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Musculoskeletal surgery for nontraumatic pain: not a great analgesic
Question clinique
Do common musculoskeletal surgical procedures produce better pain relief than no surgery?
L’Essentiel
Sure, musculoskeletal surgery is invaluable for unintentional injury. But for conditions associated with chronic pain — such as knee, shoulder, wrist, neck, or back pain — even patients with objective changes on imaging that scream out for intervention, will not, on average, have better long-term pain relief with surgery as compared with no surgery. Most of the studies were not masked and there should have been a placebo effect to bolster a difference in pain relief between surgery and no surgery. As with any intervention, some people will benefit from surgery, but, on average, patients won't be better off. 1a-
Référence
Plan de l'etude: Systematic review
Financement: Self-funded or unfunded
Cadre: Not applicable
Sommaire
These researchers identified the 14 most common musculoskeletal procedures performed across Australia, including procedures for leg pain associated with spinal stenosis, and hip, knee, back, shoulder, and wrist pain. They identified randomized controlled trials (RCTs) published in any language using the Cochrane CENTRAL database and reference lists of identified systematic reviews. Two researchers independently selected studies. They did not try to combine the study results, but simply evaluated whether surgery provided a clinically important difference in pain relief, as defined by the authors or using the published definition. Only 1% of all RCTs (n = 64) compared a procedure to no procedure and 81% of these did not mask the patient, opening them up to a placebo effect. Shoulder procedures either had no RCTs comparing with no treatment (excision of outer end of clavicle, total shoulder replacement) or a majority of studies not showing benefit (3 of 4 for rotator cuff repair and 14 of 15 for subacromial decompression). Six of 8 studies failed to show a benefit on pain for carpal tunnel decompression. Most studies of spine fusion, with or without decompression for lumbar or neck pain, failed to show a benefit. No studies of laminectomy produced a benefit. The single study of total knee replacement found a benefit, but 0 of the 11 meniscectomy studies found a benefit and only 2 of the 8 debridement studies showed a benefit. Hip surgeries have not be subjected to comparison to no therapy, and the single study of ankle arthroscopy failed to show a benefit.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Commentaires
Choosing Wisely?
This is a very important study. I'll share this with my patients when the time comes to decide on treatment of their chronic pain.
surgery for wear and tear pain.
It is not an alternative to getting fit and losing weight. Those that want surgery to fix pain instead of the former should be approached with caution.
MSK surgery for non-traumatic pain
A huge amount of this report is mostly rubbish. It could not have been taken from the main journals of MSK disorders.
The number of patients who are able to return to work after total knee replacement is > 80%.
It is agreed that spinal fusion is unacceptable, the same as knee fusion, but a well done shoulder replacement has dramatic improvement in function.
Poor understanding of CT syndrome
This study lost all credibility in my eyes as soon as they commented that CT release surgery offers no benefit for pain.
Carpal tunnel release is one of the most effective surgical procedures available. It is >90% effective in relieving CT symptoms when CT is truly present (clinical and electrodiagnostic studies support diagnosis).
Carpal tunnel syndrome rarely is associated with pain, which perhaps is why the study suggested that it does not improve pain! However, if this is the error that explains why the study said it does not help, it just further demonstrates the lack of understanding that the authors have about this condition. And it begs to question their understanding of the other conditions as well.
This demonstrates why review studies have to be interpreted with extreme caution. In so many cases, when you ask a true expert in the field they will tell you that there are exceptions, yet we put our trust in the generalizations made with systematic reviews and meta-analyses. Please interpret these top level studies with as much caution as we do for less powerful levels of evidence.
arthroscopy
apparently the number of arthroscopy procedures do not comply with outcome studies ! this study confirms it again. Still this type of surgery apparently is an easy sell with patients but not helpful in many ( or most ? ) patients as this study shows : evidence medicine ?
pain relief after surgery for non traumatic MSK pain
It is surprising that the studies reviewed shoed no benefit in pain control after carpal tunnel surgery. This seems to be completely different from my clinical experience. Most if not all of my patients who have had carpal tunnel release have had pain relief.
surgical procedures don't reduce pain
this is NOT my clinical experience
chronic pain
very relevant to my practice