Manchikanti Laxmaiah, Singh Vijay, Derby Richard, Schultz David M, Benyamin Ramsin M, Prager Joshua P, Hirsch Joshua A
Pain Management Center of Paducah, Paducah, KY, USA.
Pain Physician. 2008 Jul-Aug;11(4):393-482.
Appropriately developed practice guidelines present statements of best practice based on a thorough evaluation of the evidence from published studies on the outcomes of treatments, which include the application of multiple methods for collecting and evaluating evidence for a wide range of clinical interventions and disciplines. However, the guidelines are neither infallible, nor a substitute for clinical judgment. While the guideline development process is a complex phenomenon, conflict of interest in guideline development and inappropriate methodologies must be avoided. It has been alleged that the guidelines by the American College of Occupational and Environmental Medicine (ACOEM) prevent injured workers from receiving the majority of medically necessary and appropriate interventional pain management services. An independent critical appraisal of both chapters of the ACOEM guidelines showed startling findings with a conclusion that these guidelines may not be applied in patient care as they scored below 30% in the majority of evaluations utilizing multiple standardized criteria.
To reassess the evidence synthesis for the ACOEM guidelines for the low back pain and chronic pain chapters utilizing an expanded methodology, which includes the criteria included in the ACOEM guidelines with the addition of omitted literature and application of appropriate criteria.
For reassessment, randomized trials were utilized as it was in the preparation of the guidelines. In this process, quality of evidence was assessed and recommendations were made based on grading recommendations of Guyatt et al. The level of evidence was determined utilizing the quality of evidence criteria developed by the U.S. Preventive Services Task Force (USPSTF), as well as the outdated quality of evidence criteria utilized by ACOEM in the guideline preparation. Methodologic quality of each individual article was assessed utilizing the Agency for Healthcare Research and Quality (AHRQ) methodologic assessment criteria for diagnostic interventions and Cochrane methodologic quality assessment criteria for therapeutic interventions.
The results of reassessment are vastly different from the conclusions derived by the ACOEM guidelines. The differences in strength of rating for the diagnosis of discogenic pain by provocation discography and facet joint pain by diagnostic facet joint nerve blocks is established with strong evidence. Therapeutic cervical and lumbar medial branch blocks and radiofrequency neurolysis, therapeutic thoracic medial branch blocks, cervical interlaminar epidural steroid injections, caudal epidural steroid injections, lumbar transforaminal epidural injections, percutaneous and endoscopic adhesiolysis, and spinal cord stimulation qualified for moderate to strong evidence. Additional insight is also provided for evidence rating for intradiscal electrothermal therapy (IDET), automated percutaneous disc decompression, and intrathecal implantables.
The reassessment and reevaluation of the low back and chronic pain chapters of the ACOEM guidelines present results that are vastly different from the published and proposed guidelines. Contrary to ACOEM's conclusions of insufficient evidence for most interventional techniques, the results illustrate moderate to strong evidence for most diagnostic and therapeutic interventional techniques.
适当制定的实践指南基于对已发表的关于治疗结果的研究证据进行全面评估后提出最佳实践声明，这包括应用多种方法收集和评估广泛临床干预措施及学科的证据。然而，这些指南并非绝对无误，也不能替代临床判断。虽然指南制定过程是一个复杂的现象，但必须避免指南制定中的利益冲突和不适当的方法。有人声称美国职业与环境医学学会（ACOEM）的指南阻止受伤工人获得大多数医学上必要且适当的介入性疼痛管理服务。对ACOEM指南两章的独立批判性评估得出了惊人的结果，结论是这些指南在大多数使用多种标准化标准的评估中得分低于30%，可能不适用于患者护理。
利用扩展方法重新评估ACOEM指南中腰痛和慢性疼痛章节的证据综合情况，该方法包括ACOEM指南中的标准，以及补充遗漏的文献并应用适当的标准。
为进行重新评估，与指南制定时一样使用随机试验。在此过程中，评估证据质量，并根据盖亚特等人的分级建议提出建议。证据水平根据美国预防服务工作组（USPSTF）制定的证据质量标准以及ACOEM在指南制定中使用的过时证据质量标准来确定。利用医疗保健研究与质量局（AHRQ）诊断干预措施的方法学评估标准和Cochrane治疗干预措施的方法学质量评估标准评估每篇文章的方法学质量。
重新评估的结果与ACOEM指南得出的结论有很大不同。通过激发性椎间盘造影诊断椎间盘源性疼痛和通过诊断性小关节神经阻滞诊断小关节疼痛的评级强度差异有充分证据。治疗性颈椎和腰椎内侧支阻滞及射频神经溶解、治疗性胸椎内侧支阻滞、颈椎椎间孔硬膜外类固醇注射、骶管硬膜外类固醇注射、腰椎经椎间孔硬膜外注射、经皮和内镜下粘连松解以及脊髓刺激有中等至充分证据。还为椎间盘内电热疗法（IDET）、自动经皮椎间盘减压和鞘内植入物的证据评级提供了更多见解。
对ACOEM指南中腰痛和慢性疼痛章节的重新评估和重新评价得出的结果与已发表和提议的指南有很大不同。与ACOEM关于大多数介入技术证据不足的结论相反，结果表明大多数诊断和治疗介入技术有中等至充分证据。
