Surgery and Pain

Operating RoomImage courtesy of dream designs at FreeDigitalPhotos.net

The previous section discussed the fact that arthritis, disc bulges, tears, and degenerative changes found in x-rays, MRIs, and CT scans may not be related to your pain. This chapter will discuss surgery and pain. For starters, let’s get one thing straight. Surgery is needed and is very important for many conditions. This has been proven through research. But what we do not hear about is that there are many research studies that have found that people did well for many conditions whether they had surgery or not.

So, why not try to avoid surgery if you can? If you already had surgery and did not improve, it could be due to the fact that other issues that we discussed previously (sensitization, changes in the nervous system and etc) are the primary components to your pain, which means that there is always potential for you to take control of your pain. Feel free to review the previous sections in the Pain Science Filing Cabinet if you need to.

The purpose of listing the statements published by the researchers listed below is to make the point that you can still take control of your pain whether you had surgery or not. Also don’t forget to read the “red flags” section and always contact your physician if you have any questions.

Articles about spine surgery:

“No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation.” Published by Fairbank J 2005

“The results of our study demonstrate significantly improved pain scores at follow-up for the operative and nonoperative treatment groups, and do not demonstrate a significant difference for standardized outcome measures of pain, generalized health status, satisfaction, or disability.” Published   by Carragee EJ. 2005

“There is insufficient evidence to support the use of injection therapy in subacute and chronic low back pain.” Published by Staal JB in 2008

“We found no beneficial effect of vertebroplasty as compared with a sham procedure in patients with painful osteoporotic vertebral fractures, at 1 week or at 1, 3, or 6 months after treatment.” Published by Buchbinder R. 2009

“Individual patient data meta-analysis from two blinded trials of vertebroplasty, powered for subgroup analyses, failed to show an advantage of vertebroplasty over placebo for participants with recent onset fracture or severe pain.” Published by Staples MP in 2011

“There was no difference between spinal fusion and non surgical treatment consisting of cognitive-behavioral treatment and exercise rehabilitation. Published by Mannion AF in 2013

“The results of our study demonstrate significantly improved pain scores at follow-up for the operative and nonoperative treatment groups and do not demonstrate a significant difference for standardized outcome measures of pain, generalized health status, satisfaction, or disability.”   Published by Smith JS 2013

“The main outcome measure showed equal improvement in patients with chronic low back pain and disc degeneration randomized to cognitive intervention and exercises, or lumbar fusion.” Published by Brox JI 2013

“There is strong evidence that lumbar fusion is not more effective than conservative treatment in reducing perceived disability because of chronic low back pain among patients with degenerative spinal diseases. It is unlikely that further research on the subject would considerably affect this conclusion.” Published by Saltychev M. 2014

Articles about the Lower Extremities

“In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.”  Published by Moseley JB 2002

“There were no significant between-group (surgery or physical therapy) differences in the frequencies of overall or specific adverse events.” Published by Katz JN 2013

“In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham(placebo) surgical procedure.” Published by Sihvonen R. 2014

Articles about the Upper Extremities:

“Based on our results, it seems that the mere presence of an uncomplicated shoulder impingement syndrome is not an indication for arthroscopic acromioplasty per se, as conservative treatment with a structured exercise program provides as good results at five years at a lower cost.” Published by Ketola S 2013

“At one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.” Published by Kukkonen J. 2014

“Anatomic features defining the severity of atraumatic rotator cuff tears are not associated with the pain level. Factors associated with pain are comorbidities, lower education level, and race.” Published by Dunn WR. 2014

What does all of this mean???

As you can see from the quotes from published research studies, it is possible that you can improve because your surgery may have address a tear, disc, joint, bone, cartilage, or muscle but did not address other components of the pain process.

You shouldn’t be upset if you had surgery and did not improve, you should be happy that you have potential to experience less pain!

We must be positive, try movement and motor control exercises that you have been taught from your health care professional. (Concepts of self-correction through various movement and motor control exercises will be uploaded soon.) This is very important concept because when we stress and worry that something is wrong with a body part there can be increased pain. The next section will discuss this in more detail.

