Evidence based interventional pain practice: according to clinical diagnoses Introduction In 2012, the Nederlandse Vereniging voor Anesthesiologie Sectie Pijn- en Palliatieve geneeskunde (NVA) and the Vlaamse Anesthesiologische Vereniging voor Pijnbestrijding (VAVP) published a guideline on Interventional Pain Medicine. 1 As part of the original publication the authors highlighted that this guideline on interventional pain management can be considered an ongoing project. The searches that informed the original guidelines were at the start of this project in 2015 between 5.5 and 7.5 years out of date and so it is important that updates to this guidance include recently published literature. The methodology for literature retrieval; and selection of the publications to be withheld, as well as the method for evidence scoring, should evolve with each update”. The guideline committee decided to use the GRADE methodology, the current golden standard for the preparation of clinical guidelines. Background Clinical guidelines are systematically developed statements to assist practitioners and patients to make decisions about appropriate health care for specific clinical circumstances. NICE defines clinical guidelines as “recommendations based on the best available evidence, for the care of people by healthcare and other professionals.”2 A more detailed definition was provided by the Institute of Medicine (IOM) study entitled “Practice Guidelines That We Can Trust”: “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 benefits and harms of alternative care options.”3 As reflected in this definition, in order for guidelines to reflect the best available evidence it is important that they are based on a comprehensive systematic review of all available evidence. Systematic reviews provide an explicit approach to reviewing and summarizing evidence from studies. They follow a defined structure to identify, evaluate and summarize all available evidence addressing a particular research question. Key steps in a systematic review include specification of explicit inclusion criteria, an extensive literature search to identify all relevant studies, extraction of key data, assessment of the validity of included studies, and a structured statistical and/or qualitative synthesis of results.4 GRADE presents a systematic and transparent framework for clarifying questions, determining the outcomes of interest, summarizing the evidence that addresses a question, and moving from the evidence to a recommendation or decision. 5-8GRADE is currently the most widely accepted and used framework for developing guidelines. More than 50 organizations worldwide, many highly influential, have endorsed the framework (http://www.gradeworkinggroup.org/). It rates the quality of a complete body of evidence for a specific outcome in a specific population. Aim guideline The aim of the guideline is to update the evidence on efficacy of interventional pain management procedures. Content of the guideline In the original 2012 guideline we described for each diagnosis the definition of the diagnosis, the epidemiology, if known the etiology and pathophysiology, the signs and symptoms, if applicable the additional lab tests including X ray examination etc., the differential diagnosis, the evidence of conservative and interventional treatments, the technical aspects of the application of the invasive 2 pain management procedure and the place of the invasive procedures in the treatment algorithm. On this moment the updated guideline just limits to the quality of evidence, the considerations about risk and benefits, the cost effectiveness if available etc. and the recommendations. This updated guideline does not guide in the place of the interventional pain management procedure in the treatment algorithm. In general, interventional procedure will be offered to the patient if more conventional procedures have failed. Although in individual cases or procedures a deviation is imaginable. A next step in the process of making this guideline is creating more clarity about the place of these procedures in the treatment algorithm. This is especially important for referral doctors. Target audience The guideline is primarily intended for the anesthesiologist pain specialists applying these interventional pain managements procedures in their clinical practice. Other stakeholders are referring doctors, other workers in healthcare involved in these procedures and reimbursement policy makers. Patient perspective The patient associations were involved in the sticking point analysis before the start of the guideline development and will be involved in the authorization phase. In the implementation phase, individual