Pain Management Center of Paducah, Paducah, KY, USA.
Pain Physician. 2010 May-Jun;13(3):E141-74.
Clinical guidelines are defined as systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. The clinical guideline industry has been erupting even faster than innovation in health care, constantly adding unhealthy perspectives with broad and complex mandates to health care interventions. Clinical guidelines are based on evidence-based medicine (EBM) and comparative effectiveness research (CER). Multiple issues related to the development of clinical guidelines are based on conflicts of interest, controversies, and limitations of the guideline process. Recently, the American Pain Society (APS) developed and published multiple guidelines in managing low back pain resulting in multiple publications. However, these guidelines have been questioned regarding their development process, their implementation, and their impact on various specialties.
To reassess the APS guidelines' evidence synthesis for low back pain diagnostic interventions using the same methodology utilized by the APS authors. The interventions examined were diagnostic techniques for managing low back pain of facet joint origin, discogenic origin, and sacroiliac joint origin.
A literature search by two authors was carried out utilizing appropriate databases from 1966 through July 2008. Methodologic quality assessment was also performed by at least 2 authors utilizing the same criteria applied in APS guidelines. The guideline reassessment process included the evaluation of individual studies and systematic reviews and the translation into practice recommendations.
Our reassessment of Chou et al's evaluation, utilizing Chou et al's criteria, showed good evidence for lumbar facet joint nerve blocks, fair evidence for lumbar provocation discography, and fair to poor evidence for sacroiliac joint blocks to diagnose sacroiliac joint pain. The reassessment illustrates that Chou et al have utilized multiple studies inappropriately and have excluded appropriate studies. Also, Chou et al failed to eliminate their bias in their study evaluations.
The reassessment, using appropriate methodology and including high quality studies, shows evidence that differs from published APS guidelines.
临床指南被定义为系统制定的陈述，旨在帮助医生和患者在特定临床情况下做出适当的医疗保健决策。临床指南行业的发展速度甚至超过了医疗保健的创新速度，不断将不健康的观点纳入医疗干预措施中，这些观点广泛而复杂。临床指南基于循证医学（EBM）和比较效果研究（CER）。与临床指南制定相关的多个问题都基于利益冲突、争议和指南制定过程的局限性。最近，美国疼痛学会（APS）制定并发布了多项管理下腰痛的指南，导致了多项出版物的出现。然而，这些指南在其制定过程、实施情况及其对各专业的影响方面受到了质疑。
使用 APS 作者使用的相同方法，重新评估 APS 指南对下腰痛诊断干预的证据综合分析。检查的干预措施是治疗小关节源性、椎间盘源性和骶髂关节源性腰痛的诊断技术。
两名作者利用适当的数据库，从 1966 年到 2008 年 7 月进行了文献检索。至少有 2 名作者还利用与 APS 指南相同的标准进行了方法学质量评估。指南重新评估过程包括对个体研究和系统评价的评估，并将其转化为实践建议。
我们使用 Chou 等人的标准重新评估了 Chou 等人的评估，结果表明腰椎小关节神经阻滞有良好的证据，腰椎激发性椎间盘造影有中等证据，骶髂关节阻滞诊断骶髂关节痛有中等至较差的证据。重新评估表明，Chou 等人不适当地使用了多项研究，并排除了适当的研究。此外，Chou 等人在评估研究时未能消除其偏见。
使用适当的方法学和包括高质量研究的重新评估表明，证据与已发表的 APS 指南不同。
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