Block and burn for backs and necks bombs a big test, doctors bluster

“Block and burn” treatments are various methods of numbing or destroying nerves:

• some combination of injections of steroids or anaesthetics into muscles, joints, or epidural space
• radiofrequency ablation of nerves, which basically cauterizes nerves (“kill it with fire”)

The techniques are part of what is formally known as “interventional pain medicine” (IPM), a major medical option for spinal pain for many years now — with a lot of rearranging the deck chairs as underwhelming evidence slowly piled up.

There’s a major new review of IPM by Wang et al for all chronic spinal pain, from occiput to sacrum. A British Medical Journal clinical guideline paper by Busse et al is based on that review, and it has been a hot item on social media. (Very hype! Such viral!) And the guideline’s bottom line …

“Well-informed people would likely not want such interventions.”

Many doctors were not amused! Quelle surprise

Thirty-four medical professional societies (!) got together to demand retraction, which catapulted this science news to the top of my priority list, because Wow! That’s a lot of medical societies! They all have “serious concerns” about how those cranky conclusions were reached, and demanding “retraction” certainly makes their concerns sound Very Serious Indeed.

Okay, so, they have concerns. What they do not appear to have is … evidence supporting their profitable practices.

The concerned doctors mainly cite their clinical experience, and their personal opinions of the evidence (there are always positive trials to cherry pick, of course, and they do). But the whole point of this meta-analysis was to evaluate the evidence more rigorously than that! And so the objectors — no matter how big and fancy the choir, no matter how haughtily they can Harrumph! — mostly come off like they’re fighting the progress of evidence-based medicine. Sour grapes from the people who make their living selling these treatments (always with earnest good intentions, no doubt).

The three most dangerous words in medicine: in my experience.

Mark Crislip, MD

It’s an old story — one which strongly fits the pattern of surgery’s lateness to the EBM party (see Surgery: The ultimate placebo). And the guideline authors had a polite but firm response to all this:

“If some clinicians believe that they can correctly identify patients with chronic spine pain who will benefit from interventional procedures, we believe they should undertake high quality sham-controlled trials to provide evidence. As we note in our guideline, such evidence would alter our recommendations.”

And here’s my less diplomatic translation:

“Nice try, but that’s not how this works. You’re all kidding yourselves if you think you can reliably identify the ‘right’ patients to use these treatments on, even assuming that they exist. But if they do and you actually can, then put on your big boy pants and try science, because you shouldn’t have any trouble proving your point under properly controlled conditions, now should you? Or does your voodoo break when there’s a statistician nearby? Wake us up when you’ve got actual evidence.”

Reasonable people can disagree (but they can’t call for retraction)

There are reasonable arguments for the judicious use of blocking and burning, with informed consent, despite significant “evidence of absence.” Even the strongest evidence is never the whole story … and this evidence, while thoroughly discouraging, is not the strongest we can imagine … and there is some absence of evidence going on here too: more study is still needed, because what we have is neither uniformly negative nor of good enough quality.

Yes, actually, there is a chance … just not a very good one. I think of this meme every time I see healthcare pros objecting to evidence that their treatments don’t work, looking for ANY way to avoid the bad news. Finally got around to using it for this story, a particularly perfect fit.

For instance, the evidence on radiofrequency ablation — arguably the most important member of this category — is rated by Wang et al. as “very low certainty.” We can and should do better. It’s unlikely that better trials will bring better news — it usually goes exactly the other direction — but they might. There is a chance that there is still something worthwhile in interventional pain management, and the best doctors might even be better at finding it.

But none of those reasonable responses justify calling for the retraction of papers that report on the evidence we have so far.

The clinical guideline paper has a good infographic.

I have updated my free 4,500-word article about block and burn with this news, which is in turn an excerpt from my books about both neck pain and back pain — and both of those have substantial free introductions.