Our reviewers were split in their reviews. After a number of corrections by the authors,
in the end the size of the cohort and the quality of data gathering with sound general
methodology were decisive in favor of publication of this article.
As the authors point out it would have been helpful to create a control group—especially
a nonoperative one without any form of intervention. Patients basically served as
their own internal controls. The cumulative improvement of patients as shown in Fig
2 is impressive, assuming that all these patients had static symptoms for a more than
a few weeks before receiving their injection treatment. The differentiation of ‘responders’
and ‘nonresponders’ as demonstrated in Table 4 clearly should be viewed with suspicion
as by default the nonresponders were treatment failures and a statistical separation
by virtue of the apportioning of ‘responders’ by their inclusion criteria will lead
to a statistically significant difference, even if ‘arm pain’ was used as a primary
selection point for the two groups.
From an outcome perspective two important aspects of nonoperative treatment are duration
of symptom relief and return to regular function.
For an evaluation of duration of symptom relief, a 2-year follow-up would seem important;
hopefully Anderberg and Persson will make arrangements to keep track of their cohort.
This is notoriously difficult in patients treated nonoperatively. Perhaps the more
regimented government-sponsored healthcare system in Sweden, the origin of this study,
allows for longer tracking of even nonoperative patients.
The functional recovery question in nonoperatively treated patients may be affected
by a ‘subconscious’ down regulation of activities on the part of affected individuals
due to fear of recurrent symptoms. While the Neck Disability Index (NDI) tries to
assess functional performance with its questions 3 (lifting), 4 (work), 8 (driving),
and 10 (recreation), the actual functional performance of patients may remain decreased
in those with ongoing symptoms because of the magnitude of functional inhibition being
inadequately expressed in the NDI score due to an adaptive effect experience by the
affected patients. In addition to providing differentiated results scales—as done
with SF-36 objective measures—such as strength or dexterity testing, quantified analgesics
usage, or return to work may offer greater differentiation of the functional capacity
of patients.
Finally, the authors accumulated an impressive data set and showed that a technically
well-performed series of transforaminal cervical steroid injections can provide meaningful
symptom relief in about half of patients with cervical radiculopathy. The challenge
to Anderberg and Persson is now to identify the characteristics of the responders
by clinical and/or radiographic parameters to help us guide such patients toward early
interventional nonoperative care while the search for best possible care for the other
half must go on.
