These patient resources are developed in partnership with NHS England and the Patients Association. Using the shared decision making principles of Choosing Wisely UK, looking at the Benefits, Risks, Alternatives and what if you do Nothing (BRAN). These materials will be key tools to involving patients in decisions about their care.

Tests, treatments and procedures

Information for Patients

Surgery (an operation) to the knee for meniscal tears should only be carried out for a few clinical reasons. This is because we know that for most people with meniscal tears, their symptoms and the function of the knee will improve without an operation.

About the condition

The knee meniscus is a piece of tissue that acts as a cushion between the femur (thighbone) and tibia (shinbone). Tearing of the meniscus is one of the most common forms of knee injury. It can occur during sports or can be due to age-related wear and tear. Symptoms of a torn meniscus include pain, swelling, locking of the knee and an unstable knee. However, in many people a meniscal tear will produce no symptoms. Arthroscopic (or keyhole) surgery is performed using an instrument that is inserted into the knee joint through a small surgical cut.

What are the BENEFITS of the operation?

Most of the time an operation is not needed. In a very few cases surgery to either repair or cut out the bit of torn meniscus may help to improve a person’s knee symptoms. If there are other injuries, such as ligament damage, then these may be repaired at the same time.

What are the RISKS?

The operation may not work to improve your symptoms. Also, there are risks of any surgery, which include bleeding, infection, pain, and how the anaesthetic may affect you.

What are the ALTERNATIVES?

For some people physiotherapy, exercises to strengthen your muscles, losing weight and/or pain killers can help to improve your symptoms. You can discuss alternatives and what is best for you, with your doctor.

What if you do NOTHING?

Most knee symptoms improve with time and many people find that the injury does not affect their day to day activities. Doing nothing is unlikely to cause harm.

Information for Patients

A discectomy is surgery (an operation) to remove some disc material in the spine. It should only be performed for a few clinical reasons. It is sometimes performed to treat a herniated disc (a ‘slipped disc’). But medical evidence tells us that the operation can sometimes do more harm than good. Many people’s symptoms will improve without surgery.

About the condition

A herniated disc is when the disc material that sits between the bones of your back bulges out. This usually happens as part of the natural process of the discs ageing. It can cause pressure on the nerves coming from the spine. This can cause symptoms such as pain, tingling, pins and needles, numbness, and mild weakness. These symptoms often improve over time. More serious symptoms are severe weakness and changes in the way the bowel and bladder work, which would need urgent medical attention.

What are the BENEFITS of the surgery?

If scans show there is a slipped disc and alternative treatments have not improved the symptoms over time, a discectomy may help improve the symptoms.

What are the RISKS?

A discectomy may not improve your symptoms and may make your back pain worse. Also, any surgery involves risks, including infection, bleeding, and how anaesthetics may affect you.

What are the ALTERNATIVES?

Continuing with day-to-day activities as much as possible can benefit many people. For some, losing weight, physical exercise, physiotherapy and pain killers may also help. You can discuss alternatives, and what is best for you, with your doctor.

What if you do NOTHING?

Most back pain often settles by itself. However, for many people, periods of back pain may come and go throughout their life.

Information for Patients

Surgically inserting grommets (small temporary tubes) helps to let air into the middle part of the ear, allowing fluid (glue ear) to resolve but, should only be carried out when specific criteria are met. This is because the medical evidence tells us that the intervention in children under 12 can sometimes do more harm than good and the symptoms usually clear up of their own accord.

About the condition

Glue ear is a very common childhood problem that affects about four in five children by the age of ten. In most cases, it clears up without treatment in a few weeks. Common symptoms can include earache and a reduction in hearing. If the hearing loss is affecting both ears it can cause language, educational and behavioural problems. The procedure should only be considered if your child has at least three months of persistent hearing loss in both ears.

It’s important you and your doctor make a shared decision about what’s best for your child if they have glue ear. When making that decision you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

The insertion of grommets can be beneficial in certain circumstances. If the hearing loss is affecting both ears and it is persistent, treatment may help prevent challenges your child might face as a result of hearing loss.

What are the RISKS of the intervention?

The insertion of grommets can be uncomfortable for children. As with most procedures there is the risk of infection and bleeding. There is also a small risk the ear drum could be perforated during the procedure.

What are the ALTERNATIVES?

A simple solution which can sometimes alleviate the problem is to encourage your child to swallow while keeping their nostrils tightly closed. Your doctor may also prescribe a small balloon which is specifically designed to help glue ear by blowing it up the nose. Only a balloon designed for this purpose should be used. Temporary hearing aids could also be worn whilst waiting for symptoms to improve.

What if you do NOTHING?

Doing nothing is usually the best course of action. Most children get better within a few weeks without any treatment.

Information for Patients

Many babies develop changes in the shape of their skull during their first few months of life. This is a natural process that does not cause any harm. Medical evidence tells us that the use of a helmet does not change skull growth or shape and is no more effective than allowing your baby’s head to mould naturally. Sometimes the use of helmets may cause harm to babies.

About the condition

Flattening to the side or the back of a baby’s head is very common. It usually occurs due to the amount of time babies spend laid in a particular position during their first months of life. The flattened skull shape does not cause any harm to babies. Very rarely, an unusual shape to a baby’s head may be related to problems with the way the skull bones are joining up and then the baby will be referred to specialist doctors.

What are the BENEFITS of the therapy?

There are no benefits to the use of helmet therapy.

What are the RISKS?

Helmet therapy may lead to pain and pressure sores. It may also affect the bond between you and your baby because the helmet needs to be worn all day.

