Arthroscopic Sub acromial Decompression of Shoulder
Evidence published suggests that arthroscopic sub acromial decompression for sub acromial shoulder pain offers little benefit over a non-operative approach.
This statement does not apply to those with any of the following:
- Acute rotator cuff tears
- Sub acromial impingement pain for whom a combined rotator cuff repair and sub acromial decompression may be appropriate
- Calcific tendonitis
- Large Sub acromial spur
- Post fracture complication
- Post traumatic sub acromial bursitis
- Those with any clinical suspicion of infection, malignancy, unreduced dislocation or inflammatory arthritis, for whom appropriate local urgent pathways should be followed
- Patients should be fully informed of the benefits and risks of surgery, using shared decision making principles
029.1 Sub acromial decompression
W84.4 Endoscopic decompression of joint + Shoulder
W88.9 Unspecified diagnostic endoscopic examination of other Joint + shoulder
NHS Scarborough and Ryedale CCG DO NOT routinely commission arthroscopic sub acromial decompression shoulder surgery for the treatment of sub acromial impingement pain. Surgery can be considered for patients who have fulfilled ALL of the following criteria.
Patients should be managed conservatively with:
- Rest/activity modification
- Appropriate oral analgesia including NSAIDs
- Lifestyle factors considered, such as BMI/smoking/exercise status, and discussed as risk factors for MSK ill health/tendon pain
- At least six months active physiotherapy including, rotator cuff and scapular muscle strengthening, manual therapy and motor control retraining including class based exercise. If appropriate, six month programme can include patient self-directed continuation of exercises.
- No more than two sub acromial steroid injections, if appropriate and only considered in conjunction with physiotherapy as high recurrence rates in cases managed with injection alone
Patients who are not eligible for treatment under this policy may be considered on an individual basis where their GP or consultant believes exceptional circumstances exist that warrant deviation from the rule of this policy. Individual cases will be reviewed as per the CCG policy.
Summary of evidence/ rationale
Local data suggests that this procedure has become commonly practised within S&R CCG. RightCare data 2015/16 identified that the CCG was an outlier, against their identified peer CCGs, with an opportunity to reduce activity by £170,000 (48 procedures)1. The number of procedures carried out in 2017/18 indicates that activity has reduced by £10,000 (3 procedures).
Latest RightCare data identifies current opportunity as £110,000 (31 procedures).
The benefits of surgery are unclear, however, with some conflicting evidence. A recent randomised, placebo-controlled study compared outcomes following sub acromial decompression surgery, arthroscopy only, and no treatment for patients with sub acromial shoulder pain2. It concluded that “surgical groups had better outcomes for shoulder pain and function compared with no treatment, but this difference was not clinically important and decompression appeared to offer no advantage over arthroscopy only… The findings question the value of this operation for these indications.”
In response to these results, the British Elbow and Shoulder Society (BESS) and the British Orthopaedic Association (BOA) have issued a position statement announcing that they will be recruiting a multidisciplinary group to update the 2014 BOA commissioning guidelines for sub acromial pain and have advised “careful patient selection and informed shared decision making for arthroscopic sub acromial decompression surgery in this patient group until publication of the new guidelines”3.
Wider questions have since also been raised about distinguishing between the effects of elective surgery and those of time, rest, graduated rehabilitation and the placebo effect – “the reported outcomes of many elective orthopaedic surgical procedures may be attributed to these responses”4. The condition is a long-term one and fluctuations in symptoms are to be expected.
Further studies are being carried out; the evidence will be considered as of the review date for this statement and revised as necessary. Quality will be monitored in terms of patient outcomes when the statement is reviewed.
Public Health England, NHS RightCare Commissioning for value focus pack, Musculoskeletal conditions: trauma and injuries May 2016.
Beard et al Lancet 391: 329-338 January 2018 Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multi-centre, pragmatic parallel group, placebo-controlled, three-group, randomised surgical trial CSAW Trial.
Statement in response to recent studies regarding subacromial decompression BESS (2017) Bess/boa statement