European Spine Journal

, Volume 27, Issue 11, pp 2781–2790 | Cite as

A critical appraisal of the quality of low back pain practice guidelines using the AGREE II tool and comparison with previous evaluations: a EuroAIM initiative

  • Fabio Martino Doniselli
  • Moreno ZanardoEmail author
  • Luigi Manfrè
  • Giacomo Davide Edoardo Papini
  • Alex Rovira
  • Francesco Sardanelli
  • Luca Maria Sconfienza
  • Estanislao Arana



To assess the methodologic quality of guidelines for the management of low back pain (LBP) and compare their recommendations.


No ethics committee approval was needed for this systematic review. In March 2017, a systematic search was performed using MEDLINE, EMBASE, National Guideline Clearinghouse, and National Institute for Health and Clinical Excellence to find practice guidelines of assessment and management of LBP. The evaluation of guidelines quality was performed independently by four authors using the AGREE II tool, and the results were compared with previous appraisals performed in 2004 and 2009.


Of 114 retrieved guidelines, eight were appraised. All except one reached the level of “acceptable” in overall result, with two of them reaching the highest scores. Only two guidelines reached a level of “acceptable” in every domain; the others had at least one domain with low scores. The guidelines had the higher scores (range = 63–94%) on “Scope and purpose” and “Clarity of presentation” (47–89%). “Stakeholder Involvement” has the highest variability between the guidelines results (40–96%). “Rigor of Development” reached an intermediate mean result (34–90%), “Applicability” (42–70%), and “Editorial Independence” (38–85%). Only three guidelines had a radiologist among authors and reached higher scores compared to guidelines without a radiologist among the authors. Compared to previous assessments, low-level guidelines were 53% in 2004, 36% in 2009, and 13% in 2017.


Considering all guidelines, only one had a “low” overall score, while half of them were rated as of “high” quality. Future guidelines might take this into account to improve clinical applicability.

Graphical abstract


Systematic review Guidelines AGREE II Low back pain Lumbar pain 



This work has been conducted within the framework of the Network for Assessment of Imaging in Medicine (EuroAIM), research platform of the European Institute for Biomedical Research under the umbrella of the European Society of Radiology ( Francesco Sardanelli is chair of the EuroAIM initiative, Luca Maria Sconfienza is the coordinator of the guideline evaluation project, while the other authors are members of the EuroAIM working group.

Compliance with ethical standards

Conflicts of interest

Authors have no conflicts of interest to disclose related to the present paper.

Supplementary material

586_2018_5763_MOESM1_ESM.pptx (140 kb)
Supplementary material 1 (PPTX 139 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Fabio Martino Doniselli
    • 1
  • Moreno Zanardo
    • 2
    Email author
  • Luigi Manfrè
    • 3
  • Giacomo Davide Edoardo Papini
    • 4
  • Alex Rovira
    • 5
  • Francesco Sardanelli
    • 4
    • 6
  • Luca Maria Sconfienza
    • 6
    • 7
  • Estanislao Arana
    • 8
    • 9
  1. 1.Postgraduation School in RadiodiagnosticsUniversità degli Studi di MilanoMilanItaly
  2. 2.PhD Course in Integrative Biomedical Research, Department of Biomedical Sciences for HealthUniversità degli Studi di MilanoMilanItaly
  3. 3.Department of Neurosurgery/Interventional Radiology, Minimal Invasive Spine TherapyInstitute of Oncology in Mediterranean (IOM)ViagrandeItaly
  4. 4.Unit of RadiologyIRCCS Policlinico San DonatoMilanItaly
  5. 5.Section of Neuroradiology and Magnetic Resonance Unit, Department of Radiology (IDI), Vall d’Hebron Institut de Recerca, Hospital Universitari Vall d’HebronUniversitat Autònoma de BarcelonaBarcelonaSpain
  6. 6.Dipartimento di Scienze Biomediche per la SaluteUniversità degli Studi di MilanoMilanoItaly
  7. 7.Unità Operativa di Radiologia Diagnostica ed InterventisticaIRCCS Istituto Ortopedico GaleazziMilanoItaly
  8. 8.Spanish Back Pain Research NetworkKovacs FoundationPalma de MallorcaSpain
  9. 9.Department of RadiologyValencian Oncology Institute FoundationValenciaSpain

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