AAOS lends its expertise to development of an AUC

When the Spine Intervention Society (SIS) embarked on the development of Appropriate Use Criteria (AUC) on the diagnosis and treatment of disease and pain in the sacroiliac joint (SIJ), it engaged in a collaborative effort with several other medical societies, including the Academy.

The SIS—which includes physicians from multiple specialties, including anesthesiology, physical medicine and rehabilitation, radiology, neurology, orthopaedic surgery, and neurosurgery—had members willing to serve on the evidence and rating panels. They could write the systematic reviews and develop, evaluate, and rate the clinical scenarios.

But for the complex task of aggregating and analyzing the appropriateness ratings, SIS turned to the AAOS, which has become a leader in the logistics and technology of AUC development.

Ryan Pezold, a research analyst in the Academy's evidence-based medicine (EBM) unit, worked with SIS personnel and panelists to guide them through the process using the AUC application and balloting tool developed by the AAOS.

"SIS had begun the process of creating the AUC," he explained. "They had figured out their starting point and what the voting panel needed to vote on. They initially asked the AAOS about using our interactive AUC dissemination format. When they found out about the Academy's online system for the voting portion of the AUC, they were very interested. We helped them tailor their project to fit the balloting system."

Mr. Pezold and AAOS colleagues worked with SIS on a consultancy basis to customize the process to the SIS's desired approach. For example, he said, "Their patient indications change based on which treatment is being considered, whereas the patient indications for AAOS AUC are basically static. We worked closely with them to develop an adaptive strategy."

After the voting panels completed their work, Mr. Pezold helped the SIS develop another strategy to present the final product using the AAOS platform.

The final product
SIS recently released the final product, an AUC portal for "Fluoroscopically Guided Diagnostic and Therapeutic Sacroiliac Interventions" (http://sis.webauthor.com/go/auc/). The five modules cover the following scopes of treatment:

• clinical indications and imaging
• anticoagulants
• timing of injections
• number of injections
• lateral branch radiofrequency neurotomy

SIS President John MacVicar, MD, chaired the Task Force that developed the Multisociety Sacroiliac Interventions AUC.

"The evidence for many procedures performed for spinal pain is limited, and guidelines often ignore observational studies, regardless of their quality. An AUC is a useful resource for appropriately selecting patients and choosing procedures," he said.

"For some strange reason," he continued, "we thought developing an AUC on SIJ interventions would be a straightforward process. It turned out to be much more complex than we anticipated."

As a result, the SIS enlisted participation from the American Society of Anesthesiologists, the American College of Radiology, the American Academy of Physical Medicine and Rehabilitation, the American Academy of Pain Medicine, and the North American Spine Society, along with the AAOS.

"We thought it was very important to involve other societies and to foster relationships," said Dr. MacVicar.

Two Academy members served on the project—Wellington K. Hsu, MD, served on the evidence panel, and William C. Watters III, MD, was a member of the voting panel.

"An AUC will blend together various levels of evidence along with expert input across a wide variety of individuals," explained Dr. Watters, who has contributed to the creation of AAOS clinical practice guidelines (CPGs) and AUC. "So you get a very diverse universe of responses that the process allows you to whittle down and come up with the best recommendations. I think this will bring some standardization to questions of whether and when SIJ injections should be used."

Dr. Watters noted that the SIS AUC do not cover procedures such as SIJ fusion. "This is primarily a diagnostic and conservative-treatment AUC," he said. Additionally, the SIS AUC does not have a corresponding CPG.

Dr. Watters said the act of participating "was an enjoyable, multicultural, multisociety experience. The discussions were good and very lively. In the end, thanks to the AAOS technology, more than 10,000 scenarios were analyzed, which is amazing."

The technological aid supplied by the AAOS in automating data aggregation was "invaluable," Dr. MacVicar said. "The scale of what we were doing was large."

Recommendations
In the review of pain as an independent variable, maximal pain above L5 was negatively correlated with a recommendation for an SIJ injection. For clinical indications, the rating panel placed little emphasis on imaging findings, Dr. MacVicar explained. "Whether or not imaging had been done didn't make much difference, and the patient history had little impact."

The panel made a clear recommendation not to withhold anticoagulants or antiplatelet medications prior to an SIJ or lateral branches injection.

The panel also concluded that intra-articular injections of local anesthetic and steroid are appropriate as first interventions when pain has been present for more than 1 month, has an intensity greater than 4 on a scale of 10, and is causing functional limitations, regardless of whether conservative therapy has been provided. Under no scenarios was an intra-articular injection of steroid alone considered an appropriate first intervention.

"The AUC reflect the expertise of the rating panel," said Dr. MacVicar. "We certainly hope it will be a useful tool in clinical practice. SIJ pain can be underrecognized, and this may draw attention to a real problem and to the consideration of SIJ in lower back pain, particularly in patients who don't have evidence of a radiculopathy."

The AAOS offers its products and expertise in licensing and consulting for AUC, CPGs, and literature reviews. Those interested in these services should contact Jayson Murray, EBM unit manager at jmurray@aaos.org

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Graphic
Scenario from the SIJ for Clinical Indications and Imaging (Initial Injection)