What are the ALTERNATIVES?

There are several ways you can help your baby to not lie on the flattened part of their head so that the shape is corrected naturally.

  1. Allow your baby to spend time lying on their tummy, but only while they are awake and supervised.

All babies must be laid on their backs to sleep, to reduce the risk of Sudden Infant Death Syndrome.

  1. Change the position of toys, mobiles and the cot in the room to encourage your baby to move their head away from the flattened side.
  2. Use a sling or a front carrier to carry your baby to reduce the amount of time they spend lying on a firm flat surface.
  3. When holding your baby against you, try and encourage them to put the non-flattened side of their head against you.

What if you do NOTHING?

The flattened area of a baby’s head usually corrects itself naturally as the baby grows and becomes more mobile, because they spend less time in one position.

You can speak with your Health Visitor for more advice.

Information for Patients

Imaging means carrying out x-rays or scans. Imaging of the lower back to investigate the cause of back pain rarely helps decide how your pain is treated. Imaging should therefore only be performed after careful assessment from a clinician when they suspect a serious underlying cause of the back pain.

About the condition

Lower back pain is a very common condition and it can affect a person’s quality of life. However, it is rarely caused by serious disease and will often improve over time or with some changes to lifestyle. A doctor, or other clinician, should carry out an assessment to check there are no signs of serious causes for your lower back pain that may need further investigation.

What are the BENEFITS of the imaging?

Most people do not need imaging for their lower back pain. However, a small number of people may have other symptoms alongside the lower back pain that may suggest a serious underlying cause for their pain. Imaging may then be needed.

What are the RISKS?

Imaging may reveal minor changes that are common in lots of people and are not causing the lower back pain. Being told there are minor changes may cause unnecessary concern for people and may mean further investigations are carried out that do not provide any benefits for them.

Also, some imaging exposes people to potentially harmful radiation.

What are the ALTERNATIVES?

Continuing with day-to-day activities as much as possible can benefit many people. For some people, losing weight, physical exercise, physiotherapy and/or pain killers may also help. You can discuss alternatives, and what is best for you, with your doctor.

What if you do NOTHING?

Most back pain often settles by itself. However, for many people, periods of back pain may come and go throughout their life.

Information for Patients

Surgery (an operation) to repair an inguinal hernia should only be carried out for a very few clinical reasons. Medical evidence tells us that even if your hernia causes you mild symptoms, it is safe to monitor this. Most people will never go on to need an operation.

About the condition

An inguinal hernia is a bulging of part of your bowel through into your groin. People may see or feel a lump under the skin, which may be a bit uncomfortable and may disappear on lying down. This bulge is caused by a weakening of the wall of your abdomen and tends to affect men more often than women. The majority cause either no, or only very mild symptoms, such as occasional groin discomfort.

Very few people will go on to develop serious problems with their inguinal hernia that will require an emergency operation. These problems include blockage of the bowel or very intense pain. It is important that patients seek medical help if they notice sudden changes.

What are the BENEFITS of the operation?

The operation may reduce the likelihood of the hernia causing serious symptoms, or the bowel becoming blocked.

What are the RISKS?

Surgery carries some risks and may not always prevent some serious symptoms from occurring. The risks of inguinal hernia surgery include infection, bleeding, pain and how the anaesthetic may affect you. There is also a risk of damage to the bowel and that the hernia may come back again in the future. Medical evidence shows that there is no significant difference in the number of people suffering pain after having surgery compared to those who didn’t have surgery.

What are the ALTERNATIVES?

You can monitor any changes in the symptoms of your hernia. These changes may include increased pain, not being able to push the bulge back in, or vomiting and constipation. If these occur then you should urgently speak to a doctor. Your doctor will be able to offer more advice on managing the symptoms of the hernia.

What if you do NOTHING?

You will avoid an operation and the risks of an operation. If you do nothing there is a very small risk that you will go on to develop serious problems associated with the hernia that will require an emergency operation at a later date. But most inguinal hernias do not need an operation.

Information for Patients

A recent review of which treatments work for back pain has shown that injections are not very effective. One example is the injection of pain-killer into the facet joints. Although many of these have been used in the past, and sometimes with good, short-term relief, they do not work often enough or long enough to make them a good treatment. The risks of the procedure, such as infection, although rare, make them a poor choice.

The NHS finds that the evidence points to other treatment methods as a better option for many people.

What can you do about the condition?

Episodes of back pain are very common and normally improve within a few weeks or months. Although the pain can be very limiting and distressing, in most cases the pain isn’t caused by anything serious and will usually get better over time. If the problem persists, your GP may refer you to a specific care pathway which will include physiotherapy, group exercise classes and manual therapy along with self-management strategies.

It’s important you and your doctor make a shared decision about what’s best for you if the pain is becoming a problem. When deciding what’s best you should both consider the benefits, risks, alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

The routine use of spinal injections for low back pain is not recommended by the National Institute for Health and Care Excellence (NICE) which assesses the effectiveness of all tests, treatment and procedures.

What are the RISKS of the intervention?

The procedure itself can cause discomfort. Complications include bruising, infection of the spine and nerve damage.

What are the ALTERNATIVES?

There are many alternatives and you should discuss what might be best for you with your doctor.

Options can include exercise and weight loss, physiotherapy, pain-relief medication, and psychological support such as cognitive behavioural therapy (CBT) which can help you live a better life with the pain. If the clinician treating you feels you need further assessment they should refer you to a specialist who will consider other treatments. This includes other forms of injections which can help some people.