References:

Photo: http://www.freedigitalphotos.net/images/student-assistant-helping-doctor-in-a-surgery-photo-p281307

Brox JI, Sørensen R, Friis A, Nygaard Ø, Indahl A, Keller A, Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, Riise R, Reikerås O. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine (Phila Pa 1976). 2003 Sep 1;28(17):1913-21. PubMed PMID: 12973134.

Buchbinder R, Osborne RH, Ebeling PR, Wark JD, Mitchell P, Wriedt C, Graves S, Staples MP, Murphy B. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009 Aug 6;361(6):557-68. doi: 10.1056/NEJMoa0900429. PubMed PMID: 19657121.

Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. 2005 Jan-Feb;5(1):24-35. PubMed PMID: 15653082.

Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, Brophy RH, Carey JL, Holloway GB, Jones GL, Ma CB, Marx RG, McCarty EC, Poddar SK, Smith MV, Spencer EE, Vidal AF, Wolf BR, Wright RW. Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg Am. 2014 May 21;96(10):793-800. doi: 10.2106/JBJS.L.01304. PubMed PMID: 24875019; PubMed Central PMCID: PMC4018774.

Elattrache N, Lattermann C, Hannon M, Cole B. New England journal of medicine article evaluating the usefulness of meniscectomy is flawed. Arthroscopy. 2014 May;30(5):542-3. doi: 10.1016/j.arthro.2014.02.010. Epub 2014 Mar 15. PubMed PMID: 24642105.

Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K, Collins R; Spine Stabilisation Trial Group. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ. 2005 May 28;330(7502):1233. Epub 2005 May 23. Erratum in: BMJ. 2005 Jun 25;330(7506):1485. PubMed PMID: 15911537; PubMed Central PMCID: PMC558090. Free full text

Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84. doi: 10.1056/NEJMoa1301408. Epub 2013 Mar 18. Erratum in: N Engl J Med. 2013 Aug 15;369(7):683. PubMed PMID: 23506518; PubMed Central PMCID: PMC3690119. Free full text

Ketola S, Lehtinen J, Rousi T, Nissinen M, Huhtala H, Konttinen YT, Arnala I. No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five-year results of a randomised controlled trial. Bone Joint Res. 2013 Jul 1;2(7):132-9. doi: 10.1302/2046-3758.27.2000163. Print 2013. PubMed PMID: 23836479; PubMed Central PMCID: PMC3728648. Free full text

Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, Aärimaa V. Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96-B(1):75-81. doi: 10.1302/0301-620X.96B1.32168. PubMed PMID: 24395315.

Mannion AF, Brox JI, Fairbank JC. Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials. Spine J. 2013 Nov;13(11):1438-48. doi: 10.1016/j.spinee.2013.06.101. Epub 2013 Nov 5. PubMed PMID: 24200413.

Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002 Jul 11;347(2):81-8. PubMed PMID: 12110735.

Saltychev M, Eskola M, Laimi K. Lumbar fusion compared with conservative treatment in patients with chronic low back pain: a meta-analysis. Int J Rehabil Res. 2014 Mar;37(1):2-8. doi: 10.1097/MRR.0b013e328363ba4b. PubMed PMID: 23820296.

Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TL; Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013 Dec 26;369(26):2515-24. doi: 10.1056/NEJMoa1305189. PubMed PMID: 24369076.

Smith JS, Sidhu G, Bode K, Gendelberg D, Maltenfort M, Ibrahimi D, Shaffrey CI, Vaccaro AR. Operative and Nonoperative Treatment Approaches for Lumbar Degenerative Disc Disease Have Similar Long-Term Clinical Outcomes Among Patients with Positive Discography. World Neurosurg. 2013 Sep 15. pii: S1878-8750(13)01111-X. doi: 10.1016/j.wneu.2013.09.013. [Epub ahead of print] Review. PubMed PMID: 24047821.

Staal JB, de Bie R, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD001824. doi: 10.1002/14651858.CD001824.pub3. Review. PubMed PMID: 18646078.

Staples MP, Kallmes DF, Comstock BA, Jarvik JG, Osborne RH, Heagerty PJ, Buchbinder R. Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: meta-analysis. BMJ. 2011 Jul 12;343:d3952. doi: 10.1136/bmj.d3952. PubMed PMID: 21750078; PubMed Central PMCID: PMC3133975. Free full text

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