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.

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1. Wang X, Martin G, Sadeghirad B, Chang Y, Florez ID, Couban RJ, Mehrabi F, Crandon HN, Esfahani MA, Sivananthan L, Sengupta N, Kum E, Rathod P, Yao L, Morsi RZ, Genevay S, Buckley N, Guyatt GH, Rampersaud YR, Standaert CJ, Agoritsas T, Busse JW. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ. 2025 Feb 19;388:e079971. doi: 10.1136/bmj-2024-079971. PMID: 39971346.

2. Domenichiello AF, Ramsden CE. The silent epidemic of chronic pain in older adults. Prog Neuropsychopharmacol Biol Psychiatry. 2019 Jul 13;93:284-290. doi: 10.1016/j.pnpbp.2019.04.006. Epub 2019 Apr 17. PMID: 31004724; PMCID: PMC6538291.

3. Yong RJ, Mullins PM, Bhattacharyya N. Prevalence of chronic pain among adults in the United States. Pain. 2022 Feb 1;163(2):e328-e332. doi: 10.1097/j.pain.0000000000002291. PMID: 33990113.

4. Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017 Apr 24;4(4):CD011279. doi: 10.1002/14651858.CD011279.pub3. PMID: 28436583; PMCID: PMC5461882.

5. Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. Cochrane Database Syst Rev. 2015 Sep 1;2015(9):CD001929. doi: 10.1002/14651858.CD001929.pub3. PMID: 26329399; PMCID: PMC8734598.

6. Scott NA, Guo B, Barton PM, et al. Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review. 2009. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-

7. Williams ACC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020 Aug 12;8(8):CD007407. doi: 10.1002/14651858.CD007407.pub4. PMID: 32794606; PMCID: PMC7437545.

8. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015 Feb 17;162(4):276-86. doi: 10.7326/M14-2559. PMID: 25581257.

9. Ayub S, Bachu AK, Jain L, Parnia S, Bhivandkar S, Ahmed R, Kaur J, Karlapati S, Prasad S, Kochhar H, Ayisire OE, Mitra S, Ghosh B, Srinivas S, Ashraf S, Papudesi BN, Malo PK, Sheikh S, Hsu M, De Berardis D, Ahmed S. Non-opioid psychiatric medications for chronic pain: systematic review and meta-analysis. Front Pain Res (Lausanne). 2024 Oct 10;5:1398442. doi: 10.3389/fpain.2024.1398442. PMID: 39449766; PMCID: PMC11499177.

10. Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res. 2022;15:3729-3832
https://doi.org/10.2147/JPR.S386879

11. Manchikanti L, Kaye AD, Soin A, Albers SL, Beall D, Latchaw R, Sanapati MR, Shah S, Atluri S, Abd-Elsayed A, Abdi S, Aydin S, Bakshi S, Boswell MV, Buenaventura R, Cabaret J, Calodney AK, Candido KD, Christo PJ, Cintron L, Diwan S, Gharibo C, Grider J, Gupta M, Haney B, Harned ME, Helm Ii S, Jameson J, Jha S, Kaye AM, Knezevic NN, Kosanovic R, Manchikanti MV, Navani A, Racz G, Pampati V, Pasupuleti R, Philip C, Rajput K, Sehgal N, Sudarshan G, Vanaparthy R, Wargo BW, Hirsch JA. Comprehensive Evidence-Based Guidelines for Facet Joint Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines Facet Joint Interventions 2020 Guidelines. Pain Physician. 2020 May;23(3S):S1-S127. PMID: 32503359.

12. Manchikanti L, Knezevic NN, Navani A, Christo PJ, Limerick G, Calodney AK, Grider J, Harned ME, Cintron L, Gharibo CG, Shah S, Nampiaparampil DE, Candido KD, Soin A, Kaye AD, Kosanovic R, Magee TR, Beall DP, Atluri S, Gupta M, Helm Ii S, Wargo BW, Diwan S, Aydin SM, Boswell MV, Haney BW, Albers SL, Latchaw R, Abd-Elsayed A, Conn A, Hansen H, Simopoulos TT, Swicegood JR, Bryce DA, Singh V, Abdi S, Bakshi S, Buenaventura RM, Cabaret JA, Jameson J, Jha S, Kaye AM, Pasupuleti R, Rajput K, Sanapati MR, Sehgal N, Trescot AM, Racz GB, Gupta S, Sharma ML, Grami V, Parr AT, Knezevic E, Datta S, Patel KG, Tracy DH, Cordner HJ, Snook LT, Benyamin RM, Hirsch JA. Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines. Pain Physician. 2021 Jan;24(S1):S27-S208. PMID: 33492918.

13. Cohen SP, Bhaskar A, Bhatia A, Buvanendran A, Deer T, Garg S, Hooten WM, Hurley RW, Kennedy DJ, McLean BC, Moon JY, Narouze S, Pangarkar S, Provenzano DA, Rauck R, Sitzman BT, Smuck M, van Zundert J, Vorenkamp K, Wallace MS, Zhao Z. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med. 2020 Jun;45(6):424-467. doi: 10.1136/rapm-2019-101243. Epub 2020 Apr 3. PMID: 32245841; PMCID: PMC7362874.