What if you do NOTHING?

Doing nothing is not likely to be harmful and back pain usually improves after a few weeks. If the problem persists and is difficult to cope with, you should talk to your doctor about which treatment is best for you.

Information for Patients

Prostate specific antigen (PSA) testing is only recommended for people with a prostate who have symptoms of prostate cancer. There are possible harms from the investigations that may follow a PSA test. Medical evidence tells us these possible harms are greater than the possible benefits of doing the test for people who do not have symptoms of prostate cancer.

About the condition

A PSA test is a blood test that looks for a raised PSA level. PSA is a protein produced by the prostate gland. It may increase in people with prostate cancer. But it may also increase in conditions which are not serious, such as urinary tract infections.

What are the BENEFITS of the test?

A raised PSA level may indicate prostate cancer. This raised PSA may therefore lead to further investigations such as an MRI scan or biopsy that can tell you whether you have cancer or not. If you do have prostate cancer you can then be referred for treatment.

What are the RISKS?

There are many reasons why PSA levels may be raised which are not related to cancer. Being told you have a raised PSA after a PSA test may cause unnecessary concern. A raised PSA level could lead to unnecessary further tests, including a biopsy. Biopsies carry their own risks.

What are the ALTERNATIVES?

There is currently no reliable alternative blood test that can indicate prostate cancer. You should talk to your doctor if you have symptoms that may indicate prostate cancer. These symptoms may include blood in your urine (pee), urgency to pass urine, reduced flow of urine, unable to pass urine, needing to pass urine at night frequently, erectile dysfunction (unable to keep an erection), weight loss, lower back pain that won’t go away and bone pain. Your doctor will then help you decide if a PSA test is needed.

What if you do NOTHING?

If you have no symptoms of prostate cancer, you are unlikely to come to harm by not having the PSA test.

Information for Patients

Radiofrequency facet joint denervation is a procedure where nerves in the back are made inactive by radiofrequency waves (a type of electromagnetic radiation) to relieve back pain. This procedure is also sometimes called ‘dorsal rhizotomy’ or ‘radiofrequency ablation’. The facet joints are small pairs of joints that link the bones of your spine together. If your back pain is thought to be caused by wear and tear at these joints, making the nerves that supply these joints inactive may be helpful in reducing your pain. However, this will only help a small number of people who have been assessed by back pain specialists.

About the condition and procedure

Lower back pain is a very common complaint and can affect a person’s quality of life. However, it is rarely caused by serious disease and will often improve over time or with some changes to lifestyle. If other steps to control your pain haven’t worked then your specialist might consider radiofrequency denervation. This involves inserting a needle into your back under local anaesthetic and using heat from the needle to destroy the nerve endings in the joint.

What are the BENEFITS of the procedure?

Most people with back pain do not need this procedure. However, a small number of people who have not found benefit from other treatments may experience reduced pain after this procedure.

What are the RISKS?

There is the risk that the procedure will not work in relieving pain or that the pain may come back after a while. There are also risks of bleeding, infection, and damage to nerve structures around the spine.

What are the ALTERNATIVES?

Continuing with day-to-day activities as much as possible can benefit many people. For some people, losing weight, physical exercise, physiotherapy and/or pain killers may also help. You can discuss alternatives, and what is best for you, with your doctor.

What if you do NOTHING?

Most back pain often settles by itself. However, for many people, periods of back pain may come and go throughout their life.

Information for Patients

Adenoids are lumps of tissue at the back of a child’s throat. They may occasionally need to be removed at the same time as an operation to help relieve a condition called glue ear, where the middle ear becomes filled with sticky fluid. In this operation, tubes to drain fluid from the middle ear (grommets) are inserted into the ear. However, for most children, removing their adenoids during the glue ear operation may cause more harm than good.

About the condition

Adenoids are usually only present in children. They reach their largest size between the ages of 3-5 years old and then they slowly shrink away. Sometimes adenoids become large and inflamed and this may contribute to glue ear. Glue ear can affect a child’s hearing. Adenoids may also cause other symptoms such as frequent congestion in the nose. If a child has certain other persistent symptoms as well as glue ear, then it may benefit them to remove their adenoids during the same operation as inserting the grommets.

What are the BENEFITS of the procedure?

Most children do not need their adenoids removed when grommets are inserted. However, in a few cases, removing the adenoids may help to improve certain symptoms.

What are the RISKS?

Removing adenoids is generally considered to be a low risk procedure. However, risks include damage to teeth, lips or gums, bleeding or very rarely changes in speech. There are also risks because of the slightly increased time it takes to remove the adenoids during the operation to insert the grommets.

What are the ALTERNATIVES?

Grommets can be inserted without removing a child’s adenoids. There is no long-term difference in the hearing ability of children who do not have their adenoids removed compared to those who have them removed while grommets are inserted. You can discuss any questions you may have with your child’s doctor to help you make a decision.

What if you do NOTHING?

Adenoids tend to shrink after the ages of 3-5 years old. Any contribution of the adenoids to a child’s glue ear or hearing should resolve naturally as they grow up.

Information for Patients

Spinal fusion surgery (an operation) is where a piece of bone or surgical material is used to connect two individual vertebrae of the back together. Mechanical lower back pain means pain caused by stress and strain on the spine. Spinal fusion surgery is not helpful for mechanical lower back pain and may make the pain worse.

