Why Your MRI Doesn't Mean You Need Surgery | Dr Howard Luks

Simon Hill (0:04)

You're an orthopedic surgeon. What types of surgery do you normally focus on?

Howard Luks (0:09)

So that's changed over my career. When I came out, I was sports medicine trained in terms of my fellowship, the training I did after residency.

But my first job was as chief of sports medicine at an academic center, and we happened to be a level one trauma center. So we all took level one trauma call. So it was trauma heavy. I didn't do small little routine or cuff tears. I did shoulder reconstructions of people who were hit by cars and flew 30 feet. And so over the years as I've stopped doing trauma, now I just focus on mostly knees and shoulders.

Simon Hill (0:47)

From what I kind of gather from your writing online, you spent quite a lot of time today telling people that they might not actually need surgery. Is that an accurate reflection of the conversations that you're also having in clinic?

And did you go into to kind of orthopedics thinking that this would be something that you dedicate your time to?

Howard Luks (1:09)

It took me a long time to choose orthopedic surgery, although it shouldn't have, because I've been an athlete my entire life and I never completed a varsity season in anything because of an injury. When you're trained as a resident, you really don't get a lot of office time.

You don't spend time with the surgeons that you work with in their office. So you're sitting there, you're operating on meniscus tear, you're operating on a rotator cuff tear or a labial tear.

You don't see the hundreds of meniscus tears before them that didn't need an operation. So a lot of young surgeons tend to come out thinking from an MRI report perspective, this is torn, it can't be normal, it must need an operation. Then slowly over the years, you begin to realize that it's not the case. A lot of people think that I just come down hard and say, no surgery is necessary, never operate on this, that, and this. That's just not true.

There are meniscus tears and titer cuff tears that are going to need an operation. We just need to do a better job at determining who.

Simon Hill (2:22)

How variable would you say that the decisions are between orthopedic surgeons? If you took the same set of scans to 10 of you, how many different answers would I get?

Howard Luks (2:37)

There's a lot of variation. From what I see, a lot of older folks, folks who actually spent their career learning and becoming wise, learning from their clinical experience as well as what they learned in residency and paying attention to their patients, tend to operate less on people. I'm part of a few text groups, WhatsApp groups, and one trends a little younger and they're incredibly aggressive. They just want to think about how do we operate on what type of surgery is needed for this one. I'm always the one in the group saying, what are you guys doing? There's another group where we're almost all retired and they're like, I saw a guy today that someone operated. I can't believe that someone operated on this person.

They're far more non-surgical.

But the literature is really pretty clear on these issues. It's not like I'm not trying to stand out. I'm not making things up. I'm following 30 years of office and clinical experience where my patients actually got better and combining that with what I've read in the literature.

Simon Hill (3:51)

When you speak to the literature there, are you talking about studies that compare surgery to sham surgery and then look at differences in outcomes? Is that how we know whether surgery in a certain context would likely lead to better outcomes than conservative management?

Howard Luks (4:09)

Yes, so there are sham surgery controlled studies and there's PT controlled studies as the alternative, both for meniscus tears, for tennis elbow surgery, for rotator cuff tears, for labial tears, bone spur removal, etc. So yes.

Simon Hill (4:25)

How does a sham surgery study work if someone hasn't heard of that before?

Howard Luks (4:31)

So you're seen in someone's office and they evaluate you and they ask you if you want to join a study because your clinical findings and your imaging findings both match what they're looking for in the study.

So you're indicated and you join the study, but you're going to be randomized to a group, meaning you could wake up and have the actual surgery, or you can wake up and just have two incisions and they did nothing. You won't know until the end of the study. You won't know the next morning. So you'll go to sleep in the operating room. They will make two incisions on the front of your knee or around the shoulder, and they'll move the arm or the knee to stimulate something being done. Then they'll sew the incision up and they'll wake you up.