An Update of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Part I: Introduction and General Considerations

In 2011, the Institute of Medicine (IOM) re-engineered its definition of clinical guidelines asfollows: “clinical practice guidelines are statements that include recommendations intended tooptimize patient care that are informed by a systematic review of evidence and an assessmentof the benefit and harms of alternative care options.” This new definition departs from a2-decade old definition from a 1990 IOM report that defined guidelines as “systematicallydeveloped statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.” The revised definition clearly distinguishes betweenthe term “clinical practice guideline” and other forms of clinical guidance derived from widelydisparate development processes, such as consensus statements, expert advice, and appropriateuse criteria. The IOM committee acknowledged that for many clinical domains, high qualityevidence was lacking or even nonexistent. Even though the guidelines are important decisionmaking tools, along with expert clinical judgment and patient preference, their value andimpact remains variable due to numerous factors.Some of the many factors that impede the development of clinical practice guidelines includebias due to a variety of conflicts of interest, inappropriate and poor methodological quality,poor writing and ambiguous presentation, projecting a view that these are not applicable toindividual patients or too restrictive with elimination of clinician autonomy, and overzealous andinappropriate recommendations, either positive, negative, or non-committal. Consequently,a knowledgeable, multidisciplinary panel of experts must develop guidelines based on asystematic review of the existing evidence, as recently recommended by the IOM.Chronic pain is a complex and multifactorial phenomenon associated with significant economic,social, and health outcomes. Interventional pain management is an emerging specialty facing adisproportionate number of challenges compared to established medical specialties, includingthe inappropriate utilization of ineffective and unsafe techniques.In 2000, the American Society of Interventional Pain Physicians (ASIPP) created treatmentguidelines to help practitioners. There have been 5 subsequent updates. These guidelinesaddress the issues of systematic evaluation and ongoing care of chronic or persistent pain, andprovide information about the scientific basis of recommended procedures. These guidelines areexpected to increase patient compliance; dispel misconceptions among providers and patients,manage patient expectations reasonably; and form the basis of a therapeutic partnershipbetween the patient, the provider, and payers.Key words: Evidence-based medicine (EBM), comparative effectiveness research (CER),clinical practice guidelines, systematic reviews, meta-analysis, interventional pain management,evidence synthesis, methodological quality assessment, clinical relevance, recommendations.