About the condition

Lower back pain is a very common condition and can affect a person’s quality of life. However, it is rarely caused by serious disease and will often improve over time or with some changes to lifestyle. Surgery very rarely helps to improve back pain and should only be performed in certain rare cases. Medical evidence tells us that spinal fusion surgery is not recommended for mechanical lower back pain.

What are the BENEFITS of the surgery?

Experts agree that there is no clear benefit to performing spinal fusion surgery for most mechanical lower back pain.

What are the RISKS?

Spinal fusion surgery may not improve your symptoms and may make your back pain worse. Also,any surgery involves risks, including infection, bleeding, and how anaesthetics may affect you.

What are the ALTERNATIVES?

Continuing with day-to-day activities as much as possible can benefit many people. For some people, losing weight, physical exercise, physiotherapy and/or pain killers may also help. You can discuss alternatives, and what is best for you, with your doctor.

What if you do NOTHING?

Most back pain often settles by itself. However, for many people, periods of back pain may come and go throughout their life.

Information for Patients

Subacromial decompression is a surgical procedure that can in some circumstances relieve shoulder pain, but should only be carried out when specific criteria are met. This is because the medical evidence tells us there are alternative treatments which are usually far more effective and should be tried first.

About the condition

In cases of pure shoulder impingement, non-operative treatments like injections and physiotherapy are usually effective and safe. However, if you have persistent or worsening symptoms and alternatives to surgery have not worked this form of keyhole surgery can be carried out.

It’s important you and your doctor make a shared decision about what’s best for you especially if your pain continues to be a problem and affects your life. As with all treatments, when deciding what’s best, you should consider the benefits, the risks and all the alternatives.

What are the BENEFITS of the intervention?

Subacromial decompression helps relieve pain by removing inflamed tissue and widening the space above the group of muscles at the top of your arm, known as rotator cuff tendons. This decreases the chances of rubbing and catching.

What are the RISKS of the intervention?

The risks associated with sub acromial decompression surgery are very low, but do include infection, a stiff shoulder, damage to blood vessels or nerves and ongoing pain. There are also the small risks associated with having a general anaesthetic as with any operation.

What are the ALTERNATIVES?

In the first instance, if possible, you should try to avoid things that bring on the pain. Carefully applying ice to the painful area and taking pain killers may be of help. Physiotherapy, exercises and steroid injections may also be of benefit to most patients.

What if you do NOTHING?

If you are able to cope with the pain, it is not dangerous to do nothing. For some people symptoms can improve over time. However, if the pain does not improve or worsens then you should seek further advice from your doctor.

Information for Patients

Benign prostatic hyperplasia (BPH) is a condition where, as people with a prostate grow older, the prostate gland becomes larger. It can cause urinary symptoms (affecting your pee). Some changes in lifestyle and some medicines may help relieve the symptoms. If these are not effective then in a small number of cases, surgery (an operation) may be appropriate.

About the condition

BPH is a very common condition. It is not cancer. The increasing size of the prostate gland means that it is more difficult for urine to pass out from the bladder. This can lead to symptoms such as urgently needing to pass urine, difficulty starting urine flow, slow flow, and not completely emptying the bladder. In rare cases, there can be serious symptoms such as your kidneys not working well.

What are the BENEFITS of the surgery?

If you have found that lifestyle changes and medicines have not worked, then in some cases an operation on the prostate gland may help to improve symptoms. If the kidneys are not working well then an operation may be helpful.

What are the RISKS?

There are many sorts of operations that can be carried out. There are risks for all operations, including bleeding, infection, pain, and how an anaesthetic may affect you. There may also be a risk of developing sexual problems such as erectile dysfunction (unable to keep an erection).

What are the ALTERNATIVES?

Lifestyle changes such as avoiding caffeinated drinks, avoiding lots of fluid before bedtime and bladder training exercises are often helpful. There are also medicines to relax and shrink the prostate gland.

These changes and medicines should be tried before thinking about an operation. You can speak to a doctor or other clinician to help you decide what will work best for you.

What if you do NOTHING?

Without any lifestyle changes or treatments, symptoms of BPH may worsen over time.

Information for Patients

Surgery to reduce the size of your breasts is a procedure which should only be carried out when specific criteria are met. This is because the medical evidence tells us that the operation can sometimes do more harm than good, especially if you are overweight or if you smoke and there are other treatments which can be more effective.

About the condition

Large breasts can cause several problems for women. They can affect daily living and prevent an active lifestyle. Many patients report pain in their back, neck and shoulders. Some patients may get a rash or infection under their breast tissue. Having large breasts may mean it’s difficult to find clothes that fit and are comfortable.

It’s important you and your doctor make a shared decision about what’s best for you if your breasts are so large they are causing you problems. When making that decision you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Breast reduction surgery may improve your mobility and make everyday activities easier, but it can only be carried out in specific circumstances and when other options have been tried and shown not to work.

What are the RISKS of the intervention?

Breast reduction surgery is a major operation. There is a risk of complications which can include, bleeding, infection, significant scarring, loss of the nipple, alteration to nipple sensation and problems with breast feeding. A cup size cannot be guaranteed.  These risks are greater in smokers and patients who are overweight.

What are the ALTERNATIVES?

There are lots of alternatives you should try first. These include losing weight, having a professionally fitted bra, pain relief, physiotherapy or seeking psychological support.

What if you do NOTHING?

Doing nothing is not likely to be harmful and you should try the alternatives to surgery first.

Information for Patients

Surgery (an operation) to relieve the symptoms of chronic sinusitis (also known as chronic rhinosinusitis) is only appropriate for very few people. Medical evidence tells us that, for most people, alternative treatments are more effective. In those few people who really need surgery, an operation using a small telescope in the nasal (nose) cavity to open the sinuses may improve their symptoms.

