Invasive Procedures for Most Musculoskeletal Conditions Are Not Better Than Placebo: A Systematic Review With...

Musculoskeletal (MSK) conditions are leading causes of disability worldwide. Although clinical guidelines recommend non-pharmacological interventions, surgical and invasive procedures remain frequently used, yet their efficacy beyond placebo effects is not well established.

To systematically review the effects of invasive procedures compared with placebo controls in patients with MSK conditions.

MEDLINE, Cochrane Central Register of Controlled Trials, Scopus, EMBASE, and Web of Science were searched from inception to August 2024. Eligible studies were RCTs comparing any invasive procedure with a sham or placebo in patients with MSK conditions and measuring pain, disability, function, or quality of life. All analyses were pairwise comparisons. Risk of bias was assessed using the Cochrane RoB Tool and certainty of evidence using GRADE. Random-effects meta-analyses were conducted when at least two trials provided data.

Twenty-three RCTs (2412 participants) were included. In 18 studies (78%), invasive procedures showed no superiority over placebo, with some placebo groups demonstrating better outcomes. Moderate-certainty evidence showed vertebroplasty provided no additional benefit for pain at 1 month (MD 0.42; 95% CI -0.84 to 1.68; I² = 73%) or 6 months (MD 0.90; 95% CI -0.06 to 1.87; I² = 0%). Arthroscopic decompression did not improve shoulder function at 6 months (MD -3.68; 95% CI -8.57 to 1.22; low-certainty). Radiofrequency denervation and intradiscal therapies showed no consistent benefit over sham for low back pain (very low-certainty).

Invasive procedures were not superior to placebo for most non-life-threatening MSK conditions. Further rigorous placebo-controlled trials are needed.

This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42024534187.