.g., chart or flashcards),
and may be easily adapted into electronic medical
record software. This classification includes presentations
of pain and disability, spine-related neurological symptoms,
structural bony pathology, deformities, and serious systemic
disease but, at the same time includes people who may benefit
from primary or secondary prevention programs. Thus,
this classification helps to fulfill the WHO strategies of reorienting
models of care  to include all people who have
or are at risk for specific health problems. This classification
also accommodates a person who may present with multiple
spine-related concerns. Therefore, a person with multiple
concerns may be classified in more than one class (e.g., one
class for neck pain and a different class for low back pain). If
a patient presents with diffuse non-focal pain, the area would
be noted and the classification compatible with its severity,
chronicity, and functional interference would be assigned.
This classification was not developed to replace other
spinal disorders classification systems. Instead, it incorporates
most other attempts at categorizing spinal disorders
and, at the same time, addresses all people with
spine-related symptoms or concerns. Depending upon the
social and environmental situation, level of resources, or
clinical setting, any of the classes could be considered,
included, or removed. Thus, it can be adapted to different
environments in clinical, research, or policy development
settings. A clinician or researcher who elects to follow the
Quebec Whiplash or Bone and Joint Decade Task Force
recommendations may choose to limit their consideration
to Classes I, II, III and elect not to include the other
classes or subclasses.
A clinician or researcher whose primary
concern is non-specific low back pain may focus on
the NIH Research Standards as noted in Classes I and II
and include the subclasses addressing pain severity and
chronicity. Surgical considerations would likely focus on
patients in Classes III, IV, and V who might reasonably
be considered candidates for surgery. A population-based
primary prevention program would likely focus on Class
0. A rheumatologist or infectious disease specialist would
likely focus on Class V presentations. The comprehensive
spine care pathway could reasonably be implemented in
communities with limited resources and therefore may
incorporate the entire classification system. This classification
allows for the determination of which individuals
can reasonably be served at different levels of resources.
This spinal classification has language that can be used
by any discipline and is simple enough to be easily taught
to clinicians or stakeholders irrespective of their training
or experience. The classification can differentiate people
with spine-related symptoms that would likely require a
different clinical decision or intervention pathway. Due to
its design, it can match population needs where there are
limited resources and therefore avoid over-medicalization
of spine pain by avoiding the recommendation for a pathological
diagnosis for most people who present with spine
pain and disability but no red flags for serious pathology.
Furthermore, it also accommodates the small number of
people who may present with red flags for neurological
deficits or serious pathology that may require emergency,
surgical, or advanced pharmaceutical interventions.
The GSCI classification is consistent with most current
survey and classifications systems. The classification has
been informed by individuals participating in the modified
Delphi processes as well as the systematic reviews and
other articles being produced as part of the GSCI [1–6,
24–29, 32, 34]. It forms the basic framework for the GSCI
care pathway and recommendations for implementation of
a model of care. The classification is linked to systematic
reviews of the scientific literature for public health, assessment,
noninvasive as well as invasive interventions so that
it may be useful in the clinical setting. The review of the
evidence provides the basis for determining the indications
and contraindications for each of the multiple interventions
that may be considered for people who fall into one
or more of these classifications.
The classification is flexible in that it can be used to
address the entire spine or can be applied separately to
different spine regions or pathological processes. An
individual could be classified into one or more class at
the same point in time. For example, a person could be
in Class I for low back pain and Class II for neck pain.
Therefore, a patient with a combination of spinal regions,
symptoms, or pathological states may be accommodated
in this classification.
This classification is person-centered and can accommodate
individuals with spine symptoms that vary over time and
have different levels of severity and chronicity. It allows an
individual with spine symptoms to be assigned to more than
one class; thus, classes are not mutually exclusive. The classification
may be applied to a person entering or re-entering
the system with symptoms suggestive of the same or a different
class of spinal disorder, thus allowing for the realities of
practice. At the same time, when matched with intervention
guidelines and epidemiologic research it can be used by clinicians
to inform their patients about diagnoses, intervention
considerations, and prognoses. For the purposes of the GSCI,
this document has informed the development of the care pathway
and model of care.
Strengths and limitations
The strengths of this project include the large number of
participants from multiple countries representing both highincome/
resource and low-income/resource communities.
The participants represent a majority of scientific, policy,
and clinical disciplines with an interest in spinal disorders.
The number of comments after the first survey round and
reaching 95% consensus after the second round confirms
that the panelists were committed to the process. The fact
that there were many comments and answers to the survey
which were not in perfect agreement confirms that participants
did not merely endorse opinions or recommendations
of the principal investigators or executive team. Other
strengths include that the classification is compatible with
other available classification systems. It also has not been
defined exclusively for clinical intervention purposes and
can be used in research and policy development.
Limitations of this process were that 24% of the spine
experts and patient advocates that we invited were not available
to participate. Because they did not participate, the classification
did not benefit from their input and if they had,
the results may have been different. The list of participants
did not include many lay people or patients who may have
looked at this classification with different priorities. There
was also no input from traditional or lay healers who are
often the only health care practitioners in many communities.
Some of these issues will be addressed in the readiness
and implementation phases. This classification needs to be
tested for validity, reliability, and consistency among clinicians
from different specialties and in different communities
This paper describes the first interprofessional and international
attempt to provide a comprehensive classification for
all potential presentations of people who may seek care or
advice for spine-related symptoms or concerns. This classification
system is sufficiently comprehensive to advise the
development of a care pathway and sustainable model of
care for spinal disorders. The classification system has been
developed in a simplified manner so that it may be easily
taught to clinicians and stakeholders. At present, the validity
and reliability of the classification are not yet known. It
will need to be field-tested to determine whether stakeholders,
such as patients, policymakers, and clinicians in active
practice, find it valuable.
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.
This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creat iveco
mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution,
and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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