February 20, 2019


Surgical stitch-up: meet the placebo surgeon: Could the placebo effect work in surgery? When a doctor wanted to investigate - by opening patients up but not operating - some said it was criminal. But the resulting study has shaken the medical world (XAN RICE, 2/20/19, New Statesman)

In the summer of 2012 Carol Brennan started to feel pain in her right shoulder. Her GP prescribed painkillers but they did little to ease her discomfort. Nor did physiotherapy. Brennan's shoulder became so sore that she had to give up yoga, Pilates, even knitting. Standing upright, the 63-year-old academic was unable to raise her arm more than 45 degrees from her hip. Lying down offered little relief. The only way she could sleep was on her stomach with her right arm hanging over the edge of the bed. When she was finally referred to a specialist in late 2013, Brennan told him: "I can barely sleep and when I do I dream about pain."

Shoulder pain is a common complaint, especially among people over 50, accounting for more than 2 per cent of all primary care consultations in the UK. Usually the soreness concerns the shoulder joint, where the long bone in the upper arm, the humerus, fits loosely into the shoulder blade, like a ball and socket. The pain occurs when tendons attached to the humerus rub or catch on nearby tissue or on the acromion, the bone that extends over the joint.

More than 40 years ago, doctors proposed a surgical remedy for such shoulder pain. Removing a small area of tissue and acromial bone would increase the space around the tendon so it no longer caught or rubbed. It was a minor procedure greatly eased by advances in keyhole surgery, which allows slender tools to be passed through little cuts in the skin. Subacromial decompression, as the surgery became known, is now one of the most common operations in orthopaedics. In the UK, 30,000 are performed each year, costing the NHS £150m.

By coincidence, the specialist Brennan was referred to lived in the same village as her on the outskirts of Oxford. Andy Carr, who is now 60, is a widely respected academic surgeon and had performed the shoulder operation many times. He told Brennan that because her pain had lasted so long she was now in a position where surgery was usually offered. But first, he wanted to see whether she would consider taking part in a study of people with persistent shoulder pain.

At Oxford University's Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, which he heads, Carr was conducting a clinical trial of decompression surgery, to assess its effectiveness. He explained to Brennan that if she agreed to participate she would be randomly assigned to one of three groups. The first would receive regular surgery. The second set would get "placebo surgery", with all the surgical procedures identical to the normal operation except that no bone or tissue would be removed. Patients in these two groups would not know if they'd had the real or sham surgery. The third group would receive no treatment.

"My immediate reaction was: yes, of course I'll do it, because that's the sort of person I am," Brennan told me when we met recently for coffee in an Oxford bookshop. "But I was concerned that I might end up in the 'do nothing' category, as I was already at my wits' end."

To Brennan's relief she was assigned for surgery. In January 2014, she was shown to a ward at the Nuffield Orthopaedic Centre, where she changed into a hospital gown and was given a general anaesthetic. Inside the operating theatre, Carr made two tiny incisions in Brennan's right shoulder: one at the back for the endoscope, a thin tube fitted with a light and camera that relays pictures to a monitor, and another at the side of the shoulder to allow entry for the tool with a rotating burr used to shave bone. The procedure took around 30 minutes.

When Brennan awoke in the recovery room, she discovered she was unable to talk, an upsetting side effect of an anaesthesia that lasts for a day. Her arm was painful, heavily bandaged and in a sling. Her son drove her home. After a few days she was allowed to remove the sling and gently use her arm. When she returned to the hospital for a consultation a month later she was downbeat. "I said to the nurse: I'm still so sore. This is a disaster."

Then, as if she were slowly recovering from an illness, the pain began to subside and her mobility returned. After six months, she was able to do some light yoga and Pilates again. After a year she had gone from "a nine to a two" on the one-to-ten scale, which is the most common tool used by doctors to assess pain and requires the patient to put a number to their level of discomfort. "To all intents and purposes I was cured," she said.

Posted by at February 20, 2019 3:23 PM