The impact of pathoanatomical diagnosis on elective spine surgery patient expectations: a Canadian Spine Outcomes and Research Network study

R. Andrew Glennie MD, FRCSC1, Mayilee Canizares PhD2, Anthony V. Perruccio PhD2, Edward Abraham MD, FRCSC3,4, Fred Nicholls MD, FRCSC6, Andrew Nataraj MD, FRCSC7, Philippe Phan MD, PhD, FRCS(C)8, Najmedden Attabib MD, FRCSC3,5, Michael G. Johnson MD, FRCSC9, Eden Richardson BA4,10, Greg McIntosh MSc10, Henry Ahn MD, FRCSC11, Charles G. Fisher MD, MHSc, FRCSC12, Neil Manson MD, FRCSC3,4, Kenneth Thomas MD, FRCSC6, and Y. Raja Rampersaud MD, FRCSC1,11
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  • 1 Department of Surgery, Division of Orthopedics, Dalhousie University, Halifax, Nova Scotia;
  • | 2 The Arthritis Program, Krembil Research Institute, University Health Network, Toronto, Ontario;
  • | 3 Department of Surgery, Dalhousie University;
  • | 4 Canada East Spine Centre; and
  • | 5 Department of Neurosurgery, Saint John Regional Hospital, Saint John, New Brunswick;
  • | 6 Department of Surgery, University of Calgary, Alberta;
  • | 7 Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta;
  • | 8 The Ottawa Hospital–Civic Campus, Ottawa, Ontario;
  • | 9 Section of Orthopaedic Surgery, University of Manitoba, Winnipeg, Manitoba;
  • | 10 Canadian Spine Outcomes and Research Network;
  • | 11 Department of Surgery, University of Toronto, Toronto, Ontario; and
  • | 12 Combined Neurosurgical and Orthopedic Spine Program, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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OBJECTIVE

Patients undergoing spine surgery generally have high expectations for improvement postoperatively. Little is known about how these expectations are affected by the diagnosis. The purpose of this study was to examine whether preoperative expectations differ based on diagnostic pathoanatomical patterns in elective spine surgery patients.

METHODS

Patients with common degenerative cervical/lumbar pathology (lumbar/cervical stenosis, lumbar spondylolisthesis, and cervical/lumbar disc herniation) who had given their consent for surgery were analyzed using the Canadian Spine Outcomes and Research Network (CSORN). Patients reported the changes they expected to experience postoperatively in relation to 7 separate items using a modified version of the North American Spine Society spine questionnaire. Patients were also asked about the most important item that would make them consider the surgery a success. Sociodemographic, lifestyle, and clinical variables were also collected.

RESULTS

There were 3868 eligible patients identified within the network for analysis. Patients with lumbar disc herniation had higher expectations for relief of leg pain compared with stenosis and lumbar degenerative spondylolisthesis cohorts within the univariate analysis. Cervical stenosis (myelopathy) patients were more likely to rank general physical capacity as their most important expectation from spine surgery. The multinomial regression analysis showed that cervical myelopathy patients have lower expectations for relief of arm or neck pain from surgery (OR 0.54, 0.34–0.88; p < 0.05). Patient factors, including age, symptoms (pain, disability, depression), work status, and lifestyle factors, were significantly associated with expectation, whereas the diagnoses were not.

CONCLUSIONS

Patients with degenerative spinal conditions consenting for spine surgery have high expectations for improvement in all realms of their daily lives. With the exception of patients with cervical myelopathy, patient symptoms rather than diagnoses had a more substantial impact on the dimensions in which patients expected to improve or their most important expected change. Determination of patient expectation should be individualized and not biased by pathoanatomical diagnosis.

ABBREVIATIONS

CSORN = Canadian Spine Outcomes and Research Network; NDI = Neck Disability Index; ODI = Oswestry Disability Index; PHQ-9 = Patient Health Questionnaire 9.

OBJECTIVE

Patients undergoing spine surgery generally have high expectations for improvement postoperatively. Little is known about how these expectations are affected by the diagnosis. The purpose of this study was to examine whether preoperative expectations differ based on diagnostic pathoanatomical patterns in elective spine surgery patients.

