NASS Study: Do Patients Have Realistic Expectations of Spinal Surgery Results?

It seems like a role reversal, of sorts.

Most patients undergoing lumbar spine surgery have more optimistic expectations than their doctors for the outcomes of their procedures, according to a new study presented at the North American Spine Society’s (NASS) 30th Annual Meeting (held Oct. 14-17). The data showed 87 percent of patients view their surgeries through rose-colored glasses and 11 percent expect worse outcomes than physicians.

“While it may seem obvious that experience surgeons would have a more realistic view of surgical outcomes than patients, this wide expectation gap is distrubing,” said Gwendolyn Sowa, M.D., Ph.D., a physiatrist and NASS Annual Meeting program chair. “Before a surgery date is even scheduled, it is essential that the surgeon and patient have clear conversations about their expectations for the surgery, including recovery time, after care, and anticipated outcomes so that they can work toward the same goals.”

The study, “Concordance Between Patients’ and Surgeons’ Expectations of Lumbar Spine Surgery,” was among 21 “Best Papers” selected by NASS from the record 1,180 scientific abstracts and session proposals submitted for this year’s meeting in Chicago, Ill.

Most patients who choose to undergo lumbar surgery expect improvement in physical and psychological symptoms. The expectation of a positive outcome tends to be the driving force in their decision to have surgery but if a patient’s expectations are unrealistic, it can have a detrimental effect on the ultimate outcome.

“If patient expectations are inappropriately high, patients may abandon rehabilitation too soon if they’re not getting the results they are expecting,” said Carol A. Mancuso, M.D., the study’s lead author and an associate professor of medicine at Weill Cornell Medical College and the Graduate School of Medical Sciences, and an associate scientist at the Hospital for Special Surgery (both in New York, N.Y.). “On the other hand, if expectations are too low, this may predispose patients to poor outcomes if they are unwilling to make certain lifestyle changes and to follow postoperative precautions that are necessary to maximize the benefit of the surgery.”

In an effort to measure the level of concordance between patients and surgeons regarding the expectations for long-term recovery after lumbar spine surgery, the researchers conducted a cross-sectional study of 184 patients scheduled for a lumbar procedure and their surgeons. Patients completed an expectations survey several days before their scheduled surgery.

The survey consisted of 20 items that addressed symptoms, physical function and mental well-being, including questions about the amount of improvement they expected for each item after their surgery. Based on the responses, the investigators generated a score for each patient, ranging from 0-100, with a higher score reflecting higher expectations. They then asked the surgeons to complete an identical survey asking them to rate the improvement they expected for each item for their specific patient.

For the first 184 patients enrolled in this ongoing study, the mean survey score for the patients was 73 and the mean score for the surgeons was 57. Eighty-seven percent of patients had higher scores (ie, greater expectations) and 11 percent of patients had lower scores (ie, lesser expectations) than their surgeons, and for 43 percent, the difference exceeded a clinically important difference. Concordance within each patient-surgeon pair then was calculated as the amount of agreement between the patient score and the surgeon score, with a concordance coefficient ranging from 0, if there is no agreement at all, to 1 for perfect agreement. The concordance in scores between patient-surgeon pairs for the entire samplewas 0.37, according to the data.

“These findings provide evidence that expectations should be discussed formally with patients before surgery, and the discussion should address both the breadth of items expected and the amount of improvement expected,” Mancuso said. “Our next step will be to develop a curriculum for patients that addresses realistic expectations for surgery. The content for the curriculum will be based on surgeons’ ratings regarding appropriate expectations for most patients according to diagnosis and preoperative status.”

The authors of the study are Carol A. Mancuso, M.D.; Roland Duculan, M.D.; Frank P. Cammisa Jr., M.D.; Andrew A. Sama, M.D.; Alexander P. Hughes, M.D.; Darren R. Lebl, M.D.; and Federico P. Girardi, M.D., All are associated with the Hospital for Special Surgery.