A Critical Review of the American Pain Society
Clinical Practice Guidelines For Interventional
Techniques: Part 2. Therapeutic Interventions
Authors: Manchikanti Laxmaiah 
Published: March 2021

Background: Clinical guidelines are a constructive response to the reality that practicing physicians
require assistance in assimilating and applying the exponentially expanding, often contradictory, body
of medical knowledge. They attempt to define practices that meet the needs of most patients under
most circumstances. Ideally, specific clinical recommendations contained within practice guidelines
are systematically developed by expert panels who have access to all the available evidence, have an
understanding of the clinical problem, and have clinical experience with the procedure being assessed,
as well as knowledge of relevant research methods. The recent development of American Pain Society
(APS) guidelines has created substantial controversy because of their perceived lack of objective analysis
and recommendations perceived to be biased due to conflicts of interest.
Objectives: To formally and carefully assess the APS guidelines’ evidence synthesis for low back pain
for therapeutic interventions using the same methodology utilized by the APS authors. The interventions
examined were therapeutic interventions for managing low back pain, including epidural injections,
adhesiolysis, facet joint interventions, and spinal cord stimulation.
Methods: A literature search by 2 authors was carried out utilizing appropriate databases from
1966 through July 2008. Articles in which conflicts arose were reviewed and mediated by a third
author to arrive at a consensus. Selections of manuscripts and methodologic quality assessment was
also performed by at least 2 authors utilizing the same criteria applied in the APS guidelines. The
guideline reassessment process included the evaluation of individual studies and systematic reviews
and their translation into practice recommendations.
Results: The conclusions of APS and our critical assessment based on grading of good, fair, and poor,
agreed that there is fair evidence for spinal cord stimulation in post lumbar surgery syndrome, and
poor evidence for lumbar intraarticular facet joint injections, lumbar interlaminar epidural injections,
caudal epidural steroids for conditions other than disc herniation or radiculitis, sacroiliac joint injections,
intradiscal electrothermal therapy, endoscopic adhesiolysis, and intrathecal therapy. However, our
assessment of APS guidelines for other interventional techniques, utilizing their own criteria, showed fair
evidence for therapeutic lumbar facet joint nerve blocks, caudal epidural injections in disc herniation or
radiculitis, percutaneous adhesiolysis in post lumbar surgery syndrome, radiofrequency neurotomy, and
transforaminal epidural injections in radiculitis. Also it is illustrated that inclusion of latest literature will
change the conclusions, with improved grading – caudal epidural, adhesiolysis, and lumbar facet joint
nerve blocks from fair to good or poor to fair.
The present critical assessment review illustrates that APS guidelines have utilized multiple studies
inappropriately and have excluded appropriate studies. Our integrity assessment shows deep concerns
that the APS guidelines illustrating significant methodologic failures which raise concerns about
transparency, accountability, consistency, and independence.
Conclusion: The current reassessment, using appropriate methodology, shows evidence similar
to APS guidelines for several procedures, but differs extensively from published APS guidelines for
multiple other procedures including caudal epidural injections, lumbar facet joint nerve blocks, lumbar
radiofrequency neurotomy, and percutaneous adhesiolysis.
Key words: Guidelines, evidence-based medicine, systematic reviews, American Pain Society,
interventional pain management, interventional techniques