An Introduction to an Evidence-Based Approach to Interventional Techniques in the Management of Chronic Spinal Pain

Practice guidelines are systematically developed statements to assist practitionersand patients in making decisions about appropriate health care for specific clinicalcircumstances. Clinical practice guidelines present statements of best practice based on athorough evaluation of the evidence from published studies on the outcomes of treatment.In November 1989, Congress mandated the creation of the Agency for Healthcare Policyand Research (AHCPR). AHCPR was given broad responsibility for supporting research, datadevelopment, and related activities. Associated with this mandate, the National Academyof Sciences published a document indicating that guidelines are expected to enhance thequality, appropriateness, and effectiveness of health care services.Guidelines as a whole have been characterized by multiple conflicts in terminology andtechnique. These conflicts are notable for the confusion they create and for what they reflectabout differences in values, experiences, and interest among different parties. Despite thisconfusion, public and private development of guidelines is growing exponentially. Thereare only limited means to coordinate these guidelines in order to resolve inconsistencies, fillin gaps, track applications and results, and assess the soundness of individual guidelines.Significant diversity exists in clinical practice guidelines. The inconsistency amongstguidelines arises from variations in values, tolerance for risks, preferences, expertise, andconflicts of interest.In 2000, the American Society of Interventional Pain Physicians (ASIPP) first created treatmentguidelines to help practitioners. There have been 4 subsequent updates. These guidelinesaddress the issues of systematic evaluation and ongoing care of chronic or persistent pain,and provide information about the scientific basis of recommended procedures. Theseguidelines are expected to increase patient compliance, dispel misconceptions amongproviders and patients, manage patient expectations reasonably, and form the basis of atherapeutic partnership between the patient, the provider, and payors.The ASIPP guidelines are based on evidence-based medicine (EBM). EBM is in turn basedon 4 basic contingencies: the recognition of the patient’s problem and the construction ofa structured clinical question; the ability to efficiently and effectively search the medicalliterature to retrieve the best available evidence to answer the clinical question; clinicalappraisal of the evidence; and integration of the evidence with all aspects of the individualpatient’s decision-making to determine the best clinical care of the patient. Evidence synthesisfor guidelines includes the review of all relevant systematic reviews and individual articles,grading them for relevance, methodologic quality, consistency, and recommendations.Key words: Evidence-based medicine, clinical practice guidelines, critical appraisal,guideline development, interventional pain management, interventional techniques,evidence synthesis, clinical relevance, grading recommendations, systematic reviews