METHODS

Patients with common degenerative cervical/lumbar pathology (lumbar/cervical stenosis, lumbar spondylolisthesis, and cervical/lumbar disc herniation) who had given their consent for surgery were analyzed using the Canadian Spine Outcomes and Research Network (CSORN). Patients reported the changes they expected to experience postoperatively in relation to 7 separate items using a modified version of the North American Spine Society spine questionnaire. Patients were also asked about the most important item that would make them consider the surgery a success. Sociodemographic, lifestyle, and clinical variables were also collected.

RESULTS

There were 3868 eligible patients identified within the network for analysis. Patients with lumbar disc herniation had higher expectations for relief of leg pain compared with stenosis and lumbar degenerative spondylolisthesis cohorts within the univariate analysis. Cervical stenosis (myelopathy) patients were more likely to rank general physical capacity as their most important expectation from spine surgery. The multinomial regression analysis showed that cervical myelopathy patients have lower expectations for relief of arm or neck pain from surgery (OR 0.54, 0.34–0.88; p < 0.05). Patient factors, including age, symptoms (pain, disability, depression), work status, and lifestyle factors, were significantly associated with expectation, whereas the diagnoses were not.

CONCLUSIONS

Patients with degenerative spinal conditions consenting for spine surgery have high expectations for improvement in all realms of their daily lives. With the exception of patients with cervical myelopathy, patient symptoms rather than diagnoses had a more substantial impact on the dimensions in which patients expected to improve or their most important expected change. Determination of patient expectation should be individualized and not biased by pathoanatomical diagnosis.

In Brief

The objective of this study was to determine whether patient expectations of spine surgery were different depending on their preoperative diagnosis. The authors found that patient-reported symptoms, and not the diagnosis, had a significant impact. Cervical myelopathy patients had lower expectations than patients with other pathoanatomical diagnoses. The results of this study illustrate the importance of focusing preoperative discussions on preoperative symptoms, rather than diagnosis, when speaking about expectations from spine surgery.

Healthcare outcomes, especially for elective surgical procedures, are routinely evaluated from a patient-centered perspective.1–4 In some surgical specialties, patient satisfaction has been linked to preoperative patient expectations of outcome, but this relationship has not been fully established with respect to spine surgery.5,6 Spine surgeons have anecdotal experience on what proportions of patients will report satisfaction with surgery for various pathoanatomical diagnoses. It is unclear, however, whether these diagnosis-specific outcomes match the preoperative expectations of patients.7,8

The diagnoses related to elective 1- or 2-level spine procedures can be stratified into 4 common pathoanatomical diagnostic categories with associated clinical patterns of disability: lumbar stenosis (with associated neurogenic claudication), lumbar spondylolisthesis (with associated neurogenic claudication), cervical/lumbar disc herniation (with associated radiculopathy), and cervical stenosis (with associated myelopathy). Each of these anatomical diagnoses, however, has varied symptoms between patients. For example, although many patients with acute disc herniations will often experience severe leg pain, there are varying degrees of low-back pain between individual patients. Few surgical studies have analyzed the symptoms that patients expect to improve across different principal diagnoses.6–9 It is important that surgeons are aware of the wide-ranging patient expectations so that preoperative discussions can be more appropriately focused and informative while simultaneously providing the opportunity for unrealistic expectations to be addressed.

The primary purpose of this study was to examine whether patient-reported preoperative expectations differ across several common spinal pathoanatomical diagnostic categories. Second, we sought to determine to what degree individual patient characteristics influence specific expectations.

Methods

Design

Patients with diagnoses of degenerative conditions of the cervical or thoracolumbar spine were prospectively recruited into the Canadian Spine Outcomes and Research Network (CSORN). CSORN details have been described previously.10 Each participating institution obtained their own research ethics board approval. Patients who signed informed consent forms for surgery and registry participation were enrolled after an initial consultation with participating surgeons. There is no uniform approach, form, or video used to outline patient expectations. The discussions around expectations after surgery were solely at the discretion of the treating surgeon.

Sample

This study used preoperative (baseline) data from patients with a diagnosis of lumbar stenosis, lumbar spondylolisthesis, lumbar/cervical disc herniation, or cervical stenosis who completed their patient expectation questionnaires.

