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published 9/09/07
Getting back surgery sooner is better than getting it later
But is either one better than a placebo? Or nothing?
by Paul Ingraham, Vancouver, Canada MOREclose
Credentials and qualifications
I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.
For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.
Credentials and qualifications
I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.
For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.
The New England Journal of Medicine just published the results of some research done at Leiden University Medical Center in the Netherlands.
The New England Journal of Medicine is arguably the most credible medical journal on Earth … and this research is brand-spanking new, and it was generally a well-designed study. Because of its fine pedigree, surgeons are likely to cite this study for many years when recommending surgery to their patients. For the most part, I think that’s fair, and so does back pain expert Dr. Richard Deyo, who agrees that the research “bolsters the case that surgery is effective for patients with sciatica owing to herniated disks.” However, as always, I want my patients and readers to have some additional perspective!
The focus was primarily on the timing of surgery — rather than asking whether or not surgery should be done, the purpose of the research was to try to determine the best time for surgery.
The researchers compared the results of 125 microdiskectomies that were performed sooner with 142 that were done later. Those who waited were cared for minimally by family doctors who reassured them that most sciatica goes away within a few weeks, and then offered them surgery if their sciatica persisted for six months. What they found was that “the rates of pain relief and of perceived recovery were faster” for those who had surgery promptly, even though almost everyone was fine after a year regardless of when they had surgery.
In short, the sooner these patients had surgery, the sooner they felt better.
That’s good stuff! Pretty compelling. Or is it? In spite of many qualities, this study was not well “controlled.” Controlling research means that you make sure that you compare whatever you study to a placebo and/or to neutral subjects not receiving any treatment at all. But surgeons have been historically sloppy about this, typically doing “inbred” studies that only compare different kinds of surgeries, rather than comparing surgeries to sham surgeries and other kinds of therapeutic interventions, or comparing to no intervention. Perhaps surgeons tend to assume that surgery must be good for people and so they don’t feel the need to compare it anything else? And perhaps the ethical problems of doing sham surgeries are daunting for most researchers? It’s not clear. In any case, there are no signs of properly controlled research in the history of studying microdiskectomy.
Surgeons have been historically sloppy about this, not comparing between kinds of surgeries, and also to sham surgeries, to other kinds of therapeutic interventions, or to no intervention.
This is bad news. The few enlightened researchers who have compared real surgeries to fake interventions have been amazed at what they’ve found. Consider this bizarre study of knee surgery for osteoarthritis done in 2002 (and also published in The New England Journal of Medicine): three hundred people with osteoarthritis of the knee were operated on, and while half were given a standard knee surgery, the other half were given a bogus surgery. Incredibly, both groups experienced equal improvement in their knee pain. The head researcher was quoted after publication, “We don’t really understand the placebo effect.” No kidding!
So you can see how important it is to control surgical studies, just like any other kind of science. This is Research Methodology 101. Yet studies of back pain surgeries are woefully lacking in comparisons to sham surgeries or control groups.
And now Peul et al have continued the tradition with this new study of microdiskectomy. Although it convincingly shows that getting a microdiskectomy sooner as opposed to later is probably a good idea, they fail to convince me that either surgical approach is better than nothing at all, or something else altogether. It is possible — I’m just saying that I’m unconvinced.
This is Research Methodology 101: you have to compare surgery to a placebo to really find out if it works.
But it is also possible that subjects who’d received no surgery at all might have recovered faster than either group, or at least no slower — exactly as with the knee surgery example above. What would that have told us? What if the study was only determining the lesser of two evils? There’s no way to know without comparing those who received surgery to people who didn’t.
(We can take some comfort here in knowing that the researchers were giving delayed surgery to people who had already been doing poorly without any kind of intervention, and so those people were — sorta — a control group. This is probably why Dr. Deyo called this a controlled study (see Deyo again), even though it isn’t really. Any research methods purist will tell you that you really do have to go all the way with that, because — for all we know — most of those people could have improved quickly after that point regardless of whether or not they had surgery.)
A sham surgery comparison would also have been more informative, though less likely to happen. Why? Because the benefits of getting prompt surgery might have been due to a placebo effect. Early intervention could well seem more decisive and proactive to patients, and therefore significantly increase their optimism for a good outcome. Whoa. Deep.
Is that plausible? Yes! Expectations have been shown to be a major factor in recovery from back pain (see Schultz). But patients who have already been in pain for months by the time they have surgery may be much more weary and cynical, and therefore have much lower expectations of recovery. Psychological forces were at work on these patients, we know that those forces matter — we know that placebo can be a large factor even in places where no one expected it — and that they could completely invalidate the results. Yet the researchers did not design their study to check for this. And what a shame, because it would really be nice to know!
For more about back pain and sciatica, see:
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