About the condition

The nasal sinuses are air-filled spaces in the face and head. They produce mucous that drains into the nose. Chronic sinusitis is swelling of the nasal sinuses that lasts for longer than 12 weeks. It is a common condition that affects about one in ten adults. Symptoms include a blocked nose, discharge from the nose, changes to the sense of smell and pressure or pain in your face.

Blockage in the sinuses can be caused by infections, inflammation or allergies.

What are the BENEFITS of the operation?

For a small number of people, surgery to the sinuses will improve their symptoms.

What are the RISKS?

There is a risk that the operation will not improve your symptoms and you will still need to take treatments (medical therapy). The risks of this type of endoscopic (telescope) operation include bleeding, infection, scar tissue formation, injury around the eye and, very rarely, a risk of meningitis.

What are the ALTERNATIVES?

Medical treatments are effective for most people. These include nasal washes with salt water, nasal steroid sprays and possibly a course of oral steroids. You can discuss these alternatives with your doctor or pharmacist so you can decide what is best for you.

What if you do NOTHING?

You will avoid an operation and the risks the operation carries. It is likely that your symptoms will continue if you do nothing.

Information for Patients

There are two surgical procedures which have in the past been used to investigate and treat heavy periods. The first, dilation and curettage, was used to establish the cause of heavy periods, but today, the medical evidence tells us this procedure in inappropriate and should not be routinely carried out. The second procedure, a hysterectomy which removes a woman’s womb and therefore ends menstruation completely, can be carried out, but only when specific criteria are met and alternative treatments have been tried first.

About the condition

Heavy periods are common and can have a significant effect on a woman’s everyday life. In about half of women, no underlying reason is found. But, there are several conditions and some treatments that can cause heavy menstrual bleeding, so you should discuss your symptoms with a clinician if you are concerned.

It’s important you and your doctor make a shared decision about what’s best for you if your heavy periods are becoming a problem. When deciding what’s best you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

There are no diagnostic or treatment benefits with dilation and curettage. A hysterectomy for patients with heavy periods should only be considered in certain circumstances.

What are the RISKS of the intervention?

Complications following dilation and curettage are rare, but can include uterine perforation, infection, damaging your cervix. A hysterectomy is a significant operation and therefore inevitably carries a small risk of blood loss or complications from the anaesthetic. Other risks include infection, or a prolapse in later years. It may also cause the early onset of your menopause and should only be considered if you definitely don’t want to have children as your periods will be permanently ended.

What are the ALTERNATIVES?

A doctor will usually use an ultrasound scan or an instrument which takes a small sample of the lining of your womb to see what’s causing your heavy periods. There are a number of alternative treatment options including hormone treatment and a coil that provides contraception and are good at reducing blood loss.

What if you do NOTHING?

Doing nothing is not likely to be harmful. However, if heavy periods are having a significant impact on your life, you should seek medical advice to identify the underlying cause and discuss treatment options.

 

Information for Patients

Surgery to help you stop snoring is a procedure that should only be carried out when specific criteria are met. This is because the medical evidence tells us that the intervention can sometimes do more harm than good and there are alternative treatments which are usually far more effective.

About the condition

Snoring is a noise that occurs during sleep that can be caused by vibration of tissues of the throat and palate. It is very common and as many as one in four adults snore.

As long as it is not complicated by periods of apnoea (temporarily stopping breathing) it is not usually harmful to health, but can be disruptive, especially to a person’s partner.

It’s important you and your doctor make a shared decision about what’s best for you if your snoring is becoming a problem. When deciding what’s best you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Surgery for snoring in patients without Obstructive Sleep Apnoea (OSA) has been shown to have limited to no long term clinical effectiveness.

What are the RISKS of the intervention?

Surgery carries a small risk of severe complications including bleeding, airway compromise and in rare cases death.  There is also evidence that the majority of patients suffer persistent side effects including: swallowing problems, voice change, globus (a persistent sensation of having a lump in the back of your mouth), taste disturbance and nasal regurgitation.

What are the ALTERNATIVES?

There are a number of alternatives to surgery that can improve the symptom of snoring. These include, losing weight, stopping smoking, cutting down on alcohol, medical treatments for a blocked nose or mouth splints which can help to move your jaw forward when you are sleeping.

What if you do NOTHING?

Doing nothing is not likely to be harmful. Snoring is a common condition and can be frustrating for both the patient and partner. It is recommended a clinician rules out reversible causes and Obstructive Sleep Apnoea. The alternatives suggested above may help and far outweigh the benefits of any surgical intervention.

Information for Patients

Surgery to washout and remove debris to relieve knee pain (a knee arthroscopy) is a procedure that should only be carried out when specific criteria are met. This is because the medical evidence tells us that the intervention can sometimes do more harm than good and there are alternative treatments which are usually far more effective. However, a knee arthroscopy can considered if you have arthritis in your knee, or other specific symptoms such as locking of the knee. It can also be carried out if doctors need to assess your suitability for other procedures.

About the condition

Osteoarthritis is a common condition affecting nearly 9 million people in the UK. It initially affects the smooth cartilage lining of the joint and makes movement more difficult, leading to pain and stiffness. Once the cartilage lining starts to roughen and thin out, the tendons and ligaments have to work harder. This can cause swelling and the formation of bony spurs, called osteophytes. Severe loss of cartilage can lead to bone rubbing on bone, altering the shape of the joint and forcing the bones out of their normal position.