There were 4851 patients identified in the registry with a primary diagnosis of either degenerative or nondegenerative spine disorders who gave their consent for surgery. Patients with nondegenerative diagnoses (spine trauma, concomitant oncological diagnoses [primary or metastatic], scoliosis with a Cobb angle > 20°, infection, or fixed sagittal plane deformities [n = 590]) and those who were unable to complete their questionnaires (n = 393) were excluded from analyses. The final sample size was 3868 patients. This cohort was derived from the same registry patients enrolled between October 2012 and July 2017 that were utilized in the related study by Canizares et al.11

Outcome Variables

Preoperative expectations were assessed using a modified version of the North American Spine Society (NASS) cervical/lumbar spine questionnaire as previously reported.11,12 The cervical NASS patient questionnaire has been validated previously for patients with cervical myelopathy.12 Patients reported the changes they expected to experience as a result of surgery in relation to the following 7 separate items: 1) leg/arm pain, 2) back/neck pain, 3) independence in everyday activities, 4) sporting activities/recreation, 5) general physical capacity at work and home, 6) frequency and quality of social contacts, and 7) mental well-being. Each item was assessed on a scale of 0 to 3: 0 (no expectation of change), 1 (somewhat better), 2 (better), or 3 (much better). Finally, patients were asked: which (of the 7 categories) would be the single most important change that would make you say, “The operation helped and was a success”?

Patients provided sociodemographic information, labor force status, lifestyle (physical activity [active vs inactive], smoking status, and BMI), clinical variables (number of comorbidities [2+ vs 0–1]), depressive symptoms (Patient Health Questionnaire [PHQ-9]),13 numeric rating for back/neck and leg/arm pain, disability (Oswestry Disability Index [ODI] and Neck Disability Index [NDI]), and type of surgery.

Statistical Analysis

Stratified analyses were conducted for the 4 diagnosis groups. Continuous variables are described using means and standard deviations, and categorical variables are reported using frequencies and percentages. Bivariate comparisons were conducted using ANOVA for continuous variables and chi-square tests for categorical variables. Multivariable multinomial logistic regression was used to examine factors associated with the most important patient expectation. The numeric pain rating was represented by the worst of back/neck and leg/arm pain reported. All analyses were conducted using SAS version 9.4 (SAS Institute Inc.). Two-tailed tests with a 5% significance level were used to indicate statistical significance.

Results

Table 1 reveals baseline sociodemographic, lifestyle, and clinical characteristics by diagnosis group. Patients with lumbar disc herniation were significantly younger, had fewer comorbidities, and were more likely to be working. Patients with cervical disc herniation were also significantly younger and more likely to be working. Surgery type was significantly different, with fewer stenosis and disc herniation patients undergoing fusion in comparison with those in the other 3 diagnosis groups.

TABLE 1.

Characteristics of the study sample (n = 3868)

