A 2022 systematic review and meta-analysis of randomized, controlled trials of various interventions with and without surgery for non-fracture musculoskeletal (MSK) conditions in adults evaluated the potential benefits and harms.¹ One hundred randomized, controlled trials involving a total of 12,645 patients were selected, representing 28 different conditions at nine body sites including the neck, low back, shoulder, pelvis, hip and knee.

Except for certain spinal conditions (see below), pain data on nine of 13 conditions, function data on 11 of 11 conditions and quality-of-life data on nine of nine conditions found no clinically relevant differences between interventions with and without surgery. For serious adverse events (SAEs), 13 of 16 conditions with data; and for death, 16 of 16 conditions, found no differences in harms between surgery vs. no surgery.

Of the remaining four of 13 conditions with pain data, surgery appeared to lead to a greater improvement of at least moderate effect size for cervical disc herniation (three studies), lumbar spinal stenosis (five studies), sacroiliac joint pain (two studies), and chronic low back pain (five studies) – but did not demonstrate greater improvement in either function or quality of life.

In addition, only 14 percent of MSK RCTs comparing surgery to placebo surgery, nonsurgical intervention or no intervention demonstrated statistically significant and clinically relevant benefits for surgery.

This isn't the first time research has suggested most musculoskeletal conditions should be treated nonsurgically. Per a 2021 study, "The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs."²

A previous systematic review also suggested MSK surgeries have fewer supporting RCTs compared to other surgical procedures, and that less than 1 percent compared surgery to not performing the surgical procedure.³

And the authors of a 2017 study stated, "[F]or many conditions, best practice nonsurgical interventions are viable alternatives to surgery. Even for patients where nonsurgical treatment is not sufficiently effective, evidence supporting the effects of surgery is missing. For some conditions, surgery is even recommended against by clinical guidelines and does not provide additional benefit to nonsurgical treatment."⁴

Even after surgery, the costs⁵ and need for further nonsurgical care^6-7 can be high, suggesting that undergoing successful surgery in terms of improved pain and function is not necessarily associated with reduced societal burden of MSK conditions; or does not necessarily result in the surgical intervention being more cost-effective as an alternative or in addition to nonsurgical intervention.^6,8

These results, when combined with previous research, further support nonsurgical interventions as first-line care for MSK conditions for pain reduction, increased physical function, improved quality of life and fewer serious adverse events.

References

1. Skou ST, Poulsen E, Bricca A, et al. Benefits and harms of interventions with surgery compared to interventions without surgery for musculoskeletal conditions: a systematic review with meta-analysis. JOSPT, 2022;52(6):312-344.
2. Blom AW, Donovan RL, Beswick AD, et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ, 2021;374:n1511.
3. Harris IA, Sidhu V, Mittal R, Adie S. Surgery for chronic musculoskeletal pain: the question of evidence. Pain, 2020;161:S95-S103.
4. Siemieniuk RAC, Harris IA, Agoritsas T, et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ, 2017; 57:j1982.
5. Kroslak M, Murrell GAC. Surgical treatment of lateral epicondylitis: a prospective, randomized, double-blinded, placebo-controlled clinical trial. Am J Sports Med, 2018;46:1106-1113.
6. Kiadaliri AA, Englund M, Lohmander LS, et al. No economic benefit of early knee reconstruction over optional delayed reconstruction for ACL tears: registry enriched randomised controlled trial data. Br J Sports Med, 2016;50:558-563.
7. Multanen J, Uimonen MM, Repo JP, et al. Use of conservative therapy before and after surgery for carpal tunnel syndrome. BMC Musculoskelet Disord, 2021;22:484.
8. Skou ST, Roos EM, Laursen MB, et al. Cost-effectiveness of total knee replacement in addition to non-surgical treatment: a 2-year outcome from a randomised trial in secondary care in Denmark. BMJ Open, 2020;10:e033495.

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