It’s important you and the doctor or the specialist clinician treating you make a shared decision about what’s best for you if your knee pain is becoming a problem. When deciding what’s best you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Arthroscopy for osteoarthritis in the knee will only benefit you if there is a history of specific symptoms such as the knee locking.

What are the RISKS of the intervention?

The risks of arthroscopy include infection, bleeding and pain as well the risks of the anaesthetic for the procedure. There is also an increased risk of blood clots in the leg following the procedure.

What are the ALTERNATIVES?

There are a number of alternatives that can improve symptoms and function. These include, exercise, physiotherapy, losing weight and sometimes steroid injections. Carefully managed pain relief for relatively short periods can also be prescribed.

What if you do NOTHING?

Doing nothing is not likely to be harmful. Arthritis can be painful and affect your mobility. The less invasive options should always be considered first with knee replacement surgery only being considered as a last resort when other treatment options have been shown not to work.

Information for Patients

Most cases of trigger finger will not require surgery and this should only be considered if specific criteria are met. This is because medical evidence tells us that in most cases, alternative treatments should be tried first and can be just as effective.

About the condition

Trigger finger occurs when the tendons which bend the thumb or finger into the palm intermittently jam in a tight tunnel known as the flexor sheath. This causes either clicking or catching of the finger during movement, stiffness of the finger or locking of the finger in the palm of the hand.

It is important that you and your doctor make a shared decision about what is best for you if your trigger finger becomes a problem. When deciding what is best, you should consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Although surgery is usually very effective, it should only be considered after other treatments have been tried first and haven’t resolved the problem or when your finger is locked in the palm of your hand or if you are diabetic.

What are the RISKS of the intervention?

The risks of surgery are small, but include infection, numbness, stiffness and a tender scar in the palm of the hand. These usually cause temporary problems, but very occasionally can be permanent.

What are the ALTERNATIVES?

Cortisone injections are the recommended first line of treatment for most trigger fingers. However, cortisone injections are less likely to be effective if you are diabetic.

If your trigger finger is causing no problems then no treatment is required and the problem may go away on its own.  Avoiding activities which seem to cause the problem may help if that’s possible. You might also try wearing a splint on the affected finger, but these can be cumbersome. The recommended treatment is one or two steroid injections which usually resolve the issue. A steroid injection carries a very small risk of an infection which could in rare cases be serious.

What if you do NOTHING?

Trigger finger is often no more than a nuisance and doing nothing will not be harmful to your health.

Information for Patients

Surgery to remove a benign or harmless skin lesion is a procedure that should only be carried out when specific criteria are met. This is because the medical evidence tells us they will often disappear of their own accord over time and there are risks associated with surgical intervention.

About the condition

A lesion is a general term that we use for things like moles, cysts, skin tags, warts, ulcers and other lumps and bumps we sometimes get on our skin. These lesions might have an impact on our appearance, but are otherwise are usually harmless. Some benign lesions, such as warts, may clear up on their own. However, if they don’t then your pharmacist can provide useful information on how to manage them.

Treatment to remove skin lesions should only be carried out in certain circumstances and if certain criteria are met. If your GP is has concerns or if the lesion persistently catches on your clothing or bleeds recurrently then you can be treated by the GP or referred to an appropriate specialist for an opinion.

As with all treatments, when deciding what’s best, you should consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Treatment to remove a skin lesion should only be carried out in certain circumstances, for example, if the lesion is painful, bleeds regularly, if it becomes repeatedly infected or if it impacts on your everyday activities, such as causing pain at your joints or affects your vision.

What are the RISKS of the intervention?

Surgical removal carries a small risk of complications such as bleeding, scarring and infection.

What are the ALTERNATIVES?

Most benign lesions can be left alone. Your GP or pharmacist can advise you if the lesion is troublesome.

What if you do NOTHING?

Most benign skin lesions are little more than a nuisance and are unlikely to cause any harm if you do nothing.

Information for Patients

Surgery to remove chalazia or meibomian cysts should only be carried out when specific criteria are met. This is because the medical evidence tells us that the intervention can sometimes do more harm than good, most get better by themselves and there are alternative treatments which can be just as effective.

About the condition

A chalazion is a harmless bump or nodule inside the upper or lower eyelid which is caused by a blocked or swollen oil gland. They normally disappear after a few weeks or months, so surgical removal should only be considered if the condition has persisted for six months, if your vision is impaired or if your doctor has concerns about infection or malignancy.

It’s important you and your doctor make a shared decision about what’s best for you if you have a chalazion. When making that decision you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Surgery to drain the cyst may help, but it will only be considered if you have had the chalazion for at least six months or it is having a serious impact on your vision and after less invasive measures have been tried first.

What are the RISKS of the intervention?

Incision of chalazia can be uncomfortable. The procedure itself is likely to cause swelling and sometimes bruising of your eyelids and the cyst itself could still take some weeks to disappear. Other risks include infection, bleeding, scarring and in rare cases, loss of vision. Chalazia can also return after they have been removed.

What are the ALTERNATIVES?

Most chalazia will disappear without the need for medical intervention. Applying a warm compress for a few minutes a few times a day can help, as can gentle massage. If you do this a few times a day, the gland will often become unblocked and further treatment won’t be necessary.

What if you do NOTHING?

Doing nothing is not likely to be harmful. Chalazia can vary in size over a few weeks or months but usually discharge spontaneously without any medical intervention.

