Findings underscore importance of patient and surgeon communication prior to surgery

Most patients undergo elective lumbar surgery to improve their pain and funcational limitations. However, data presented at the North American Spine Society 2015 annual meeting indicate that the level of improvement that patients expect following lumbar surgery may not be realistic and frequently exceeds the expectations of their surgeons. The paper, "Concordance between Patients' and Surgeons' Expectations of Lumbar Spine Surgery," was recognized as one of the meeting"s "Best Papers."

Unrealistic patient expectations have the potential to hinder final outcomes, explained Carol A. Mancuso, MD, of the Hospital for Special Surgery, New York. "Although high expectations can be motivating, they can also predispose to poor outcomes if patients become discouraged with recuperation time, abandon rehabilitation, and ignore recommended lifestyle changes that may minimize progression of the underlying condition," she said. "On the other hand, expectations that are too low may predispose patients to poor outcomes if they lack the motivation to participate in rehabilitation and are unwilling to make lifestyle changes and follow postoperative precautions."

Cross-sectional study
Dr. Mancuso and her fellow researchers sought to compare the level of concordance between patients and their surgeons with respect to outcome expectations after lumbar surgery. The first phase of the single-center study involved 262 patients (53 percent male; mean age = 54 years) scheduled to undergo lumbar spine surgery by one of five fellowship-trained spine surgeons. Among the 262 patients, 21 percent had an acute disk herniation and 79 percent had another degenerative condition; 29 percent had undergone previous spine surgery. 

The researchers collected patient-reported outcome measures (modified Oswestry Disability Index [ODI] and the Geriatric Depression Scale) from all patients 10 days prior to surgery. In addition, patients—and their surgeons—each completed a 20-item survey about the patients' physical function and well-being and the expected level of improvement in those areas following surgery. Scores ranged from 0 to 100; higher scores reflected higher expectations.

Wide variation in expectations
The patients' mean ODI score was 56, and 59 patients (32 percent) screened positive for depression. The mean expectations survey score among all patients was 73, 15 points higher than the mean expectations score among the surgeons. When matched against surgeon scores, 85 percent of patients had higher survey scores (eg, greater expectations) and 13 percent of patients had lower scores (eg, lesser expectations) than their surgeons. The researchers noted that for 41 percent of the patients, the difference in expectations was clinically significant.

A concordance coefficient ranging from -1 (perfect disagreement) to +1 (perfect agreement) was used to calculate concordance within each patient-surgeon pair. Overall, the concordance in scores between patient-surgeon pairs was 0.37.

"These findings provide evidence that expectations should be discussed formally with patients before surgery. The discussion should address both the breadth of items expected and the amount of improvement expected," Dr. Mancuso said.

"Our next steps will be to develop an educational intervention to attempt to modify patient expectations and to conduct 2-year follow-ups to ascertain if less concordance is associated with worse outcomes," she said.

Dr. Mancuso's coauthors are Roland Duculan, MD; Frank P. Cammisa Jr, MD; Andrew A. Sama, MD; Alexander P. Hughes, MD; Darren R. Lebl, MD; and Frederico P. Girardi, MD.

Bottom Line

• Expectations of improved physical function and reduced pain are a major factor in a patient"s decision to undergo lumbar spine surgery.
• Patient expectations of the impact of lumbar surgery on function and pain frequently exceed those of their surgeons.
• Unrealistic patient expectations—too high or too low—can have detrimental effects on ultimate outcomes.
• Surgeons should formally discuss expectations with patients prior to surgery.

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