Unlike drugs, orthopedic surgeries can be sold to the public before they undergo any rigorous testing to ensure they are safe and effective.
Thus, millions of surgeries for knee, shoulder, and back pain have been done even without any research to confirm they actually work.
Recently, a significant amount of such research has been completed, and it has found that many popular surgeries work no better than a placebo. And yet many of these surgeries are still being performed at the rate of hundreds of thousands per year.
Yes, its depressing. But this is something you should know about if you are in the business of treating chronic pain, or if you have chronic pain and are considering surgery.
Read on for a detailed review of relevant research. (By the way, most of the following is an excerpt from my upcoming book, Playing With Movement).
Osteoarthritis of the knee is common, but does not necessarily result in pain – many people have significant arthritis and no pain at all. And many people with knee pain have no arthritis. Despite this poor correlation, surgery to correct arthritis is very popular, numbering as many as a half million per year.
About 15 years ago, two of the most common arthroscopic knee procedures were debridement (removal of damaged cartilege or bone) or lavage (irrigation with saline solution). The goal of either surgery is removing rough fragments of cartilage that may be irritating the joint. The surgery’s benefits were known to be not so impressive, so people started to wonder whether they were caused by placebo.
To test this possibility, researchers conducted a study featuring a “sham” surgery:
Guess what? The sham group did just as well as the surgical group at all points in time.
This strongly suggests that the surgery worked by changing psychology, not structure.
Years later, hundreds of thousands of these surgeries were still being performed at the cost of $3 billion a year.
Subsequent research confirmed that this surgery provides no more benefit than common sense interventions like exercise, weight loss, and the occasional use of over-the-counter pain medicine.
In 2015, researchers summarized the results of nine studies on arthroscopic procedures for the knee, and concluded that they showed little if any benefit, and the possibility for serious harm
A recent editorial in the British Journal of Medicine offered the scathing opinion that arthroscopic surgery for knee pain is: “a highly questionable practice without supporting evidence of even moderate quality.”
A 2017 clinical guideline states that: “We make a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease … further research is unlikely to alter this recommendation.”
Despite this compelling research, arthroscopic knee surgery continues to be the most common orthopedic procedure in the US, with close to 700,000 performed each year!
As with knees, there is a wealth of evidence that backs can have major structural damage and still not hurt. Further, backs can hurt a lot even when they have no apparent damage
Low back fusion is a common procedure, and is intended to stabilize vertebrae that might be moving into contact with sensitive structures like nerves.
In 2013, the Spine Journal published a study comparing spinal fusion to non-operative treatment such as cognitive behavioral therapy and exercise. It found no difference in long term outcomes and concluded that “the use of lumbar fusion in chronic low back pain patients should not be favored” over conservative care and exercise
The research on shoulder surgery follows a similar (but less clear) pattern.
MRIs consistently show that a great many people without pain have torn rotator cuffs or damaged structures in the shoulder. Despite this fact, the most common diagnoses to explain shoulder pain involve damage to the rotator cuff, or “impingement” on the rotator cuff by the acromion process.
Although we cannot rule out the possibility that surgery will be substantially more effective than exercise for certain patients, several studies have found that popular shoulder surgeries, such as acromioplasty, are no better than exercise. Further, it has been shown that labral repair and biceps tenodesis surgeries are no better than sham surgery.
There is also evidence suggesting that when surgery is effective at relieving pain, it is not because of actual repair of structure. MRIs of repaired rotator cuffs taken within a year after surgery often show that the cuff has fallen apart again, even though the patient has recovered. According
A blog post in the British Journal of Sports Medicine summed up the situation as follows: “in the light of the current evidence base, the benefits of surgical intervention for the treatment of [shoulder pain] seem glorified and overrated.”
Let me make something clear: None of the above should be construed to mean that we should not trust orthopedic surgeons, or that surgery is never a good idea as a way to treat chronic pain.
Many surgeries have been proven to work and are definitely a good idea under certain circumstances.
The major takeaway here is that the medical establishment has some major blindspots and biases in the way it treats chronic pain.
It consistently seeks to explain and treat pain in reference to simple structural “defects”, while ignoring complex neurophysiological processes that are often far more important.
Clinicians should be aware of these biases, and learn as much as possible about the complexity of pain so that they can help improve the way it is treated.
And chronic pain clients need to ask their surgeons some good questions before going under the knife.
Original article: Many Orthopedic Surgeries Don’t Work