Information for Patients

Surgery to remove a ganglion should only be carried out when specific criteria are met. This is because the medical evidence tells us that the intervention can sometimes do more harm than good. There are alternative treatments and often no treatment is needed.

About the condition

A ganglion is a swelling filled with clear jelly that usually develops near a joint or tendon. Ganglia can occur alongside any joint in the body, but are most common on the wrist, hands and fingers. They can range from the size of a small seed to the size of a golf ball and they feel like a smooth lump under the skin.

Ganglia at the wrist rarely cause significant symptoms, but can be uncomfortable and sometimes painful.  Ganglia in the palm of your hand may cause discomfort when carrying objects.

The clinician treating you may insert a hypodermic needle into the ganglion to establish that the lump is nothing more than a cyst full of jelly. Sometimes this procedure itself relieves the pain and gets rid of the ganglion, but many come back. If the ganglion does come back it does not always need further treatment. If it causes sufficiently troublesome symptoms which interfere with hand function then surgical removal may be considered.

It’s important you and your doctor make a shared decision about what’s best for you if your ganglion is becoming a problem. When deciding what’s best you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Surgery can relieve pain and discomfort and improve hand function if needle aspiration has not been successful.

What are the RISKS of the intervention?

The risks of surgery include pain, bleeding, infection, scarring and recurrence of the ganglion. It can take up to six weeks to recover and for your hand function to return fully.

What are the ALTERNATIVES?

If the ganglion is not causing troublesome symptoms there is no need to do anything, and it may well resolve spontaneously in time.

What if you do NOTHING?

Doing nothing will not be harmful to your health and most ganglia go away in time without treatment. Most people are not bothered by ganglia and treatment should only be considered if there are significant symptoms or restrictions.

Information for Patients

Surgery to remove varicose veins, should only be carried out when specific criteria are met. This is because the medical evidence tells us that there are alternative treatments which can be just as effective and as with all surgical procedures there are risks attached.

About the condition

Varicose veins are swollen and enlarged veins that can occur in your legs. They develop when the small valves inside the veins stop working properly. In a healthy vein, blood is prevented from flowing down the leg by a series of tiny valves that open and close to let blood through. If the valves weaken or are damaged, the blood can flow backwards and collect in the vein, eventually causing it to become swollen and enlarged (varicose).

It is important that if you have symptomatic veins or complications that your doctor refers you to a vascular specialist. It is important that your vascular specialist then explains the treatment options to you, including the benefits and risks of intervention and what will happen if you do nothing.

What are the BENEFITS of the intervention?

The first treatment option is endothermal ablation, which uses radio waves or laser to burn and close the affected veins from inside the vein. The second, known as ultrasound guided foam sclerotherapy, involves injecting a foam medication into the affected vein to scar and block the vein. Open surgery (also known as ‘stripping’) remains an option for some patients, but should only be carried out if other alternatives are not suitable.

What are the RISKS of the intervention?

The risks of intervention are very low but include deep vein thrombosis (DVT), nerve damage, infection and pain. The procedure is usually carried out under local anaesthetic. Most people can return to normal activities including work within 24 hours.

What are the ALTERNATIVES?

Compression stockings can be helpful but are only recommended if you are not suitable for intervention. Regular exercise, avoiding standing for long periods of time or elevating the affected area when resting may relieve some symptoms.

What if you do NOTHING?

Varicose veins don’t always need treatment, however interventions should be performed if the veins are causing you pain, discomfort, swelling or are leading to other complications such as bleeding, skin discolouration, thrombosis or ulceration.

Information for Patients

In many cases Carpal Tunnel Syndrome (CTS) will not require surgery and this should only be carried out when specific criteria are met. This is because medical evidence tells us that in most cases, alternative treatments should be tried first and can be just as effective.

About the condition

CTS occurs when there is pressure on the median nerve at the wrist. It causes tingling, numbness and pain in the hand and fingers. If it only causes minor symptoms then it requires no treatment.

It’s important you and your doctor make a shared decision about what’s best for you if CTS is causing you problems. When deciding what’s best you should both consider the benefits, risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Surgery prevents patients with constant numbness of their fingers from becoming worse and it usually improves the numbness and can restore normal sensation. It also has a high success rate in patients with intermittent symptoms who have had a good, but only short-term, response to other treatments which should be tried first.

What are the RISKS of the intervention?

Carpal tunnel release surgery is usually very successful, but has risks and complications which usually cause temporary problems such as pain, infection, scarring, tenderness and bleeding. Following surgery, the hand may be weak and sore for 3-6 weeks, but recovery of normal hand function is expected.

What are the ALTERNATIVES?

CTS can develop due to an underlying medical condition such as diabetes, arthritis, thyroid dysfunction, or being overweight, but often there’s no underlying cause.  Treating these conditions can sometimes improve symptoms. Adapting your workplace and getting support with daily activities may reduce your pain and tingling.  If you have intermittent symptoms which interfere with everyday activities you should first be treated with corticosteroid injections or asked to try wearing a splint on your wrist at night. If these options fail to control the symptoms or they come back over time, then surgery can be carried out. If there is constant numbness of the fingers then surgery is the first advised treatment, rather than splints or steroid injections.

What if you do NOTHING?

The symptoms may gradually become worse, but may also improve without any treatment, which is often seen in pregnancy. Mild cases with intermittent symptoms causing little or no interference with sleep or activities should not require any treatment. If more severe cases are left untreated there is a risk of permanent nerve damage, with numbness in the fingers and weakness of the thumb, which may become so severe that it does not respond to treatment.

