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
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
