Never mind the treatment, what about the tests?BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4619 (Published 10 November 2009) Cite this as: BMJ 2009;339:b4619
All rapid responses
Andrew Bamji raises the real dilemma of expensive and unnecessary
tests emerging with the introduction of open access magnetic resonance
imaging to primary care in some areas1. He correctly states that
persistent symptoms for six weeks or four weeks with motor signs require
investigation, but scanning all cases is pointless when only 1% require
surgery. However this leaves the unanswered question of what to do for all
these symptomatic patients. In primary care, application of the World
Health Organisation analgesic stepladder is helpful and indeed many
patients are helped, if not optimally, by oral anti-inflammatory drugs2.
This may predict a more useful response to targeted anti-inflammatory
therapy by cervical steroid epidural. There is systematic review evidence
of efficacy for this 3 and evidence-based practice guidelines 4 and a
Cochrane review of medicinal and injection therapies for mechanical neck
disorders5.This approach should be known by healthcare staff and more
available to patients as in skilled hands this technique is carried out
under local anaesthetic as a daycase with few problems6.
Unfortunately the full spectrum of multidisciplinary pain services are too
frequently forgotten and primary care commissioning teams would do well to
balance diagnostics and therapies within care plans that deliver not just
the diagnosis but all the options for symptom control which ultimately is
what we would all want as patients. Similarly, the apparent failure to
consider all the evidence for injection therapies as well as other options
has resulted in the President resigning from the Pain Society and the
National Institute for Clinical Excellence reconsidering its
recommendations for back pain.
1. Andrew N. Bamji. Never mind the treatment, what about the tests? BMJ
2009; 339: b4619.
2. World Health Organisation. Cancer pain relief, 2nd ed. Geneva: WHO,
3. Benyamin RM, Singh V, Parr AT, Conn A, Diwan S, Abdi S. Systematic
review of the effectiveness of cervical epidurals in the management of
chronic neck pain. Pain Physician. 2009 Jan-Feb;12(1):137-57.
4. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal
N,Shah RV. Singh V, Benyamin RM, Patel VB, Buenaventura RM, ColsonJD,
Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR,
Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J,
Manchikanti L. Interventional techniques: Evidence-based practice
guidelines in the management of chronic spinal pain. Pain Physician
5. Peloso PMJ, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie SJ,
Cervical Overview Group. Medicinal and injection therapies for mechanical
neck disorders. Cochrane Database Syst Rev 2007; 3:CD000319.
6. Derby R, Lee SH, Kim BJ, Chen Y, Seo KS. Complications following
cervical epidural steroid injections by expert interventionalists in 2003.
Pain Physician 2004;7:445-449
Competing interests: No competing interests