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Common shoulder surgery may offer little pain relief

Study questions value of subacromial decompression

Adrian O'Dowd

Tuesday, 21 November 2017

People who undergo commonly performed shoulder surgery may gain very little benefit in terms of reducing their shoulder pain, claims a study* published today in The Lancet.

Researchers from the University of Oxford found that decompression surgery does not reduce shoulder pain any more than placebo surgery for people with shoulder impingement.

In the UK, shoulder pain accounts for 2.4% of all GP visits and 4.5 million visits to the doctor each year in the USA.

For subacromial shoulder pain, treatment options include subacromial decompression – one of the most commonly used surgeries in orthopaedics. In England, the number of such surgeries has risen from 2,523 in 2000, to 21,355 in 2010.

The researchers’ study involved 32 hospitals and 51 surgeons across the UK.

In the study, 90, 94 and 90 people who had suffered shoulder pain for at least three months despite having physiotherapy and steroid injections underwent decompression surgery, placebo surgery or no treatment, respectively.

Decompression surgery is a keyhole surgery that involves removing a small area of bone and soft tissue in the shoulder joint to open up the joint and prevent rubbing or catching when the arm is lifted.

In the placebo surgery, surgeons conducted a procedure to look inside the affected joint, but no tissue was removed.

Both surgeries were carried out as keyhole procedures to ensure that patients were not aware of which surgery they had undergone.

Six and 12 months after they entered the trial, participants completed questionnaires rating their symptoms, including pain (from 0-48, with a higher number meaning less pain).

Overall, symptoms lessened in all three groups from the start of the trial, but at six months, people who had had decompression surgery and those who had had placebo surgery rated their pain and function at a similar level, with no statistical difference – 32.7 points and 34.2 points, respectively.

Comparatively, both forms of surgery showed a small benefit over no treatment (rated at 29.4 points in the no treatment group), but the authors said the difference was unlikely to result in a noticeable difference in symptoms.

The authors acknowledged some limitations to their study, including that some patients did not continue with their assigned treatment, there were long waiting times within the study, and the research did not look at the recurrence of pain after a year.

Nevertheless, they concluded: “The findings (which should be communicated to patients during the shared treatment decision-making process) question the value of this type of surgery for these indications, and might discourage some surgeons from offering decompression surgery and dissuade some patients from undergoing the surgery.”

Co-chief investigator Professor Andrew Carr from the National Institute of Health Research Biomedical Research Centre, University of Oxford, said: “Over the past three decades, patients with this form of shoulder pain and clinicians have accepted this surgery in the belief that it provides reliable relief of symptoms, and has low risk of adverse events and complications.

“However, the findings from our study suggest that surgery might not provide a clinically significant benefit over no treatment, and that there is no benefit of decompression over placebo surgery.”

Co-chief investigator Professor David Beard, University of Oxford, said: “Our findings call into question the value of shoulder decompression surgery for this group of patients, and should be communicated to patients and doctors considering this type of surgery.”

Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. DOI: 10.1016/S0140-6736(17)32457-1.

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