14. U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S. Department of Health and Human Services website: https://www.hhs.gov/ash/advisory-committees/pain/reports/index.html

PSPS ReActiv8 Position Statement

The Pacific Spine and Pain Society (PSPS) is dedicated to bridging the gap between spine surgery and pain medicine which often encounter the same patients. PSPS serves as an open forum to promote and criticize emerging technologies; it is rooted in research, clinical excellence, and patient-centric care. This includes advocacy and policy for access to care through our collaboration with other societies, the government, and third-party payers.

Patients with intractable axial or mechanical chronic low back pain are commonly seen by our disciplines. Many are refractory to physical therapy and medication, have no indications for surgery and may be chronic consumers of opioids. Their symptoms may be caused by impaired neuromuscular control of the multifidus muscles, which normally provide functional stability to the lumbar spine. This condition is specific, well understood and described in the literature, and diagnosable with simple functional tests. Because historically there were no effective and durable treatments for functional instability, we often resorted to palliative treatment of its symptoms with medication, injections, and rhizotomy and in some cases patients opted for lumbar fusion as a last resort.

Restorative neurostimulation targets the root cause of functional instability. Through bilateral stimulation of the L2 medial branch of the dorsal ramus nerve it (re)activates the multifidus muscles and afferent proprioception to facilitate restoration of neuromuscular control.

Several clinical studies, including the randomized, sham-controlled, double blinded pivotal trial, have consistently documented that this therapy is safe, fully reversible and provides substantial clinical benefits with up to 4-year durability evidence. Furthermore, published Real World Evidence is consistent with those of the RCT and other prospective studies.

Restorative neurostimulation addresses a real and important treatment gap we are facing and therefore exemplifies an ‘emerging technology, rooted in research, clinical excellence’ requiring our advocacy and policy for access to ‘patient-centric care’. Therefore, the PSPS Advocacy and Policy Committee is of the opinion that the current evidence base supports coverage of restorative neurostimulation for patients with intractable CLBP associated with multifidus dysfunction who are refractory to available conventional treatments and not indicated for spine surgery.

The members of PSPS urge commercial insurers and other third-party payers to take immediate steps towards creating a coverage policy that recognizes the unmet clinical need and the ample evidence in support of restorative neurostimulation in this very specific and severely affected patient group. This is an appropriate action that affords well indicated patients the opportunity to access this novel therapy while allowing appropriate governance of utilization. We are happy to contribute to any of the policy development work that might be required. Please don’t hesitate to reach out to us if we can be of assistance.

Respectfully,
The Pacific Spine and Pain Society Advocacy and Policy Committee

PSPS Position Statement

Centers for Medicare Services,

The leadership and membership of the Pacific Spine and Pain Society has determined to provide a statement in response to the multiple Centers for Medicare Services Medicare Administrative Contractors (MACs) that have posted draft local coverage determinations (LCDs) for sacroiliac joint procedures indicating that these are not medically necessary. Those MACs include: NGS, Noridian, Palmetto and WPS. These LCD decisions impact not only Medicare beneficiaries but patients with Medicare Advantage and commercial plans.

The Pacific Spine and Pain Society is comprised of a multidisciplinary collegium of physicians and advanced practice providers who are committed to the evidence-based treatment of chronic pain. The providers of this society aim to educate themselves so as to provide patients with safe and effective treatments. Interventional techniques are an important option and often an alternative to initiation of opiate therapy.

In the instance of sacroiliac joint pain, radiofrequency ablation has proven an important interventional treatment option. Pain originating from the sacroiliac joint is a common cause of back pain. It is estimated that 15-30% of mechanical low back pain is from this anatomic source [1]. Conventional treatments for this condition include physical therapy, anti-inflammatory medications, chiropractic and intraarticular steroid injections.

Sacroiliac joint radiofrequency ablation was described as a treatment to reduce pain involving the sacroiliac joint in 2003 [2]. Leveraging established knowledge of the innervation of the sacroiliac (SI) joint this procedure applies the known therapy of radiofrequency ablation to the lateral branches of the sacral nerves [3]

There are multiple well-designed research studies which have demonstrated the efficacy of this therapy. This year, Dr. Lowe published a systematic review of 16 randomized controlled trials (RCTs) that reported on long-term results of SI joint radiofrequency ablation [4]. Fifteen of these RCTs shared positive results of this therapy as measured by Oswestry Disability Index & Numerical Rating Scale.

It is the position of the Pacific Spine and Pain Society that denying patient access to SI joint RFA leaves a significant treatment gap when conservative measures have been exhausted. Over decades of research, some of which has been summarized in Dr. Lowe’s systemic review, have demonstrated that SI joint RFA is safe and effective. Without this option, patients may be driven to options with greater risk such as chronic opioid therapy or those that are more invasive, such as SI joint fusion. It is the request of the Pacific Spine and Pain Society that the Centers for Medicare Services preserve this treatment option for our patients suffering with chronic sacroiliac joint pain.

1. Cohen, et al. Expert Review of Neuroptherapeutics. 2013 Jan;13(1):99-116.
2. Cohen et al. Reg Anesth Pain Med. 2003 Mar-Apr;28(2):113-9.
3. Pino et al. Reg Anesth Pain Med. 2005 Jul-Aug;30(4):335-8.
4. Lowe et al. Cureus. Jun 2022;14(6):e26327.