When surgery is necessary and unavoidable, and how to assess if there are alternative solutions?
When a doctor suggests surgery, it’s natural to have a range of questions and doubts. Very few people remain indifferent. The key question that arises is: surgery – yes or no? Is surgery truly unavoidable, or is there another way that could yield equally good results? Often, patients seek a second or even third opinion to ensure they are making the best possible decision. But what if different specialists recommend different approaches? How can you know whom to trust and on what factors to base your decision?
In some situations, surgery is unavoidable. Severe fractures, ligament ruptures, deformities that hinder movement, or urgent neurological conditions require a quick response. The sooner the procedure is carried out, the better the outcomes. Timely intervention prevents further damage, reduces the risk of long-term disability, and ensures better functional recovery.
On the other hand, there are conditions where surgery is not always the first and only option. In cases of chronic pain, degenerative changes, or mobility issues, there is often the possibility of conservative treatment that can yield equally good results. In such cases, the decision to undergo surgery becomes more complex – the risks, expected benefits, and long-term consequences on quality of life need to be evaluated.
For some patients, surgery is seen as a quick and final solution to the problem. However, it carries certain risks, potential complications, a lengthy recovery, and the need for additional rehabilitation, and it often does not address the root cause of the condition. Therefore, it is crucial to understand when surgery is truly necessary and if there are other possible solutions.
Why are opinions divided?
Patients often encounter differing opinions from medical professionals, which makes the decision-making process even more challenging. One doctor may recommend immediate surgery, another may suggest conservative treatment, and a third may propose postponing surgery and opting for long-term monitoring.
Why do these differences arise?
The answer lies in different medical approaches:
- Conventional medicine is focused on recognizing anatomical or pathological changes using diagnostic methods such as MRI, CT scans, and X-rays. If a clear injury or lesion is present (e.g., fracture, tumor, severe inflammation), surgical or pharmacological interventions are often recommended to target the specific issue.
- Functional medicine – Focused on biomechanical assessment of movement and analyzing how certain (pre-existing) structural changes truly affect the functionality of the body. The emphasis is on the overall state of the body and the cause-and-effect relationships between different systems. Special attention is given to diet, lifestyle, environment, and psychological factors that may contribute to the onset or maintenance of the disease.
Many specialists (such as orthopedic surgeons) naturally focus on anatomical damage and its surgical resolution, while physiatrists, physiotherapists, osteopaths, and similar professionals tend to prefer a functional approach, which includes rehabilitation, targeted exercises, and lifestyle changes.
The optimal approach when deciding on surgery is to combine both perspectives: consider the radiological findings (MRI, X-ray, CT) and conduct a functional assessment of movement, strength, and pain. This allows for an informed treatment decision that takes into account both “visible” pathological changes and the overall functioning of the body.
In medical literature, there is an increasing amount of research indicating that certain procedures may not be as necessary as once thought. One such example is the study titled Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear, published in 2013 in the prestigious New England Journal of Medicine (NEJM). The study found no significant difference between the group that underwent real surgery and the group that underwent a sham (placebo) surgery in terms of pain relief, knee function improvement, and patient satisfaction. This finding significantly influenced clinical practice, as it highlighted that degenerative meniscal damage, without clear mechanical symptoms (such as knee locking), can often be successfully treated with conservative methods, including physical therapy, muscle strengthening exercises, and lifestyle changes.
This study was part of the FIDELITY project (Finnish Degenerative Meniscal Lesion Study) and compared the effects of arthroscopic partial meniscectomy with a sham surgery in patients with degenerative meniscal damage. The research had a significant impact on the medical community, especially because such knee changes are very common in middle-aged and elderly individuals, for whom surgery had previously been a routine intervention.
This research has driven changes in orthopedic practice guidelines, reducing the number of unnecessary knee arthroscopies in the older population, and it is still considered one of the most important randomized controlled trials (RCT) in the treatment of degenerative meniscal lesions.
The study included 146 patients aged 35 to 65, with clinical symptoms of degenerative meniscal tears that had not resolved after conservative treatment. They were randomly assigned to two groups: one underwent real arthroscopic partial meniscectomy, while the other underwent the same procedure without actual intervention on the meniscus (sham surgery), and patients did not know which group they belonged to (double-blind method). Participants were followed for 12 months. The study was led by Dr. Raine Sihvonen, Dr. Mika Paavola, and Dr. Antti Malmivaara, experts in orthopedics and public health.
