The North American Spine Society published guidelines Jan. 29 for the diagnosis and treatment of low back pain in adult patients.
The publication, "Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Low Back Pain," focuses on 82 clinical questions and is the largest clinical guidelines that NASS has produced.
Paul Matz, MD, a neurosurgeon with Casper-based Wyoming Neurosurgery and Spine and the evidence-based guideline development committee co-chair, spoke to Becker's Spine Review about the motivation behind the guidelines and what he hopes it will achieve.
Question: What was the motivation and the end-goal behind the NASS clinical guidelines?
Dr. Paul Matz: Prior guidelines had focused on a specific disease entity and NASS wanted to tackle one on a very broad entity, simply because low back pain is so common and affects so many people, and because there really hasn't been a comprehensive review of it. As NASS is a multidisciplinary organization focusing on spine, the consensus was that other guidelines that looked at low back pain had really been from the perspective of the type of group that did the examination and there hadn't been a multidisciplinary group that looked at such a broad question. So that's why NASS chose to undertake it, knowing the trepidation that it was such a broad subject.
Q: What was the biggest point of contention in the guidelines?
PM: Well, it started with the definition. Because when you say, 'low back pain,' are you simply saying isolated low back pain or are you saying low back pain with radiculopathy? So, a lot of the time was spent on trying to define isolated low back pain. What we settled on was low back pain that didn't radiate below the knee, with the idea that some radiation in the thigh can be produced by low back pain.
The important thing was we settled on non-radicular low back pain. But the issue with that was that there are a lot of clinical studies when we ask questions that included radicular pain and if they didn't isolate the subgroups — meaning the patients with low back pain without radicular pain and those with it — we had to exclude that study. Your guideline conclusions are only as good as the studies you include so that in some ways probably effected the conclusions that we had, relative to the guidelines compared to some other ones that may have included radicular pain. I think that was probably the biggest point of contention.
Q: Do payers look at these guidelines? If so, how do you think they will interpret them?
PM: I suspect that yes, they will look at them. But there is always that concern: Will the guidelines affect my patient's coverage for certain treatments? NASS' clinical guidelines are intended as educational documents and we include a statement that they're not standards of care, nor should they be used as the sole reason for denial of treatment and services. In a very broad subject, if you look at where we are now and where we can move to, you need a review and that's what the guidelines offer. There's always the concern that it could affect coverage but that's not the intent. The intent is, if a payer looks at it, to use it as an educational device and use it as a way to move forward, as opposed to using it as a sole reason.