Lumbar Stenosis (n = 1146)Lumbar Spondylolisthesis (n = 1103)Lumbar Disc Herniation (n = 768)Cervical Stenosis (myelopathy) (n = 540)Cervical Disc Herniation (n = 311)p Value
Sociodemographic factors
 Mean age, yrs (SD)64.8 (11.4)62.3 (12.0)45.2 (13.8)59.6 (12.8)52.2 (10.8)<0.0001
 Sex<0.0001
   Male447 (39.0)669 (60.7)364 (47.4)228 (42.2)127 (40.8)
   Female699 (61.0)434 (39.3)404 (52.6)312 (57.8)184 (59.2)
Education<0.0001
 <High school193 (17.2)141 (13.2)68 (9.0)102 (19.3)33 (10.8)
 High school474 (42.2)487 (45.4)314 (41.8)248 (47.0)149 (48.9)
 >High school455 (40.6)444 (41.4)370 (49.2)178 (33.7)123 (40.3)
Labor force status<0.0001
 Currently working275 (26.0)300 (29.6)333 (47.2)150 (31.5)128 (46.7)
 In labor force but not working101 (9.6)105 (10.4)208 (29.5)98 (20.6)71 (25.9)
 Not in labor force680 (64.4)607 (60.0)164 (23.3)228 (47.9)75 (27.4)
Lifestyle factors
 Smoking<0.0001
   Current189 (16.6)180 (16.4)161 (21.2)143 (26.6)86 (28.0)
   Former/nonsmoker947 (83.4)917 (83.6)598 (78.8)394 (73.4)221 (72.0)
 Physical activity0.0379
   Active488 (43.8)482 (44.8)314 (41.9)207 (39.1)150 (49.5)
   Inactive625 (56.2)594 (55.2)436 (58.1)322 (60.9)153 (50.5)
 BMI*0.0027
   Underweight/normal251 (22.7)314 (29.7)220 (29.9)140 (27.1)88 (28.8)
   Overweight454 (41.0)391 (36.9)295 (40.0)184 (35.7)114 (37.3)
   Obese402 (36.3)354 (33.4)222 (30.1)192 (37.2)104 (34.0)
Clinical factors
 No. of comorbidities<0.0001
   0–1416 (36.3)384 (34.8)492 (64.1)207 (38.3)157 (50.5)
   ≥2730 (63.7)719 (65.2)276 (35.9)333 (61.7)154 (49.5)
 Mean depressive symptoms score (SD)36.3 (25.2)38.3 (26.1)45.9 (24.8)42.7 (26.8)44.6 (26.3)<0.0001
 Mean VAS score (SD)7.9 (1.6)7.9 (1.6)7.9 (1.8)6.5 (2.7)7.4 (1.9)<0.0001
 Mean ODI/NDI score (SD)§47.6 (15.8)47.0 (14.4)50.6 (15.5)42.7 (20.0)46.2 (16.7)
Surgery type<0.0001
 Fusion435 (38.0)858 (77.8)162 (21.1)443 (82.0)217 (69.8)
 Nonfusion711 (62.0)245 (22.2)606 (78.9)97 (18.0)94 (30.2)

VAS = visual analog scale.

Values represent the number of patients (%) unless stated otherwise. Frequencies do not add up to the total sample size within the diagnosis group due to missing data.

BMI: underweight/normal (< 25.0), overweight (25.0–29.9), and obese (≥ 30.0).

Based on the PHQ-9 depression scale. Scores were rescaled to a 0–100 scale such that higher scores indicate greater depression symptoms.

Worst of back/neck pain and leg/arm pain from the VAS (score 0–10), where higher values indicate greater pain.

ODI score for thoracolumbar patients and NDI score for cervical patients. Scores were rescaled to a 0–100 scale such that higher scores indicate greater pain/disability.

Table 2 presents expectations stratified by diagnosis. A higher proportion of disc herniation patients expected to be much better compared with those patients with lumbar stenosis, spondylolisthesis, cervical myelopathy, or radiculopathy across 6 of the 7 expectation dimensions; the exception was alleviation of back pain. Patients with lumbar radiculopathy had similar expectations to their counterparts with other diagnoses for relief of axial pain; the exception was patients with myelopathy, whose expectations were not as high for having neck pain relief. Of note, a higher proportion of myelopathy patients did not expect changes in arm pain (n = 112, 20.7%) or neck pain (n = 80, 14.8%).

TABLE 2.

