The American College of Radiology (ACR), American Society of Neuroradiology, Society of Interventional Radiology, and 31 other societies are demanding that the BMJ retract guidelines that recommend against all injections and most radiofrequency neurotomy procedures for chronic back and neck pain.
"Our societies are concerned about the methodology and conclusions drawn in these publications and their potential impact on patient care," stated the ACR in a March 20 bulletin. The challenges stem from a systematic review and network meta-analysis, subsequent clinical practice guidelines, and accompanying editorial published February 19 in the BMJ.
The practice guideline was based on an analysis of 132 eligible studies and 81 trials that explored 13 interventional procedures or combinations of procedures, according to the research. The authors concluded that commonly performed interventional procedures for axial or radicular chronic noncancer spine pain may provide little to no pain relief.
"Their works have stimulated important dialogue about the role of interventional procedures in managing chronic spine pain and have called appropriate attention to the need for high-quality randomized controlled trials (RCTs) to allow progressive improvement in clinical care for patients with spine pain," stated the joint response of the ACR and societies, adding that the guideline conclusions aggregate disparate groups of patients, conditions, spinal regions, and procedures.
"Conflating these groups in analysis is convenient but misguided; in guideline development, it is misleading and irresponsible," the response explained. "Another fatal flaw of the proposed guidelines is that they use studies of abandoned procedures and non-standard and non-covered techniques to draw conclusions about the use and coverage of commonly used and well-accepted techniques.
"We urge the BMJ to retract the flawed guideline publication .... We frankly cannot understand why this would be acceptable in any field of medicine, and we reject the authors' position that the guidelines reflect a reasonable interpretation of the meta-analysis."
Reaction to recommendations has been mixed. In an email to AuntMinnie, a spokesperson for the BMJ said the journal would not retract the articles. Those who wish to further address the issue are invited to use the journal's Rapid Responses section. A snapshot of responses generated so far includes the following:
Harsha Shanthanna, MD, PhD, an anesthesiologist and pain physician at St. Joseph's Healthcare in Ontario, Canada, raised the point that the research highlights the lack of level 1 evidence in this field.
"Formulation of guidelines cannot consider interventional options in isolation but within the broader framework of [chronic lower back pain] CLBP management," Shanthanna wrote. "A more constructive approach would have been to recommend a higher threshold and longer duration of pain reduction commensurate with the invasiveness and resource utilization of an intervention, along with tools to better identify responders, so that performance of these procedures is tied to better outcomes."
David Radley, MD, an anesthetist at Hereford County Hospital at the Wye Valley National Health Service Trust in the U.K. wrote, "Perhaps a more constructive way of looking at these treatments might be to engage our efforts in trying to better identify which patient groups are most likely to benefit." And, "implications of recommendations will be widely and deeply felt. Further work is recommended to identify how to use these treatments better."
Lead author of the original research, pain researcher Jason Busse, MD, from McMaster University in Ontario, Canada, responded on March 10 that the guideline panel was composed of methodologists, patient partners, and clinicians with a collective experience administering thousands of interventional procedures for chronic spine pain. The panel was free of important financial and intellectual conflicts of interest and independently confirmed by the BMJ to ensure objective appraisal of the evidence, he said.
Find the detailed seven-page response, including recommendations and policy implications, through the ACR website.