Information for Patients

In some cases surgery to treat Dupuytren’s Contracture is not necessary. This is because medical evidence tells us that in most cases, alternative treatments should be tried first and can be more effective.

About the condition

Dupuytren’s contracture is a condition caused by fibrous cords which form in the palm of the hand and fingers. These draw the finger or fingers and sometimes the thumb into the palm and prevent them from straightening fully.  Affected fingers will not straighten again without treatment and may gradually bend further and further into the palm. It is not usually a painful condition, but it does reduce hand function.

Treatment is recommended if the symptoms become troublesome. This is usually when the deformity prevents you from being able to put your hand flat on a table. However, if contractures are left to get too severe then treatment is less likely to be successful. If your fingers do start to contract, you should ask your GP to refer you to a hand surgeon who will be able to explain the benefits and risks of the possible treatments and what is likely to happen if you do nothing. This will allow the two of you to come to a shared decision as to which treatment, if any, is best for you.

What are the BENEFITS of the intervention?

The aim of treatment is to straighten the affected fingers and restore hand function and to prevent the contracted fingers from becoming so bent that they cannot be straightened with any treatment.

What are the RISKS of the intervention?

Open surgery to release the fibrous cords is done under anaesthetic. Incisions are made in the hand to remove the diseased tissue and straighten the fingers. This carries some risks including infection, numbness and finger stiffness. In about 1:3 cases, the condition recurs within five years.

What are the ALTERNATIVES?

There are two alternatives, the first involves cutting through the fibrous band with a needle to allow the finger to be straightened under a local anaesthetic. The second is to inject a drug into your contracted finger to dissolve part of the fibrous band. The finger is then pulled straight by your surgeon a few days later under local anaesthetic. Neither treatment is as effective in straightening the finger as open surgery and both have higher risks of recurrence. The risk of a major problem is much lower with needle treatment than surgery.

What if you do NOTHING?

Doing nothing is not likely to be harmful to your health, but the more the affected fingers bend into the palm, the less likely that any treatment can straighten them. Advanced hand contractures can significantly and permanently reduce hand function.

Information for Patients

Surgery to treat haemorrhoids, commonly known as piles, should only be carried out when specific criteria are met. There are many alternative and non-invasive treatments for treating haemorrhoids that should be considered before surgery.

About the condition

Haemorrhoids are swellings containing enlarged blood vessels found inside or around your bottom. In some cases, haemorrhoids are little more than a nuisance and you may not be too bothered by them. You might experience soreness, redness and swelling around the anus or bleeding when straining on the toilet or have blood in your poo or have a lump hanging down outside your anus which may need to be pushed back in after going to the toilet.

You should talk to your doctor if you have these symptoms to ensure the underlying cause is haemorrhoids and not something more serious. If confirmed, you should make a shared decision about what’s best for you. If your haemorrhoids are becoming a problem, you should both consider the benefits, the risks and the alternatives to surgery and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Surgery is effective for haemorrhoids that hang down and have to be pushed back or which remain permanently outside the anal canal. It can also be considered if you have tried alternatives first and they have not worked.

What are the RISKS of the intervention?

When considering surgery it is important to consider the significance of your symptoms, the benefits of surgery and the complications. The risks of haemorrhoid surgery may include infection, pain, bleeding, urinary retention, fissuring (a tear or cut in the anus), stenosis (narrowing of your anus) and in rare instances faecal incontinence (lack of control over bowel motions).

What are the ALTERNATIVES?

Often less severe haemorrhoids can be treated by simple measures including eating more fibre, drinking more water and avoiding straining on the toilet. Laxatives can be helpful to soften your stool. There are also other treatments that will help alleviate the symptoms of haemorrhoids, such as creams, ointments and suppositories. Some types of haemorrhoids can be treated without the need for surgery by specialist doctor in an outpatient clinics.

What if you do NOTHING?

Once a diagnosis of haemorrhoids has been made, doing nothing, isn’t likely to be harmful. Haemorrhoids often cause little more than discomfort and treatment should be tailored to your symptoms and based on a clinical assessment of the severity of  condition.

Information for Patients

Surgery to remove your tonsils (tonsillectomy) for recurrent tonsillitis is a procedure which should only be carried out when specific criteria are met. Although the operation was common many years ago, this is no longer the case because the medical evidence tells us the intervention can sometimes do more harm than good and there are alternative treatments for treating sore throats.

About the condition

Recurring sore throats are a very common condition. It must be recognised that not all sore throats are due to tonsillitis and they can be caused by other infections of the throat. In these cases, removing the tonsils will not improve symptoms.

It’s important you and your doctor make a shared decision about what’s best for you or your child if the sore throat is becoming a problem. When deciding what’s best you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Surgery to remove your tonsils will only benefit those with recurrent episodes of acute tonsillitis.

What are the RISKS of the intervention?

Tonsillectomies require an operation and the risks include: infection, bleeding, pain, difficulty swallowing and the risks of anaesthetic. Pain after surgery can be severe for up to a fortnight after the procedure.

What are the ALTERNATIVES?

There are many alternative treatments to ease a sore throat. During acute episodes, you should rest, as the symptoms usually improve after a few days. Drink plenty of water and gargle regularly with salt water. Pain killers, throat lozenges or sprays to reduce the inflammation can all be bought over the counter at your chemist.

What if you do NOTHING?

Sore throats can be painful and you may not be able to eat or drink comfortably. Doing nothing will not be harmful, some of the suggested alternatives above may help ease the symptoms, and prevent the need for surgery. If the symptoms persist and you cannot tolerate the pain you should see your doctor.