Expectations by diagnostic groups

No. of Patients (%)
Lumbar Stenosis (n = 1146)Lumbar Spondylolisthesis (n = 1103)Lumbar Disc Herniation (n = 768)Cervical Stenosis (n = 540)Cervical Disc Herniation (n = 311) 
Leg/arm pain
 No change*49 (4.3)41 (3.7)12 (1.6)112 (20.7)19 (6.1)
 Somewhat better43 (3.8)59 (5.4)26 (3.4)65 (12.0)17 (5.5)
 Better318 (27.8)260 (23.6)155 (20.2)167 (30.9)87 (28.0)
 Much better736 (64.2)743 (67.4)575 (74.9)196 (36.3)188 (60.5)
Back/neck pain
 No change95 (8.3)72 (6.5)56 (7.3)80 (14.8)21 (6.8)
 Somewhat better120 (10.5)78 (7.1)88 (11.5)65 (12.0)26 (8.4)
 Better347 (30.3)340 (30.8)223 (29.0)178 (33.0)91 (29.3)
 Much better584 (51.0)613 (55.6)401 (52.2)217 (40.2)173 (55.6)
General physical capacity: at work & home
 No change76 (6.6)52 (4.7)14 (1.8)30 (5.6)10 (3.2)
 Somewhat better101 (8.8)78 (7.1)39 (5.1)68 (12.6)25 (8.0)
 Better421 (36.7)383 (34.7)239 (31.1)232 (43.0)119 (38.3)
 Much better548 (47.8)590 (53.5)476 (62.0)210 (38.9)157 (50.5)
Independence in everyday activities
 No change67 (5.9)75 (6.8)38 (5.0)47 (8.7)32 (10.3)
 Somewhat better84 (7.3)65 (5.9)31 (4.0)68 (12.6)25 (8.0)
 Better390 (34.0)392 (35.5)215 (28.0)196 (36.3)109 (35.1)
 Much better605 (52.8)571 (51.8)484 (63.0)229 (42.4)145 (46.6)
Sporting activities/recreation
 No change67 (5.9)75 (6.8)38 (5.0)47 (8.7)32 (10.3)
 Somewhat better84 (7.3)65 (5.9)31 (4.0)68 (12.6)25 (8.0)
 Better390 (34.0)392 (35.5)215 (28.0)196 (36.3)109 (35.1)
 Much better605 (52.8)571 (51.8)484 (63.0)229 (42.4)145 (46.6)
Mental well-being
 No change293 (25.6)264 (23.9)138 (18.0)171 (31.7)90 (28.9)
 Somewhat better140 (12.2)134 (12.2)74 (9.6)73 (13.5)35 (11.3)
 Better355 (31.0)348 (31.6)239 (31.1)172 (31.9)106 (34.1)
 Much better358 (31.2)357 (32.4)317 (41.3)124 (23.0)80 (25.7)
Frequency & quality of social contacts
 No change159 (13.9)139 (12.6)64 (8.3)80 (14.8)42 (13.5)
 Somewhat better88 (7.7)96 (8.7)47 (6.1)47 (8.7)31 (10.0)
 Better346 (30.2)310 (28.1)200 (26.0)190 (35.2)90 (28.9)
 Much better553 (48.3)558 (50.6)457 (59.5)223 (41.3)148 (47.6)

No change, or do not know.

Table 3 shows the frequency distribution of the most important expected change by diagnosis group. There were differences in the most important expected change from surgery for each diagnosis group. Disc herniation and lumbar stenosis patients ranked relief of leg pain as the most important expected change. Cervical myelopathy patients ranked general physical capacity as the most important, and improvement with independence in everyday activities as second most important. Spondylolisthesis patients identified relief of back pain (31.1%) as the most important change, followed by relief of leg pain (29.5%) as the second most important.

TABLE 3.

Most important expected change*

No. of Patients (%)
Lumbar StenosisLumbar SpondylolisthesisLumbar Disc HerniationCervical StenosisCervical Disc Herniation
Leg/arm pain373 (32.6)1325 (29.5)2297 (38.7)169 (12.8)489 (28.6)2
Back/neck pain278 (24.3)2343 (31.1)1144 (18.8)390 (16.7)390 (28.9)1
General physical capacity: at work & home211 (18.4)3198 (18.0)3174 (22.7)2181 (33.5)171 (22.8)3
Independence in everyday activities203 (17.7)4155 (14.1)481 (10.6)4143 (26.5)238 (12.2)4
Sporting activities/recreation39 (3.4)550 (4.5)542 (5.5)520 (3.7)65 (1.6)6
Frequency & quality of social contacts37 (3.2)623 (2.1)628 (3.7)636 (6.7)517 (5.5)5
Mental well-being5 (0.4)79 (0.8)72 (0.3)71 (0.2)71 (0.3)7
Total1146 (100.0)1103 (100.0)768 (100.0)540 (100.0)311 (100.0)

Superscript numbers are ranked from 1 to 7, with 1 representing the most commonly reported within each diagnosis group.

Table 4 displays results of the multinomial logistic regression model. With the exception of cervical myelopathy patients, there were no significant differences in the most important expected change among patients in the other diagnosis groups. Myelopathy patients had decreased odds of reporting pain improvement as the most important expected change.

