A critical appraisal of Evicore's guidelines for advanced diagnostic imaging of the spine for lower extremity pain with neurological features.

Background: This analysis aims to evaluate the methodological quality of Evicore's spinal imaging guidelines for lower extremity pain with neurological features with or without lower back pain by leveraging the AGREE II tool. The AGREE II tool provides a framework to assess guideline development. It is well validated and has been used to evaluate many other guidelines previously. Methods: Five appraisers used the AGREE II appraisal tool to conduct a comprehensive review of Evicore's spinal imaging guidelines for lower extremity pain with neurological features. Appraisers provided an overall assessment of the guidelines as well as specific scores pertaining to domains including scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Results: Appraisers assigned numerical grades of 2, 2, 2, 3 and 4 (out of 7 total points, with 7 being the highest) for overall quality of the guidelines. Three appraisers recommended use of the guideline with modifications and two appraisers did not recommend the guideline. The AGREE II ratings had good reliability across the different raters [intraclass correlation coefficient (ICC) =0.881, 95% confidence interval (CI): 0.77, 0.94]. Conclusions: Evicore's guidelines would greatly benefit from increased identification and diversification of guideline development parties and stakeholders, increased rigor of development including a more robust discussion of the body of evidence and its strengths and limitations, and incorporation of more explicit suggestions for implementation of guideline recommendations by healthcare providers.