Regardless of the research conducted, it is important to highlight that the decision to undergo surgery should be made individually for each patient based on a thorough medical evaluation. Ideally, it should involve collaboration between multiple experts from different fields. Surgeons, physiatrists, orthopedic specialists, and physiotherapists all have complementary roles in assessing the patient’s condition. The goal of the medical team is to find the optimal solution that will provide the best functional results. An individualized approach, considering the specific needs of the patient and a joint decision between the patient and the doctor, is crucial in choosing the appropriate therapy. najbolje funkcionalne rezultate. Individualizirani pristup, uzimanje u obzir specifičnih potreba pacijenta i zajednička odluka između pacijenta i liječnika ključni su u odabiru odgovarajuće terapije.
What are the key factors in the decision?
1. Is the problem a result of trauma or a chronic process?
If the problem is the result of a serious acute injury, such as a fracture or severe dislocation, surgery is often unavoidable because the body alone cannot repair such large and significant damage. In such traumas, there is a mechanical break in the continuity of the bone, tendon, or ligament, and delaying treatment further can cause improper healing, permanent deformity, or chronic joint instability. On the other hand, if symptoms develop gradually, the scenario may involve degenerative processes, muscle weakness, poor postural mechanics, or biomechanical imbalance. In such cases, conservative methods are often applied in practice, such as physical therapy, targeted exercises (kinesiotherapy), manual techniques, and lifestyle changes.
It is particularly important to emphasize that even in traumatic injuries, such as partial ligament tears, timely rehabilitation can significantly contribute to better functional recovery, thus reducing the need for surgical intervention. Advanced diagnostic methods (MRI, ultrasound) and continuous monitoring of the patient’s functional status enable more precise differentiation between injuries that require immediate surgery and those where a conservative approach is possible. Therefore, an individual assessment of each case is crucial: it depends on the type and extent of the damage, but also on how the body responds to initial treatment methods.
2. How important are age and lifestyle factors?
The patient’s age and lifestyle often play a decisive role in the ability to regenerate and in choosing the optimal treatment approach. Younger patients have a better tissue healing capacity, greater elasticity in muscles and ligaments, and are typically more willing to undergo intensive rehabilitation, which often allows for the possibility of conservative treatment if the injury is not critical. In the older population, especially if degenerative changes are present (e.g., osteoarthritis or osteoporosis), surgery is sometimes a necessary step to prevent further complications or properly correct existing deformities.
However, even in older patients, well-planned rehabilitation (before and after surgery) can reduce the risk of side effects, improve functional recovery, and shorten recovery time. Ultimately, it’s crucial to assess other factors such as physical activity level, postural habits, working conditions, and the presence of chronic diseases (e.g., diabetes or cardiovascular issues). A person who engages in regular physical activity, maintains a healthy body weight, and has good muscle support may delay or even avoid surgery, whereas a sedentary lifestyle and advanced degenerative changes often make surgery the most likely option. In any case, a multidisciplinary approach and individualized guidelines (from orthopedic surgeons, physiatrists, physiotherapists, cardiologists, nutritionists) provide the best evaluation of when surgery is truly necessary and when equally satisfactory results can be achieved with conservative methods.
3. Psychological aspects: Fear of surgery or preference for surgical intervention
Psychological factors are crucial in the decision-making process regarding surgery. Fear of surgery can lead to postponing a necessary operation, while some patients may prefer surgery as a quicker solution to their health problems. Sometimes, patients who are dealing with long-term pain and functional limitations may experience feelings of anxiety or frustration due to uncertainty, which can prompt them to seek faster solutions, including surgical intervention. Fear can also affect the emotional and mental well-being of the patient, causing insecurity and reduced trust in treatment, which further impacts the decision-making process. On the other hand, there is also the so-called “fear of missing out” (FOMO) phenomenon, when patients, due to the fear of missing out on surgical intervention, excessively seek surgical options, neglecting conservative therapies that could be equally effective.
Psychological preparation of the patient, along with counseling and support, can significantly help reduce stress and bring a clearer decision, as well as increase the chances of successful recovery. Open communication with doctors and understanding all options helps patients make the best decision for their health.
