An Update of Comprehensive Evidence-Based
Guidelines for Interventional Techniques in
Chronic Spinal Pain. Part I: Introduction and
General Considerations
Authors: Manchikanti Laxmaiah 
Published: March 2021

In 2011, the Institute of Medicine (IOM) re-engineered its definition of clinical guidelines as
follows: “clinical practice guidelines are statements that include recommendations intended to
optimize patient care that are informed by a systematic review of evidence and an assessment
of the benefit and harms of alternative care options.” This new definition departs from a
2-decade old definition from a 1990 IOM report that defined guidelines as “systematically
developed statements to assist practitioner and patient decisions about appropriate health
care for specific clinical circumstances.” The revised definition clearly distinguishes between
the term “clinical practice guideline” and other forms of clinical guidance derived from widely
disparate development processes, such as consensus statements, expert advice, and appropriate
use criteria. The IOM committee acknowledged that for many clinical domains, high quality
evidence was lacking or even nonexistent. Even though the guidelines are important decisionmaking tools, along with expert clinical judgment and patient preference, their value and
impact remains variable due to numerous factors.
Some of the many factors that impede the development of clinical practice guidelines include
bias due to a variety of conflicts of interest, inappropriate and poor methodological quality,
poor writing and ambiguous presentation, projecting a view that these are not applicable to
individual patients or too restrictive with elimination of clinician autonomy, and overzealous and
inappropriate recommendations, either positive, negative, or non-committal. Consequently,
a knowledgeable, multidisciplinary panel of experts must develop guidelines based on a
systematic review of the existing evidence, as recently recommended by the IOM.
Chronic pain is a complex and multifactorial phenomenon associated with significant economic,
social, and health outcomes. Interventional pain management is an emerging specialty facing a
disproportionate number of challenges compared to established medical specialties, including
the inappropriate utilization of ineffective and unsafe techniques.
In 2000, the American Society of Interventional Pain Physicians (ASIPP) created treatment
guidelines to help practitioners. There have been 5 subsequent updates. These guidelines
address the issues of systematic evaluation and ongoing care of chronic or persistent pain, and
provide information about the scientific basis of recommended procedures. These guidelines are
expected to increase patient compliance; dispel misconceptions among providers and patients,
manage patient expectations reasonably; and form the basis of a therapeutic partnership
between the patient, the provider, and payers.
Key words: Evidence-based medicine (EBM), comparative effectiveness research (CER),
clinical practice guidelines, systematic reviews, meta-analysis, interventional pain management,
evidence synthesis, methodological quality assessment, clinical relevance, recommendations.