hospitals will translate the content of the guideline in patient information leaflets and websites. Authorisation The guideline is authorized by the Nederlandse Vereniging voor Anesthesiologie, the Nederlandse Vereniging voor Neurologie and the Nederlandse Vereniging van Revalidatieartsen. Funding Project Guideline ‘Evidence based interventional pain practice’ development was funded by the Quality Fund for Medical Specialists (SKMS). Summary A summary of the guideline can be found here. Guideline committee Members guideline committee Prof.dr. F.J.P.M. Huygen (chairman); ErasmusMC, Rotterdam Drs. J.W. Kallewaard, Rijnstate Ziekenhuis, Arnhem Prof.dr. M. van Kleef, MUMC, Maastricht Prof.dr. M. van Tulder, VU, Amsterdam Dr. K. Van Boxem, World lnstitute of Pain Benelux Ziekenhuis Zuid Oost Limburg, Genk Dr. J. Van Zundert, Vlaamse Anesthesiologische Vereniging voor Pijnbestrijding, Ziekenhuis Zuid Oost Limburg, Genk Prof.dr. K. Vissers, World lnstitute of Pain USA ,Radboud UMC, Nijmegen 3 Executive members guideline committee Mrs. N. Van Hecke Drs. M. van Grotel, executive director Nederlandse Vereniging voor Anesthesiologie Independent epidemiologist Prof. dr. J. Kleijnen, MUMC Maastricht/York 4 Methods Research question What is the effectiveness of interventional pain management techniques that can be administered by anesthesiologists for the following conditions: 1 Trigeminal neuralgia 2 Cluster headache 3 Persistent idiopathic facial pain 4 Cervical radicular pain 5 Cervical facet joint pain 6 Cervicogenic headache 7 Whiplash Associated Disorders 8 Occipital neuralgia 9 Thoracic radicular pain 10 Thoracic facet joint pain 11 Lumbosacral radicular pain 11a Failed Back Surgery Syndrome 12 Lumbar facet joint pain 13 Spinal canal stenosis 14 Sacroiliac joint pain 15 Discogenic pain 16 Complex regional pain syndrome 17 Herpes zoster and postherpetic neuralgia 18 Painful diabetic polyneuropathy 19 Meralgia paresthetica 20 Carpal tunnel syndrome 21 Phantom pain 23 Traumatic plexus lesion 25 Chronic refractory angina pectoris 26a Raynaud’s syndrome 26 Chronic ischemic pain of the extremities 27 Chronic pancreatitis 28 Pain in patients with cancer Sticking point analysis After determining the research question, we did a sticking point analysis. We performed an inventory of sticking points in health care and possible impeding factors for the introduction of the future directive. We questioned the following stakeholders: Nederlandse Vereniging voor Neurochirurgie, Nederlandse Vereniging voor Orthopedie, Nederlandse Vereniging voor Neurologie, Koninklijk Genootschap van Fysiotherapeuten, Nederlands Huisartsen Genootschap Vereniging van Revalidatieartsen. 5 V&VN pijnverpleegkundigen/verpleegkundig specialisten pijn, Nederlands Instituut van Psychologen Pijnpatienten naar één stem Nederlandse Vereniging voor Rugpatiënten We received answers from Pijnpatienten naar één stem and the NHG. Pijnpatienten naar één stem asked attention for 2 topics, namely: 1. Communication (treatment, not being taken seriously, not listening well, joint decision making, talking about sexuality, little consultation between practitioners, unclear head treatment, adherence) and 2. Satisfaction (obtained advice and the result of the treatment are disappointing, waiting list). The NHG asked for a connection of the updated guideline to NHG Standards (NHG-Standard Pain) Review of the literature An independent epidemiologist, Prof.dr. J. Kleijnen, MUMC, Maastricht/York, was asked to review the literature. This review aimed to identify and summarize relevant evidence using GRADE methodology to inform guidelines on interventional pain management produced by the NVA and VAVP. This objective was achieved by: conducting a review of existing systematic reviews, randomized controlled trials (RCTs) and, where appropriate, observational studies of pain management for Trigeminal Neuralgia; Cluster Headache; Persistent Idiopathic Facial Pain; Cervical Radicular Pain; Cervical Facet Pain; Cervicogenic Headache; Whiplash-Associated Disorders; Occipital Neuralgia; Thoracic Pain; Lumbosacral Radicular Pain; Failed back surgery syndrome; Pain due to Spinal Canal Stenosis; Pain Originating from the Lumbar Facet Joints; Sacroiliac Joint Pain; Discogenic Low Back Pain; Complex Regional Pain Syndrome; Herpes Zoster and Post-Herpetic Neuralgia; Painful Diabetic Polyneuropathy; Carpal Tunnel Syndrome; Meralgia Parasthetica; Phantom Pain; Traumatic Plexus Lesion; Pain in Patients with Cancer; Chronic Refractory Angina Pectoris; Ischemic Pain in the Extremities and Raynaud’s Phenomenon and Pain in Chronic Pancreatitis. Inclusion criteria Studies that meet the following criteria were eligible for inclusion: