Rethinking Spine Surgery: Inspirations from Rural India


Dr. Shekhar Bhojraj with PGSSC faculty and research fellows

As a current neurosurgeon in training in the United States, it’s hard to imagine spine surgery without colored metallic pedicle screws and endless trays full of unique gadgets and instruments that each have a specific function to allow us to reconstruct the human spine. However, in many places around the world, this specialized and expensive equipment just isn’t available. This unfortunately creates a large discrepancy between the millions of people who have painful and disabling pathologies and their ability to receive adequate and timely treatment.


But one man is determined to address this problem head on. Dr. Shekhar Bhojraj is an orthopedic spine surgeon on a mission to deliver comprehensive spine care to rural India and break the paradigm that we must always use costly surgical equipment.

Here, at PGSSC, Dr. Bhojraj presented his work in India, the “land of contrasts”, where he founded the Spine Foundation in 1998 because he felt he had “a social responsibility to make spine care affordable and accessible.”


With this program, Bhojraj and his team deliver need-based spine care in the form of evaluation camps, education and training of local providers, and systems and team development. They also include a spine fellowship program that lasts for two years and provides training in both private and public healthcare environments. Dr. Bhojraj states that the driving principals of his organization are the key to his success, and include:


1. Conservatism

2. Simplistic Surgical Techniques

3. Low cost, low tech, and affordable systems

4. Easy to learn and reproducible methods


To me, the ability to perform spine surgery at reduced costs with local materials seems too good to be true. But Dr. Bhojraj has seen and published promising results! For example, his teams have used rectangular loops and sublaminar wires in place of pedicle screws and rods for treatment of spine deformities. They often use materials made locally or discounted materials from medical devices companies.


What is refreshing about this practice is that it defies the commercial determinants of health that so often manipulate our health care system. This innovation is founded out of necessity in resource poor settings but may be exactly what high income countries need as well.


This philosophy is shared by many, and often is referred to as “co-development.” Originally coined by Nigel Crisp, the Senior Manager of the National Health Service, co-development describes the relationship of bi-directional flow of information, technology, and health care service between high income countries and low- and middle- income countries. Perhaps when tackling our own health care problems, we should think outside the box and search in places where innovation may be at its peak. Spine surgery is no exception, and delivery of care to all people may be within reach if we engage with a little creativity.

© 2019 by Harvard Program in Global Surgery and Social Change

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