According to a study titled “Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia,” conducted by Dr. Rachael Powell, Dr. Azize Manyande, and colleagues, and published in 2016 in the prestigious Cochrane Database of Systematic Reviews, it was shown that appropriate psychological preparation for patients can reduce pain and negative emotions after surgery, and even shorten the average hospital stay by approximately half a day. This study was based on a systematic review of 105 previously conducted studies, which included a total of 10,302 participants.
Since the study focused on patients who were undergoing planned surgery under general anesthesia, the researchers analyzed different psychological preparation techniques, such as cognitive and behavioral interventions, relaxation techniques, hypnosis, and counseling about the procedure itself (e.g., what to expect during and after the surgery). The included studies followed patients for up to one month after the surgery, measuring factors like pain intensity, recovery speed, and anxiety levels.
The collected data indicated that well-designed and individualized psychological preparation can significantly alleviate surgical stress, with no indications that such interventions could harm patients. This research has thus laid a strong foundation for future guidelines on the importance of education, counseling, and emotional support before planned surgeries.
The results of the study have been widely accepted in the international medical community and are considered an important addition to creating a comprehensive approach to the patient before and after surgical interventions.
What if symptoms don’t improve or worsen after surgery?
Although surgery is often necessary in cases of acute trauma and severe damage, it is not uncommon for symptoms to continue or even worsen in chronic conditions (without clear injury, fall, or impact). The reason is usually that the surgical intervention itself does not address the root causes, such as poor postural mechanics, muscle weakness, excessive body weight, or other biomechanical and life factors that led to the damage.
Therefore, it is crucial to conduct:
• A detailed functional assessment with thorough findings to precisely determine the condition and the optimal treatment plan.
• Comprehensive rehabilitation and habit correction, before and after surgery, to promote better recovery and long-term results.
• A multidisciplinary approach, including the cooperation of physiatrist, physiotherapist, kinesiologist, surgeon, and nutritionist, to ensure comprehensive and expert treatment.
When deeper causes are detected and corrected in a timely manner, recovery will be faster, and the likelihood of long-term success greater. Surgery is a “mechanical solution” to a specific problem, but with the right rehabilitation plan and lifestyle changes, new complications will be prevented and better functional outcomes ensured.
Conclusion: To operate or not? It all depends on the context.
Diagnostic findings play a key role in the decision to undergo surgery, but it is important to view them in a broader context, along with a detailed analysis of symptoms, functional limitations, and treatment options.
Proper preparation, comprehensive rehabilitation, and an individualized approach are essential to achieving the best possible results, whether the patient opts for surgery or conservative treatment.
“We advocate a holistic approach to treating painful conditions and injuries. While surgeries are sometimes the only solution, a high-quality rehabilitation program often brings equally good results without the need for surgery,” said Nikola Tomas, the leading kinesiotherapist at the Kinesis Core team.
He added that it is crucial to consider not only diagnostic findings but also the patient’s functional condition and all available therapeutic options before making a decision.
“We treat every person with utmost seriousness because our goal is the long-term preservation of health and functionality. Experience shows us that the decision to operate must be carefully considered; many patients have achieved significant improvement through properly guided rehabilitation without the need for surgery. However, there are situations where surgery becomes necessary. It all depends on the individual case, and thorough evaluation, including advanced diagnostic methods, is key to making the best decision.”
“In addition to analyzing the current condition, we also look for the real cause of the problem. In this way, we don’t just address the symptom but also the root cause of the dysfunction, helping the patient in the long run to avoid recurrence of issues and ensure a better quality of life,” Tomas emphasized when responding to a question about his past experiences.
He concluded that surgical outcomes are better if the patient undergoes both postoperative rehabilitation and quality preoperative rehabilitation, which reduces muscle atrophy, improves stability, and enables a quicker return to normal activities.
When considering surgery, ask yourself the following questions:
- Have all conservative treatment methods been exhausted?
- Does surgery offer a clear advantage over other options?
- Have you consulted with multiple experts and explored all the options?
The most reliable decision is made with the advice of experts who analyze your case from all important aspects. Ultimately, when you are well-informed, you make the best decision for your health.