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Re: Manchikanti L, Singh V, Falco FJ, et al. Cervical medial branch blocks for chronic cervical facet joint pain: a randomized, double-blind, controlled trial with one-year follow-up. Spine 2008;33:1813-20.

Re: Manchikanti L, Singh V, Falco FJ, et al. Cervical medial branch blocks for chronic cervical facet joint pain: a randomized, double-blind, controlled trial with one-year follow-up. Spine 2008;33:1813–20. We read with interest the study by Manchikanti et al. Although the abstract left the impression of a novel and promising treatment for neck pain, the manuscript gave us the sense of being led down 1 path when the data pointed toward another. Interestingly, all of the research into the potential therapeutic value of medial branch blocks (MBB) comes from a single center, with the only exception showing MBB are less effective than intraarticular injections. When a new treatment paradigm is conceived—in this case therapeutic use of MBB—2 duties follow. The first is to explain concept validity. In this study, the established use of MBB as a short-lived diagnostic test to select patients for medial branch, radiofrequency neurotomy has somehow morphed into a therapeutic endeavor with unexplained lasting benefits. What is the rational for this? Long-term benefit from radiofrequency neurotomy is a reasonable expectation. Although evidence is limited regarding intraarticular corticosteroid injections, a solid rationale exists to expect long-term benefits. Therapeutic injections adjacent to nerves under pathologic conditions, such as radiculopathy from disc herniation or carpal tunnel syndrome, are well established. However, there is no known pathology of the medial branch nerves that leads to cervical facet joint pain. Theories of sensitization of pain pathways remind us of other complex reasoning strategies to explain simple problems and do not alter our logical skepticism. Given the lack of a proven clinical basis, the second duty becomes even more important, to demonstrate efficacy of this new treatment. Such proof is typically provided in a double-blinded randomized placebo-controlled trial (DBRPCT). The authors justify the current study by explaining it to be a pragmatic clinical trial (PCT). Although the authors correctly describe the differences between DBRPCTs to determine efficacy and PCTs to demonstrate effectiveness, they overlook the key underlying principles of PCTs. Specifically, PCTs are intended to compare accepted treatment alternatives in a variety of practice settings, collecting data from a broad range of health outcomes. In this study, none of the treatment groups comprise a generally accepted treatment for chronic neck pain, the patients are from a single clinic, and the outcome measures are limited. Thus, we cannot help wondering whether the original intent of the study designers was to determine efficacy of therapeutic MBB with a DBRPCT. This makes sense because the study design contains several hallmark features of a DBRPCT. The outcome measures are concise and validated, and the treatment groups are perfectly designed to test the efficacy of corticosteroid and/or Sarapin (High Chemical Co., Levittown, PA) against a commonly used placebo-bupivacaine. The authors of this study conclude that MBB in all forms (with or without corticosteroids and/or Sarapin) are equally effective treatments for chronic neck pain. We choose to follow a more logical path. As a DBRPCT, this study produced negative findings and determined that therapeutic MBB are no better than placebo. Thus, a study of their effectiveness is unnecessary.