Achieving a definition and mechanism of evaluation for spinal surgical conversion within the National Back and Radicular Pain Pathway.


To achieve consensus amongst relevant stakeholders regarding what constitutes spinal surgical conversion (from primary to secondary care) within the National Back and Radicular Pain Pathway (NBPP) and what would be an appropriate mechanism to evaluate this.

Data from the Getting It Right First Time (GIRFT) project team highlights wide variation in service delivery across the UK making the evaluation and refinement of NBPP aspects imperative.


Members of the NBPP clinical network convened in parallel with a National Surgical conference, British Association of Spinal Surgeons (April 2019). The corresponding author summarised relevant background information including the results of a scoping literature review. This confirmed divergence in the definition and reported rates of conversion.

Delegates were invited to join an open discussion regarding the definition and evaluation of surgical conversion and to answer a short series of pre-planned questions via the conference app.

  • Q1-Should the NBPP adopt a definition of inclusion i.e referred to secondary care for a specific clinical reason and that decision is validated in secondary care (Y/N).
  • Q2-What should the NBPP include in a definition of inclusion i.e. surgery, injection, more imaging, referral to another service, all of the above or other (free text response).
  • Q3-Should the NBPP adopt a definition of exclusion i.e. patients referred from primary to secondary care are rejected without further investigation (Y/N).
  • Q4-Should the NBPP consider a single measure of conversion or a spread to accommodate inherent service variation i.e. mean and SD (free text).
  • Q5-Should the NBPP consider including a contextual descriptor of the numerical measure to better understand local service delivery (Y/N).

Raw numerical data (n/%) are presented where appropriate. Free text data were analysed thematically into groups (JG and EB). Where disagreement occurred discussion with the senior author (DD, subject matter expert) was conducted to achieve consensus.


Results suggest participants were in favour of a definition of inclusion 88% (n=37/42) v exclusion 71% (n=29/40), with 87% (n=33/42) in favour of adopting the mean (±SD) as a measure of conversion.

Overwhelmingly 97% (n=36/37) of respondents were in favour of incorporating a contextual descriptor.

Initial coding of free text data suggested the definition of conversion was broad with 7 different groups emerging ((surgery alone (20.6%), surgery + injection (26.5%), surgery + injection + imaging (8.8%), surgery + injection + pain management programme (8.8%), all interventions (14.7%), any intervention not available in primary care (17.6%), others (2.9%)).

Analysing this data further suggested considerable alignment between groups.

Two groups were identified regarding what constitutes surgical conversion within the NBPP, i) a spinal surgical procedure in isolation 20.6% (n=7), ii) any treatment/investigation including surgery not available in primary care 76.4% (n=26).

The NBPP should adopt a broad definition of what constitutes surgical conversion. Such a broad definition is not unexpected given the diverse range of services and settings across which the pathway is delivered


A widely adopted definition and metric for the evaluation of this critical part the NBPP will enable commissioners and clinicians alike to better identify and report variance within the NBPP.

Funding acknowledgements

No funding was provided for the conduct of this survey.

Additional notes

This work was presented at Physiotherapy UK 2019