Guideline warfare over interventional therapies for low back pain: Can we raise the level of discourse?

As guidelines proliferate and are used to inform efforts to improve the quality and efficiency of care, disputes over guideline recommendations are likely to become more common and contentious. It is appropriate for guidelines to come under close scrutiny, given their important clinical and policy implications, and critiques that point out missing evidence, improper methods, or errors in interpretation can be valuable. But for critiques to be valid, they should be based on accurate information and a sound scientific basis. A 2009 guideline sponsored by the American Pain Society (APS) on the use of invasive tests and interventional procedures found insufficient evidence to make recommendations for most interventional procedures. It was subsequently the subject of lengthy critiques by the American Society of Interventional Pain Physicians (ASIPP) that sought to challenge the methods used to develop the APS guideline, point out alleged errors in the evidence review commissioned to inform the guideline, and question the integrity of the APS guideline process. We show that the ASIPP critiques contain numerous errors and fail to adhere to scientific standards for reviewing evidence, and provide suggestions on how future disputes regarding guidelines might be addressed in a more constructive manner. Perspective: In order to best serve patients and clinicians, debates over guidelines should be based on accurate information, adhere to current methodological standards, acknowledge important deficiencies in the evidence when they are present, and handle conflicts of interest in a vigorous and transparent manner.