Does joint OR SPINE surgery work ?
Anne Brennan: Williamstown South Physiotherapy
(updated 2024)
I was happy to see Dr Norman Swan on the national investigative program, Four Corners, reporting that radiology (which includes X-rays and MRI scans) puts patients on an unknown train to surgery with no evidence it helps.
Its not just Dr Swan saying this. The Australian Guidelines for the Treatment of Acute Musculo Skeletal pain are clear: radiology should be used, only, to rule out fractures, dislocation and serious medical concerns NOT to diagnose pain (NHMRC, 2003). Diagnoses such as ‘wear and tear’/bones grinding together, osteoarthritis, bulging discs, pinched nerves, instability, impingement or a torn tendon have been linked to the development of problem pain. Understandably, many think, if told something is damaged, that rest or surgery are the only viable options. And this is simply not true. Most pain management programs are filled with people made worse in the long run by surgery and prolonged rest.
99% of joint and spine surgery lacks rigorous science of the standard used to test drugs or vaccines. Funding for trials to evaluate surgery is sparse and ethics committee don’t allow placebo surgery or anaesthetics for obvious reasons (see below). One notable exception investigated knee arthroscopy, proving this surgery no better than a placebo. Yet they are still performed.
Sadly, the ABC program had little impact: it was business as usual for radiology, joint replacements and reconstructions.
It can be hard to argue against these surgeries. Most know someone who experienced significant pain relief after their hip or knee replacement or felt more confident skiing or playing football after their knee reconstruction. However, this may be for reasons other than what surgeons and patients think.
For example: it does not matter what is operated on for back pain: some surgeons operate on small spinal joints, some remove the discs and others fuse bones with, apparently, an equal degree of success or failure. Surgery to fix a bulging disc can help even if the bulge remains. Equally: it can fail when the bulge is successfully removed. Similarly, the success or otherwise of surgery to repair a torn shoulder tendon has nothing to do with whether the tendon was actually successfully repaired.
Why would surgery help if it doesn’t do what it is meant to do?
The research shows that combination non- surgical treatments (or ‘multi modal’ therapies), are effective for pain relief. Surgery is a multi modal treatment. Any of its elements could significantly reduce pain in the short term and probably work better adn more enduringly in combination. Combination treatments create confounding variables. It is hard to say what actually works whether it is ath surgery itself or the other aspects of treatment. This means surgery cannot be compared to exercise alone nor its success taken as evidence that a worn out hip caused pain. Instead, the following components of a surgical approach, should be taken into account:
1. Anesthetics which include ketamine and muscle relaxants.
2. Cutting tight muscle, small joint and spinal nerves to reach the joint.
3. Anti- inflammatory medication: Surgeons inject antiinflammation medication directly into joints during surgery.
4. Strong pain relieving drugs combined with supported exercise rehabilitation after surgery.
5. Changed beliefs about pain. Irrefutably, carefully progressed exercise helps pain. All medical guidelines for musculoskeletal pain/osteoarthritis/ spine pain recommend this as a primary treatment. However many patients and practitioners see exercise without surgery as a ‘time waster’ despite evidence to the contrary. Many believe (wrongly) that exercise without surgery damages joints (Katz, Brophy et al. 2013) (Thorstensson, Lohmander et al. 2009).
6. Sick leave and support is forthcoming after surgery. Family and workplaces rally with meals and support but not if its 'just' a sore hip.
7. Time out from aggravating activities. Surgery forces lifestyle changes. People must back off from activities that create pain such as playing or watching sport too long. If walking hurts, surgery MAKES them use a walking stick or frame for a few days until the pain relief and gentle exercises soothe the problem. Few will do this without surgery.
7. Support for exercise rehabilitation. It can take 60 minutes a day for 6 weeks to retrain muscles using a graduated, supervised exercise program with a skilled therapist. Activities that cause aches or sharp pain must be modified in the interim. The support and funding needed for safe progressive exercise is usually available only AFTER surgery.
8. Cost. Unfortunately, surgery is cheaper (for patients) than exercise rehabilitation alone. Public funds pay for intensive and prolonged exercise rehabilitation after surgery (Pain Australia 2010). Under Medicare funding, Australians are entitled to only 5 free half hour sessions ($300.00 worth )to prevent surgery compared with many $1000.00s for surgery. That is : it is easier and cheaper for an individual to get pain relief and undertake supervised rehab after surgery than without it but much mroe expensive for society.
9. The placebo effect can help (see below ***)
WHY NOT HAVE SURGERY?
# It doesn’t help when really needed: if pain was spreading or severe beforehand. One third of knee replacement surgery increases pain and/or disability. If surgery did help, then it is likely that a carefully supervised and supported multimodal rehabilitation program would have helped also.
# Post operative pain relief is linked to opiate addiction.
# Surgery has not been shown to improve long term function/performance. Patients might report surgery was ‘great’, but two years on, still can’t play bowls or golf or travel or walk or garden as easily as before.
# Undoubtedly, surgery does provide enormous short term relief for many. However within two years of spinal surgery, one study showed those who had surgery were in a similar state as those that didn’t. This might seem like an advantage but it defers the need for individuals to learn to preempt, prevent and effectively deal with pain. Successful surgery trains them, instead, to see surgery, rather than a careful rehab program, as the ‘go to’ solution for pain.
# Anesthetics are mostly safe but they do carry risks. They can cause short term confusion, memory loss and, possibly, hasten the effects of dementia.
# Rehabilitation can be arduous, leaving many weak and unsteady. This can compromise health in some, especially the elderly.
#Surgery might help one area, only for pain to pop up in another. The knee replacement was ‘great’ but within a few months: feet are sore. The recurrence or spread of pain can lead many to multiple joint surgery.
Think of the star recruit who returns to play after two knee reconstructions (a success) but then endures lifelong knee problems (see my article on cruciate repair).
BOTTOM LINE: try intensive carefully rehabilitation with (short term) significant life style adjustments BEFORE ANY joint or spine surgery. If done well and carefully guided (and I’m not pretending it is easy), rehab should help avert surgery. And…even if it doesn’t help, research shows that, at the very least, exercise rehab before surgery improves function after it.
2022 update : Rachelle Buchbinder, an academic, epidemiologist and Rheumatologist, has written a book called Hippocrasy, which addresses many of the above issues. Her co author is Orthopaedic surgeon, Ian Harris. It argues, persuasively, that sometimes the least harmful treatment for patients is for medical practitioners to do nothing. Yet they are trained to offer something which results in over servicing.
***A randomized controlled trial means: a randomly selected control group is given fake ( placebo ) treatment while an experimental group receive the real treatment. This helps work out how much placebo and patient/practitioners bias, beleifs and hopes affects outcomes.
For a trial to PROVE that hip surgery was more effective that exercise, the control group would need to undergo exactly the same treatment BAR the actual joint replacement as those having the real procedure. In a rigorous trial into hip surgery, the control group would need to receive the same cut into the joints, the same anesthetic, the same anti inflammation medication injected directly into the hip, and the same post operative drugs adn teh same intensive rehabilitation. To eliminate the placebo effect, participants, nursing staff and doctors and outcome researchers would not know who had a replacement and who didn’t. This has only happened once, when it proved that knee washouts were no better than a placebo. It is extremely unlikely to happen again due to ethical concerns.