Thirty-four medical professional societies have called for The BMJ to retract a recently published guideline recommending against the use of interventional procedures, such as steroid or anaesthetic injections, to treat chronic back pain.
The journal published the guideline in February as part of its Rapid Recommendations program alongside a meta-analysis and systematic review of published research on the procedures, which the guideline panel used to inform its recommendations. The publications received international news coverage and enough chatter on social media platforms such as X and Bluesky to place them in the top 5 percent of all articles scored by Altmetric, a data company that tracks digital mentions of research.
The societies, led by the International Pain and Spine Intervention Society, represent clinicians who prescribe or perform the interventional spine procedures the guideline recommends against. The groups “have serious concerns about the methodology and conclusions drawn in these publications and their potential impact on patient care,” they wrote in a statement dated March 18, and summarized in a rapid response on the BMJ’s website. The statement has since been published in The Spine Journal and Interventional Pain Medicine.
The authors of the guideline and meta-analysis have stood by their work in responses to the critiques and comments to Retraction Watch. The BMJ “have no plans to take further action” beyond publishing the critiques and authors’ responses, Caroline White, a spokesperson for the journal, told us.
The systematic review included 132 previously published trials, of which 81 yielded data for the meta-analysis. The authors found “no commonly performed interventional procedure provided convincing evidence of important pain relief or improvement in physical functioning,” they wrote. “Indeed, in many instances the evidence showed moderate certainty of little to no effect.”
After reviewing the findings, the guideline panel, which included some of the authors of the review, “concluded that all or almost all informed patients would choose to avoid interventional procedures” for chronic spine pain, they wrote, “because all low and moderate certainty evidence suggests little to no benefit on pain relief compared with sham procedures, and these procedures are burdensome and may result in adverse events.”
The guideline authors speculated “the substantial reimbursement associated with these procedures may act as a perverse incentive” for their use.
In an editorial accompanying the articles, Jane C. Ballantyne of the University of Washington School of Medicine in Seattle noted some existing guidelines on the procedures recommended their use, while others recommended against them. Ballantyne, an anesthesiologist and pain medicine specialist, had served as a peer reviewer for the systematic review and meta-analysis before publication, according to The BMJ’s open review documents.
The new publications, she wrote: “will not be the last word on spine injections for chronic back pain, but it adds to a growing sense that chronic pain management needs a major rethink that is perhaps best achieved by a better balance of reimbursements between procedural and non-procedural chronic pain treatments.”
The radiology and pain medicine societies detailed several critiques of the work in their letter asking The BMJ to retract the guideline, “based on extensive clinical experience and a review of the evidence.” The meta-analysis inappropriately combined data from trials of different procedures in patients with different diagnoses and areas of spine pain, they wrote, which “allowed pooling of data at the expense of interpretable conclusions.”
The guideline, in turn, lumped together “disparate groups of patients, conditions, spinal regions, and procedures,” they wrote. “Conflating these groups in analysis is convenient but misguided; in guideline development, it is misleading and irresponsible.”
The guideline also drew on studies of techniques that are no longer used, left out studies the medical societies deemed important for supporting the benefit of the techniques, and inaccurately extracted data from another positive study, the statement claimed.
Joshua Rittenberg, president of the International Pain and Spine Intervention Society, posted summaries of the letter on The BMJ’s website as rapid responses to the guideline and meta-analysis. He acknowledged the interventional procedures “are not universally effective,” but argued they could help “appropriately selected patients.” Rittenberg did not respond to our request for comment.
In responses to the critiques, Jason Busse of McMaster University in Hamilton, Ontario, and coauthors disputed the assertion the meta-analysis had included studies on procedures not commonly used in practice, and denied excluding any eligible trials. They also defended their method of pooling data, as subgroup analyses they conducted “found no evidence for systematic differences in treatment effects” for different spinal regions, procedure approaches, or conditions.
“We are aware that our findings are disappointing to clinicians that administer interventional procedures for chronic spine pain, and have carefully considered all Rapid Responses submitted to the BMJ,” Busse and Liang Yao, the corresponding authors of the guideline and meta-analysis, respectively, wrote in comments to Retraction Watch.
“If some clinicians believe that they can correctly identify patients with chronic spine pain who will benefit from interventional procedures, we believe they should undertake high quality sham-controlled trials to provide evidence,” they wrote. “As we note in our guideline, such evidence would alter our recommendations.”
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A someone who’s had a spinal injury, the meta analysis seems on point. Any medical interventions i tried had no effect other than the side effects of the intervention.