Editor's Note: This This two-part article is intended to review the research on common elective procedures. As the author states in part 1 (December 2021 issue), "We should be familiar with the surgical interventions that might be effective in relieving [patients'] symptoms and which ones are best avoided. Patients will appreciate your ability to explain the pro and cons of surgical interventions so they can make better choices."
Lumbar Spine Surgery
Lumbar spine decompression for spinal canal stenosis: Three meta-analyses comparing surgical procedures with nonsurgical treatment showed similar effects for operative and nonoperative interventions.15 To date, no randomized, controlled trial has compared lumbar spinal decompression with no treatment or placebo. Only a single randomized, controlled trial compared segmental decompression with conservative treatment. Both treatment groups showed improvement during follow-up, with no difference in walking ability.16
Current studies comparing surgical versus nonsurgical care for lumbar spinal stenosis have been to date poorly done. Even the experts in the field cannot conclude whether a surgical or conservative approach is better for lumbar spinal stenosis. There is also a lack of studies with detailed protocols and descriptions of nonsurgical treatments.17 I have a remedy for this: We need more chiropractic trials to be published.
Lumbar spine fusion for degenerative disc disease: The two meta-analyses comparing lumbar spine fusion with nonoperative management both reported no differences in Oswestry Disability Index scores; however, one review reported that lumbar spine fusion was associated with surgical complications. Both trials compared lumbar spine fusion with cognitive intervention and exercises, and showed no differences in success rates and return to work.18
This is extremely important: Spinal fusion in the lumbar spine does not demonstrate significant improvement in clinical symptoms compared to nonsurgical intervention. Decompression is associated with fewer complications when compared to fusion.
Compared with conservative therapy, surgical treatment provided faster relief from back pain symptoms in patients with lumbar disc herniation but did not show a benefit over conservative treatment in midterm and long-term follow-up.19 It appears that the jury is out as to when to perform lumbar spine surgery. Patients should be made aware complications of spine surgery and that they may not be better off long-term.
Total Joint Replacement
Total Knee: A randomized, controlled trial of total knee replacement reported in 2015 found that patients with late-stage knee osteoarthritis who had a total knee replacement, followed by nonsurgical treatment, realized greater pain relief and functional improvement after 12 months than those who received nonsurgical treatment alone.20 However, after 12 months, both groups had substantial improvement with respect to outcomes and only 26 percent of patients in the nonsurgical treatment group had undergone a total knee replacement.
The other interesting finding is that the 26 percent of patients who did undergo surgery demonstrated that participation in supervised exercise before surgery was associated with faster postoperative recovery. However, total knee replacement was associated with a higher number of serious adverse events than nonsurgical treatment. The takeaway from this study is that all patients need to have supervised exercise therapy before considering surgery.
Total Hip: The Blom, et al., study, "Common Elective Orthopedic Procedures and Their Clinical Effectiveness: Umbrella Review of Level 1 Evidence,"1 found no individual randomized, controlled trials comparing total hip replacement versus nonsurgical treatment. There are many studies comparing different types of hip replacements and surgical procedures; i.e., including studies that compare the clinical effectiveness of total hip replacement versus resurfacing arthroplasty for the treatment of end-stage osteoarthritis. But to date, there are none comparing the surgery to nonsurgical treatment. The Blom paper notes that with the recent COVID situation and the need to postpone elective surgeries, we may finally see some studies.
Summarizing the Evidence: What You and Your Patients Should Know
There are no randomized, controlled trials comparing total hip replacement and meniscal repair for acute tears with nonoperative care. There have been clinical trials that have some evidence to support the superiority of total knee replacement over nonoperative care; but also suggest supervised rehabilitative exercise can delay the need for surgery and improve surgical outcome when surgery is needed.
There is strong evidence to support carpal tunnel decompress over nonoperative care. However, randomized, controlled trials have shown that arthroscopic anterior cruciate ligament reconstruction, arthroscopic partial meniscectomy, arthroscopic repair for acute rotator-cuff tears, arthroscopic subacromial decompression, lumbar spinal decompression for spinal canal stenosis, and spinal fusion for degenerative disc disease have similar outcomes to nonoperative care.
Make sure patients are aware of the data and all of the possible complications associated with these interventions if they are considering one. They need to understand their options. If a patient does not know what all their options are, can we really call it elective surgery?
Editor's Note: References below support the citations for parts 1 and 2 of this article.
References
- Blom AW, Donovan RL, Beswick AD, et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ, 2021 Jul 7;374:n1511.
- Jarvik JG, Comstock BA, Kliot M, et al. Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial. Lancet, 2009 Sep 26;374(9695):107481.
- Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med, 2015;373:1597-606.
- Matar HE, Platt SR, Board TN, Porter ML. Overview of randomized controlled trials in primary total hip arthroplasty (34,020 patients): what have we learnt? J Am Acad Orthop Surg Glob Res Rev, 2020;4(8):e20.00120.
- Biedert RM. Treatment of intrasubstance meniscal lesions: a randomized prospective study of four different methods. Knee Surg Sports Traumatol Arthrosc, 2000;8:104-8.
- Frobell RB, Roos HP, Roos EM, et al. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial BMJ, 2013;346:f232.
- Biedert RM, Op Cit.
- Kise NJ, Risberg MA, Stensrud S, et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two-year follow-up. BMJ, 2016;354:i3740.
- Karjalainen TV, Jain NB, Heikkinen J, et al. Surgery for rotator cuff tears. Cochrane Database Syst Rev, 2019;12:CD013502.
- If you are ever interested in an unbiased review of any procedure and diagnostic test or even management of specific treatments in health care, I recommend going to the Cochrane Library and Database first to see if there is a review. The Cochrane Database of Systematic Reviews (CDSR) is the leading resource for systematic reviews in health care. (ISSN: 1469-493X). The Cochrane Library (ISSN 1465-1858) is a collection of databases that contain different types of high-quality, independent evidence to inform health care decision-making.
- Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet, 2018 Jan 27;391(10118):329-338.
- Gerritsen AA, de Vet HC, Scholten RJ, et al. Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial. JAMA, 2002 Sep 11;288(10):1245-51.
- Hui AC, Wong S, Leung CH, et al. A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome. Neurology, 2005 Jun 28;64(12):2074-8.
- Jarvik JG, et al., Op Cit.
- Brox JI, Reikerås O, Nygaard Ø, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain, 2006 May;122(1-2):145-55.
- Brox JI, Nygaard ØP, Holm I, et al. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis, 2010;69(9):1643-1648.
- Zaina F, TomkinsLane C, Carragee E, Negrini S. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev, 2016;1:CD010264.
- Brox JI, et al., 2010, Op Cit.
- Gugliotta M, da Costa BR, Dabis E, et al. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open, 2016 Dec 21;6(12):e012938.
- Skou ST, et al., Op Cit.
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