Advocacy in action: Challenging controversial BMJ guidelines.
Introduction: A High-Stakes Debate with Real-World Consequences
The field of chronic pain management is an arena of intense scientific scrutiny and a profound need for innovation. This tension recently erupted when The British Medical Journal (BMJ) published a clinical practice guideline by Busse et al. strongly recommending against many common interventional spine procedures for chronic back pain. The American Society of Pain and Neuroscience (ASPN) issued a swift rebuttal ( https://aspnpain.com/wp-content/uploads/2025/03/ASPN-Response-to-BMJ-Article.pdf), calling the guideline an "egregious error" and demanding its retraction. This conflict is more than an academic dispute; it is a case study on the imperative for professional advocacy to safeguard patient access to care and uphold scientific integrity.
I. Deconstructing the Guideline: The BMJ's Challenge to Interventional Spine Care
The guideline from Busse et al. was a sweeping condemnation of interventional spine care. It issued strong recommendations against procedures like radiofrequency ablation and epidural steroid injections for both chronic axial and radicular spine pain, suggesting most patients should decline them. The authors based this on a network meta-analysis guided by the GRADE framework, presenting it as a definitive synthesis of evidence.
II. The Counter-point: ASPN's Detailed Case for Retraction
ASPN's rebuttal systematically dismantled the guideline, alleging five core failures:
"Egregious Error" in Statistical Analysis: The letter claimed the authors violated PRISMA-NMA standards by including biased studies, inflating heterogeneity, and applying a "clear double standard" in its use of the GRADE framework to favor a null hypothesis.
Methodological and Specialty Bias: It challenged the panel's composition, which lacked sufficient representation from practicing interventional pain specialists, leading to an undervaluation of procedural nuances.
Misleading Risk Assessment: The rebuttal argued the guideline presented a "skewed risk-benefit analysis" by amplifying rare harms sourced from case reports while downplaying the risks of alternatives like long-term opioid therapy.
Restrictive and Flawed Recommendations: ASPN criticized the "strong recommendations" based on low-to-moderate certainty evidence, arguing this inappropriately denies patient access and suggests an "agenda-driven purpose."
The BMJ's Culpability: The response held The BMJ's editorial leadership responsible for disseminating "low-quality research" that could restrict insurance coverage for non-opioid treatments and cause patient harm, culminating in the call for retraction.
III. A Broader Scientific Consensus: Why This Is More Than One Society's Opinion
ASPN's rebuttal was amplified by a chorus of other leading medical societies, representing specialties like Anesthesiology, Neurosurgery, and Radiology, creating a unified professional front against the guideline. These organizations argued the guideline was a dangerously oversimplified analysis that threatened to undo decades of progress in personalized pain care.13 The dialogue extended beyond formal letters, with experts dissecting the guideline's flaws in forums like the
Pain Medicine podcast, making the scientific debate more accessible to the wider medical community (https://podcasts.apple.com/us/podcast/in-response-bmj-interventional-spine-guidelines-2025/id1599145046?i=1000700256310, https://painmed.org/ep-34-in-response-bmj-interventional-spine-guidelines-2025/).
The collective critique focused on fatal methodological flaws. A primary issue was the inappropriate grouping of dissimilar studies, mixing different procedures, patient populations, and spinal regions, which inevitably drives results toward a null finding. Critics also noted the inclusion of outdated or abandoned procedures while omitting robust evidence for modern techniques like basivertebral nerve ablation. Perhaps most damning was the guideline's failure to assess the technical quality of the interventions, treating studies of poorly executed procedures with the same weight as those performed to the highest standard.
This multi-society response functions as a critical form of post-publication peer review, an essential corrective mechanism when a prominent publication poses a threat of widespread negative impact.
Table 1: Comparative Analysis of Methodological Critiques: BMJ Guideline vs. Multi-Society Rebuttal
Make it stand out
Whatever it is, the way you tell your story online can make all the difference.
IV. From Publication to Policy: The Cascade Effect of Clinical Guidelines
The fierce response was driven by the real-world cascade effect of clinical practice guidelines (CPGs). A "strong recommendation" in a journal like The BMJ is a policy-making event, heavily influencing health insurers and regulatory agencies that use CPGs to define "medically necessary" care and justify coverage decisions. ASPN warned this could lead to restricted insurance coverage for essential non-opioid treatments.
The direct threat to patient access is severe. Patients could be denied effective care, leading to increased suffering and disability. Worse, it could create perverse incentives, pushing patients toward riskier and more expensive alternatives like major surgery or long-term opioid use.13 This cascade effect places an immense ethical burden on high-impact journals to consider the foreseeable harms of a publication. ASPN's response directly accuses
The BMJ of failing this gatekeeping duty, arguing the journal bears "immense responsibility" for the potential fallout.
V. The Mission of Advocacy: The Core Function of the Modern Medical Society
The actions taken by ASPN exemplify the core function of a modern medical society: to serve as the collective voice and intellectual guardian of a specialty. ASPN's mission is to "improve education, highlight scientific curiosity, establish best practice," and be "a part of the solution to societal issues such as the opioid crisis". Similarly, the American Medical Association (AMA) works to "remove obstacles to patient care".
By publishing a detailed rebuttal, ASPN worked to establish best practice and remove an obstacle to care, fulfilling its foundational mission.This aligns with the ethos of organizations like C.R.I.S.P Center for Research & Innovation in Spine & Pain, which are dedicated to advancing spine care through advocacy for evidence-based policy. This response is part of a long tradition of physician-led advocacy, from fighting scope of practice expansions that threaten patient safety to battling administrative burdens like prior authorization. These efforts demonstrate that leveraging collective expertise to advocate for patients is a critical professional obligation.30
Conclusion: A Call for Principled Dialogue and Responsible Science
The confrontation between ASPN and The BMJ illustrates a vital principle: principled, evidence-based advocacy is an essential function of a self-correcting scientific community. It is a necessary check against flawed research being codified into harmful policy. The rebuttal led by ASPN was a scholarly demand for higher standards, transparency, and a patient-centered approach that respects clinical nuance.
This episode must be a catalyst for reform. The future of guideline development depends on true collaboration between methodological experts and experienced clinicians. It requires a humble approach that acknowledges the limitations of data and resists issuing absolutist recommendations based on uncertain evidence. This is the only path toward building a healthcare system that leverages the best of science to serve the best interests of patients.
