Clinical Question

Do common musculoskeletal surgical procedures produce better pain relief than no surgery?

Bottom Line

Musculoskeletal surgery is invaluable for unintentional injury. But for conditions associated with chronic pain (e.g., knee, shoulder, wrist, neck, back pain), even patients with objective changes on imaging that need intervention will not have better long-term pain relief with surgery 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. Some people will benefit from surgery, but on average patients will not be better off. (Level of Evidence = 1a–)

Synopsis

The 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 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 with 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 them with no treatment (excision of outer end of clavicle, total shoulder replacement) or most studies not showing benefit (three of four for rotator cuff repair, and 14 of 15 for subacromial decompression). Six of eight 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 none of the 11 meniscectomy studies found a benefit, and only two of the eight debridement studies showed a benefit. Hip surgeries have not been compared with no therapy, and the single study of ankle arthroscopy failed to show a benefit.

Study design: Systematic review

Funding source: Self-funded or unfunded

Setting: Not applicable

Reference: Harris IA, Sidhu V, Mittal R, et al. Surgery for chronic musculoskeletal pain: the question of evidence. Pain. 2020;161(suppl 1):S95–S103.

Editor's Note: Dr. Shaughnessy is an assistant medical editor for AFP.