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Only some musculoskeletal conditions benefit from surgery
Clinical Question
As compared with nonsurgical interventions, do surgical approaches to common musculoskeletal problems offer a benefit?
Bottom line
Cervical disc, lumbar spinal stenosis, chronic low pain, and sacroiliac joint surgery produce a clinically relevant decrease in pain, and surgical approaches to patellar dislocation, anterior cruciate ligament tear, and shoulder dislocation decrease the likelihood of serious adverse events that can result in disability or the need for further care. For other problems, surgery, on average, provides little in the way of a clinically relevant reduction in pain, improved function or quality of life, or prevention of adverse effects. (LOE = 1a)
Overuse alert: This POEM aligns with the following Choosing Wisely Canada recommendations:
1. The Canadian Orthopaedic Association’s recommendation: Don’t use arthroscopic debridement as a primary treatment in the management of osteoarthritis of the knee.
2. The Canadian Spine Society’s recommendation: Don’t perform fusion surgery to treat patients with mechanical axial low back pain from multilevel spine degeneration in the absence of: (a) leg pain with or without neurologic symptoms and/or signs of concordant neurologic compression, and (b) structural pathology such as spondylolisthesis or deformity.
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Foundation
Setting: Various (meta-analysis)
Synopsis
These researchers searched 5 databases, including Cochrane CENTRAL, and identified 100 randomized controlled trials enrolling a total of 12,645 patients across 28 different conditions at 9 body sites. The studies compared a surgical intervention with a nonsurgical intervention in adults and were published in 1 of 5 different languages. The authors followed PRISMA guidelines for conducting and reporting the study results. Thirty trials were considered to be at high risk of bias with regard to evaluating benefit, mainly due to a lack of masking of participants, intervention providers, and outcome assessors. The studies evaluated the effect of surgery on pain, functioning, and quality of life, while also looking at the likelihood of serious adverse effects. For the outcomes of benefit, the authors reported on whether there was a statistically significant benefit, and also whether the difference was clinically relevant using a standard mean difference (Cohen's effect size) of at least .5 (medium or higher magnitude of benefit). The risk of severe adverse effects was defined as those that could significantly compromise the clinical outcome, result in significant disability or incapacity, require inpatient or outpatient hospital care, prolong hospital care, be life-threatening, or result in death. All results were based on at least 2 studies, though for some of the outcomes the number of participants was small, or the results were heterogenous among the studies. The results are as follows:
- Cervical disc herniation and radiculopathy pain: clinically relevant benefit on pain
- Lumbar disc herniation: no clinically relevant benefit on pain, functioning, or quality of life
- Lumbar spinal stenosis: clinically relevant effect on pain and function
- Low back, lumbar spondylolisthesis: no clinically relevant effect on pain or function
- Chronic low back pain: clinically relevant effect on pain, no effect on function or quality of life
- Sacroiliac joint pain: clinically relevant effect on pain, function, or quality of life
- Shoulder, rotator cuff tear: no clinically relevant benefit on pain, functioning, or quality of life
- Shoulder impingement and pain: no clinically relevant benefit on pain, functioning, or quality of life
- Shoulder dislocation: less risk of a severe adverse event
- Knee, patellar dislocation: no clinically relevant effect on pain, though less risk of a severe adverse event
- Knee, anterior cruciate ligament tear: no clinically relevant benefit on pain, functioning, or quality of life, though less risk of a severe adverse event
- Knee, degenerative meniscal tears: no clinically relevant benefit on pain, functioning, or quality of life
- Hip, femoroacetabular impingement syndrome: no clinically relevant benefit on pain, functioning, or quality of life
- Foot, Achilles tendon rupture: no clinically relevant benefit on pain, functioning, or quality of life
- Wrist, carpal tunnel syndrome: no clinically relevant benefit on pain or functioning
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
Excellent article
New information of great importance in management of a variety of orthopaedic issues
Where are the results listed?
Click 'Read other POEMs' to read a list of results from this systematic review.