PSPS Advocacy Update: PSPS Respond to Contentious BMJ Publications

The Pacific Spine and Pain Society is a multidisciplinary medical society representing medical providers who are committed to the treatment of patients with chronic pain. Our members include greater than 3,000 providers who practice in specialties including neurology, radiology, neurosurgery, orthopedic surgery, anesthesiology & rehabilitative medicine. The physician and advanced practice providers work in diverse practice environments across Pacific Coast of the United States, dedicated to reducing suffering and improving function among those afflicted by chronic pain conditions.

The treatment of chronic pain is profoundly complex and varied. Providers who commit their careers to the practice of pain management determine to care for those patients with the most refractory, pervasive & disabling of conditions. Patients suffering with prolonged discomfort present are in need of expert providers who are able to assess and diagnose the pathological etiology of their pain and respond to this with disease-targeting treatments. Additionally, those providers who are committed to serving patients with chronic pain attend to the functional implications of chronic pain which include economic, social, psychological and relational consequences.

The Pacific Spine and Pain Society and the membership it represents must respond with a statement of concern in response to the recent article published in the British Medical Journal, Common interventional procedures for chronic non-cancer spine pain: a systemic review and network meta-analysis of randomized trial by Wang, et al (1).

We would like to address salient points, some of which have already rightly been made by other pain and surgery societies:

• Questionable Expertise of Authors
  The authors of the study were not interventional pain specialists, yet they presented themselves as experts in the field. The authorship does not include a research or clinical expert in practice of pain management. Given the complexity and nuances of interventional pain management, expert interpretation by specialists is essential to ensure accurate analysis and appropriate clinical recommendations.
• Inappropriate Grouping of Diagnoses
  The approach of grouping multiple diagnoses under a single category and applying the same procedural intervention is problematic. Proper diagnosis is critical to ensuring that the most appropriate procedure is selected for each patient. For instance, a multilevel spinal fusion would not be recommended for a single-level unilateral paracentral disc extrusion, yet such broad categorization in the analysis could lead to misleading conclusions and poor clinical outcomes.
• Lack of Procedural Accountability
  There is no clear mechanism for verifying whether the procedures analyzed were performed correctly. Without the ability to review procedural imaging or technique, there is no assurance that the reported outcomes accurately reflect best practices. This lack of accountability undermines the validity of the conclusions drawn.
• Heterogeneity of Studies
  The studies referenced exhibit substantial heterogeneity, which raises concerns about the consistency and reliability of the pooled results. Variability in study design, patient selection, and procedural techniques limits the ability to draw definitive conclusions.

Given these concerns, the conclusions drawn from the referenced studies should be interpreted with caution, as they may not reliably guide clinical decision-making in interventional pain management.

Chronic pain has a profound global impact, affecting social, economic, and quality-of-life metrics. Numerous studies have documented its widespread consequences, emphasizing the urgent need for effective management strategies. (2,3)

The potential harm of poorly conducted research on chronic pain patients cannot be overlooked. Several studies highlight the lack of evidence or limited efficacy of conservative treatments and medication management. (4-9) While interventional pain procedures often receive scrutiny due to their invasive nature, their safety and effectiveness have been well-documented in high-quality research studies. In contrast, the risks associated with long-term opioid therapy are well established, reinforcing that it should not be the first-line treatment for chronic pain.

It is particularly concerning that, despite rigorous, evidence-based guidelines developed by respected pain societies, misconceptions persist.(10-13). Even the Department of Health and Human Services has advocated for a multimodal approach that includes interventional pain procedures as part of comprehensive pain management. (14)

While the field of interventional pain management must continue to generate robust evidence, a substantial body of literature already supports both the safety and efficacy of these procedures. Failure to acknowledge this evidence not only misguides clinical practice but also negatively impacts patients and has far-reaching social and economic consequences.

Finally, the Pacific Spine & Pain Society underlines that the inclusion of researchers who have specialized training and clinical experience in the topic of their research is likely to yield the most meaningful research products. For research efforts that seek to influence the medical practice guidelines, the context of intimate and professional commitment to treating those afflicted with chronic pain conditions is both appropriate and ethical.

PSPS will continue to listen to its members and advocate on their behalf. To become more involved with advocacy for interventional pain management and spine surgery, join PSPS for free.

View full response and references here.