Fake Surgery vs Real Surgery? Any Difference? Part-I
Surgery for spine or joint pain is very common. According to the CDC, there were 63 million visits to orthopedic surgery centers in 2010. The American Association of Neurological Surgeons estimates that there were 1.5 million spinal surgeries performed in 2011. When people are told they need surgery for spine or joint pain, very few actually question that idea. After all, with all these surgeries performed each year, it’s obvious that these surgical procedures have been thoroughly studied and found to be effective, right?
Unfortunately, that line of thinking is wrong. Unlike pharmaceutical drugs, surgical procedures do not have to undergo rigorous testing. A drug must be shown to be superior to a placebo (a substance without any real benefit). Only recently has this idea started to spread into surgical studies by comparing a real surgery to a “sham” surgery. But everyone knows multiple people who had great results from surgeries, so it’s obvious that they will be shown to be effective when compared to these “sham” surgeries, right? Unfortunately, that’s also wrong.
A 2014 review[i] looked at 53 studies that compared real surgery to a placebo or sham surgery. It found that in 27 (51%) of the trials, the outcomes were no different between the real procedure and the sham procedure or placebo. In the other 26 studies, surgery was better, but the authors noted the differences were “generally small.” Think about that; in over 50% of the time, a surgery is no better than fake surgery. For the other 50%, the benefit of surgery was “generally small” according to the authors. Obviously, not every surgery has been compared to a sham surgery, and future studies will show many very effective surgeries. However, I imagine more people would question surgery if they were told the best case scenario for their surgery was a “generally small” improvement compared to a fake surgery.
We’re going to take a closer look at some of these studies. Part 1 of this article will deal with surgeries related to low back pain, while Part 2 will look at a few shoulder and knee surgeries. You might be surprised at the results.
Vertebroplasty for Low Back Pain caused by Osteoporotic Vertebral Fractures[ii]
Osteoporosis is a condition where bones become very fragile and brittle. It is most common in elderly people, particularly women. In some patients, this can lead the vertebrae (spinal bones) to become compressed and fracture. Vertebroplasty is a treatment where a cement-like substance is injected into the compressed bone to stabilize the fracture and give it strength.
This study took 78 patients with osteoporotic fractures. Half received an injection into their back that filled their vertebrae with the cement-like substance. The other half received a needle placed into their back to mimic the injection. There were no differences in pain, function, quality of life or perceived improvement at 1 week, 1 month, 3 months or 6 months!
Intradiscal electrothermal therapy for chronic LBP[iii]
Chronic low back pain is a big deal and a huge burden on society. One method of treatment is using intradiscal electrothermal therapy (IDET). This involves placing a wire into the intervertebral discs, which is the tissue between each of your spinal bones. An electrical current is passed through the wire, which then heats up enough to destroy the nerve endings in the disc. The idea for this surgery is that if you kill the nerve endings which are detecting damage or danger in the discs, then they can no longer transmit these signals and then the patient won’t feel pain anymore.
For this study, they took 57 patients with chronic low back pain that showed intervertebral disc degeneration and annular (outer portion of the disc) tears on imaging. I’ve written before about how those findings are generally meaningless but you can read that HERE. These patients also did not respond to prior conservative therapy. One group received the IDET treatment, while the other group had the wire placed in the disc but no current was passed through it (sham group).
At 6 month follow-up, there were no differences in pain, function, depression or any other outcome between the two groups. It is also interesting to note that not a single patient in either group met the criteria for a successful outcome. So there’s that.
Alright, that’s it for Part I. Unfortunately, that’s also it for sham surgery studies regarding low back pain. Hopefully, they’ll get around to doing sham surgery studies for more common surgeries such as fusions, discectomies, and laminectomies.
Stay tuned for Part II where we look at some recent studies involving shoulder and knee surgeries.
[i] BMJ 2014; 348
[ii] BMJ 2018; 361
[iii] Spine 2005; 2369-77
Jeff Remsburg DC MS DACBR Cert