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. J Orthop Sports Phys Ther. 2022 Jun;52(6):312-344. doi: 10.2519/jospt.2022.11075. (Systematic review)

OBJECTIVE: To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions.

DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials (RCTs).

LITERATURE SEARCH: MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021.

STUDY SELECTION CRITERIA: RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year.

DATA SYNTHESIS: Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials.

RESULTS: One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias.

CONCLUSION: The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion. J Orthop Sports Phys Ther 2022;52(6):312-344. doi:10.2519/jospt.2022.11075.

Discipline Area Score
Physician 6 / 7
Comments from MORE raters

Physician rater

Very important!

Physician rater

The takeaway is that, in general, we should proceed with extreme caution when considering surgery in musculoskeletal conditions, but this conglomerate approach isn't particularly helpful. What we need is to know whether surgery works (efficacy, safety, and cost-effectiveness) in specific musculoskeletal problems, and in which groups of patients.

Physician rater

Study too wide, hard to implement in practice.
Comments from PAIN+ CPN subscribers

Ms. Sandy Ketler (6/14/2022 1:08 PM)

Caution is warranted in moving to surgical options. Relief of function is important to patients.