Pamela A. Popper, Ph.D., N.D.
Wellness Forum Health
While the FDA eventually approves almost every drug submitted for review, at least there is the appearance of oversight. There is no such approval process for surgical procedures, however. A recent New York Times article notes that while people think that surgical procedures determined to be useless will be discontinued, the reality is that this is rarely the case. The burden is on patients to ask for evidence that a procedure is effective since surgeons continue to promote many that have been determined to be useless.[i]
The Times cites as an example spinal fusion, which fuses discs together to relieve back pain. While most surgical procedures are not tested for efficacy, this one was and four clinical trials showed that spinal fusion was no better than exercise and therapy to help patients overcome their fear of back pain.[ii] According to the Times article, this did not stop surgeons from performing the procedure. In fact, there was an increase in the number of surgeries performed following publication of a meta-analysis showing it was useless. It was only when insurance companies started refusing to pay for it that the rates declined.
But the rates of other surgeries proven to be useless have continued to increase. The Times reports that vertebroplasty and Kyphoplasty, which involve injecting substances into the spine to relieve compression were shown to be no better than sham procedures.[iii] Lead author Dr. David Kallmes told the Times “I think there is a placebo effect not only on patients but on doctors,” which leads doctors to think that the procedure works when it clearly does not.
The article reports that the operation that has been the subject of the most scrutiny in randomized trials is surgery to repair a torn meniscus, which is cartilage in the knee. Degeneration occurs with age and about 400,000 surgeries are performed every year to address it. The problem is that there is no clear connection between meniscal tears and knee pain, and as a result many people who have the surgery continue to have knee pain. Randomized trials have shown that people who have the surgery fare no better than people who just have physical therapy.[iv] The conclusion in an editorial commenting on the surgery says it all. The surgery is “a highly questionable practice without supporting evidence of even moderate quality,” adding, “Good evidence has been widely ignored.”[v]
In terms of what the patient should do, the author of the editorial says that the patient should choose, but should be given realistic information. He suggests saying, “We have randomized clinical trials that produce the highest quality of evidence. They strongly suggest that the procedure is next to useless. If there is any benefit, it is very small and there are downsides, expense and potential complications.” He goes on to say, “I cannot imagine that anybody would say, ‘Go ahead. I will go for it.’”
[i] Gina Kolata “Why ‘Useless Surgery Is Still Popular.” New York Times August 3 2016
[ii] Sohail M, Deyo R. “Systemic Review of Randomized Trials Comparing Lumbar Fusion Surgery to Nonoperative Care for Treatment of Chronic Back Pain.” Spine 1 April 2007;32(7):816-823
[iii] Kallmes D, Comstock B, Heagerty P et al. “A Randomized Trial of Vertebroplasty for Osetoporotic Spinal Fractures.” NEJM 2009;361:569-579
[iv] Katz J, Brophy R, Chaisson C et al. “Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis.” NEJM 2013;368:1675-1684
[v] Järvinen T, Guyatt G. “Arthroscopic surgery for knee pain.” BMJ 216;354