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14 Articles in Volume 19, Issue #1
Analgesics of the Future: NKTR-181
Antidote to CDC Guideline; Plantar Fasciitis; Patient Input
Assessing and Treating Migraine in Women and Men
Demystifying Opioid-Induced Hyperalgesia
Editorial: Have We Gone Too Far? Can We Get Back?
How to Compel Patients to Complete Home Exercises
Inflammation Targeted Nanomedicine
Intravenous Stem Cell Administration for Ileitis
Invasive Surgery: Effective in Relieving Chronic Pain?
Pain Catastrophizing: What Practitioners Need to Know
Pain Therapy Options for the Home
Regenerative Medicine
The Future of Pain Management
Whole Body Vibration: Potential Benefits in the Management of Pain and Physical Function

Invasive Surgery: Effective in Relieving Chronic Pain?

Surgical interventions were not effective in reducing pain for some patients.
Page 19

with Wayne B. Jonas, MD, and Dmitry Arbuck, MD

Invasive surgery may not be any more effective than sham procedures in reducing chronic pain, according to a meta analysis published by Wayne B. Jonas, MD, in Pain Medicine last September. A clinical professor of family medicine at the Uniformed Services University and at Georgetown University School of Medicine, Dr. Jonas and his team performed a systematic review of 25 randomized controlled trials published between 1959 and 2013, involving 2,000 patients undergoing surgery for chronic pain. Procedures performed included either endoscopic or percutaneous insertion of instruments to manipulate tissues. In these studies, sham groups received identical interventions, excepting any steps with therapeutic effects.

Chronic pain was defined as pain lasting at least 3 months, and the review included trials on: low back pain (n = 7), arthritis (n = 4), angina (n = 4), abdominal pain (n = 3), endometriosis (n = 3), biliary colic (n = 2), and migraine (n = 2). Data on back and knee pain were pooled together for a random-effects meta-analysis.

“[T]here are few studies in any one pain condition, resulting in substantial clinical heterogeneity across populations and interventions,” the authors noted in their paper. “None of the studies were double-blind, precluding full rigor in the evaluation.” Dr. Jonas added, “The quality of previous studies varie[d] and the sample sizes [were] often small and not replicated.” Evaluation tools included the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system, as well as the Cochrane risk of bias tool.

Surgical interventions were not effective in reducing pain for some patients. (Source: 123RF)

Lack of Evidence for Invasive Procedures

For all conditions studied, 87% of within-group improvement was attributable to the sham procedures. “I was expecting that the sham procedures would produce some beneficial effect,” Dr. Jonas told PPM. “Placebos usually do benefit patients, especially surgical placebos, because you go through a big ritual and everyone believes it. But, I was not expecting placebo to explain almost all of the effects.”

Surgical intervention did not result in significant pain reduction in patients with either low back or knee pain (n = 445 patients, P = 0.26; and n = 496, P = 0.26 respectively), according to their findings. Additionally, the use of invasive procedures significantly increased the risk of adverse events, compared to sham (12% vs 4%; P = 0.01). “There is currently insufficient evidence to support the specific efficacy of invasive procedures for the treatment of chronic pain,” the authors wrote. “Given their high costs and safety concerns, more rigorous studies are required before invasive procedures are routinely used for patients with chronic pain.”

Additional Perspective

Dmitry M. Arbuck, MD, provided his perspective on the findings. Dr. Arbuck is a clinical assistant professor of medicine and psychiatry at Indiana University School of Medicine, a clinical associate professor of psychiatry and pain medicine at Marian Osteopathic School of Medicine, and director of the Indiana Polyclinic. “This meta-analysis shows that mixing protracted pain and chronic pain can create skewed and invalid results as it does not separate fundamentally different conditions,” he said. “There is still confusion in the pain community in regard to understanding chronic pain.”

He described how protracted pain, for instance, which also may last longer than 3 to 6 months, is often mistakenly defined as chronic pain. “Protracted pain is actually acute pain that is based on persisting tissue damage,” he said, and “regardless of the length of such an acute pain model, it responds to interventional treatments.” Chronic pain, on the other hand, is a disease based on central sensitization and is detached from tissue damage. “This disease poorly responds to local interventional treatment. The more centralization develops, the less interventional treatments help,” he said, elaborating with this example: “Imagine if someone pokes you with a needle for 6 months every day. You have acute pain for 6 months because of the needle prick. This is protracted pain. The longer you are hurt, the more your central nervous system gets involved. If the pain is fully centralized, when you stop the trigger, the pain continues. Even if longer lasting pain is more likely to be centralized, there are plenty of cases when it does not happen and pain does not progress from protracted to chronic. Thus, interventional treatments may work very well in such patients even after months and years of suffering.”

Overall, Dr. Jonas said his team believes the “findings further support the call for patients to seek out non-pharmacologic approaches to manage chronic pain, which have been proven and are recommended by [multiple] organizations.” He noted, however, that these are not meant to be standalone therapies. “Rather, they should be integrated with conventional treatments for optimal pain and opioid management.”

Last updated on: February 4, 2019
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Demystifying Opioid-Induced Hyperalgesia
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