TABLE 4.

Most important expectation: results from a multinomial logistic regression model with other expectations (sporting activities/recreation, mental well-being, or frequency and quality of social contacts) as reference

OR (95% CI)
Pain (back/neck or arm/leg)General HealthDisability
Diagnosis group
Lumbar spondylolisthesis1.08 (0.72–1.60)1.08 (0.70–1.67)0.83 (0.53–1.31)
Lumbar disc herniation1.14 (0.73–1.78)1.22 (0.76–1.99)0.94 (0.55–1.60)
Cervical stenosis0.54 (0.34–0.88)*1.39 (0.85–2.28)1.17 (0.69–1.97)
Cervical disc herniation1.81 (0.99–3.29)1.72 (0.90–3.28)1.38 (0.68–2.79)
Lumbar stenosis1.001.001.00
Sociodemographic factors
 Female vs male1.34 (1.00–1.78)1.06 (0.78–1.45)1.21 (0.87–1.68)
 Age1.01 (1.00–1.03)*1.02 (1.00–1.03)*1.03 (1.01–1.04)**
 Education (ref: <high school)
   High school0.81 (0.48–1.35)1.03 (0.59–1.79)0.79 (0.45–1.39)
   University/college0.59 (0.35–1.00)0.85 (0.49–1.49)0.65 (0.37–1.14)
Labor force participation (ref: not in labor force)
 Currently working0.76 (0.54–1.08)0.86 (0.59–1.26)0.33 (0.22–0.50)***
 Not currently working0.90 (0.57–1.42)1.64 (1.01–2.67)*0.75 (0.45–1.26)
Lifestyle factors
 Current smoker vs nonsmoker0.97 (0.67–1.40)0.99 (0.67–1.47)1.66 (1.10–2.50)*
 Physically active vs inactive0.82 (0.61–1.08)0.63 (0.46–0.86)**0.74 (0.53–1.03)
 BMI (ref: normal/underweight)
   Overweight1.00 (0.73–1.38)1.12 (0.79–1.58)1.04 (0.71–1.53)
   Obese1.42 (0.99–2.04)1.56 (1.06–2.31)*1.68 (1.11–2.54)*
Clinical factors
 No. of comorbidities (≥2 vs 0 or 1)0.98 (0.73–1.31)1.05 (0.76–1.44)1.08 (0.77–1.52)
 Depressive symptoms§0.95 (0.93–0.98)**0.98 (0.95–1.01)0.97 (0.94–1.01)
 Pain1.22 (1.13–1.32)***1.02 (0.94–1.10)0.97 (0.89–1.06)
 Disability††1.01 (1.00–1.02)*1.00 (0.99–1.02)1.02 (1.00–1.03)*
 Surgery type (fusion vs other)1.03 (0.75–1.42)1.03 (0.73–1.46)1.04 (0.72–1.49)

p < 0.0001;

p < 0.01;

p < 0.05;

p < 0.1.

Underweight/normal (< 25.0), overweight (25.0–29.9), and obese (≥ 30.0).

Based on the PHQ-9 depression scale. Scores were rescaled to a 0–100 scale such that higher scores indicate greater depression symptoms.

Worst of back/neck pain and leg/arm pain from a VAS (0–10), where higher values indicate greater pain.

ODI score for thoracolumbar patients and NDI score for cervical patients. Scores were rescaled to a 0–100 scale such that higher scores indicate greater pain/disability.

Patients with higher pain scores had increased odds of ranking improvement in neck/back or arm/leg pain as their most important expected change. Higher disability was associated with increased odds of reporting pain improvements as the most important expected change. Patients with depression within the PHQ-9 score had decreased odds of reporting back/neck or arm/leg pain as the most important reason for undergoing surgery. Patients who were currently working had decreased odds of indicating disability as their most important expected change resulting from surgery; those patients who were currently working expected to keep working after surgery. Patients who reported being physically active had decreased odds of reporting improvements in general health as the most important expected change. Compared with normal/underweight patients, obese patients had increased odds of ranking expected improvements in general health and disability.

Discussion

In this large cohort, patients with spinal pathology had high expectations for improvement with surgical intervention. To our knowledge, this is the largest study that characterizes preoperative expectations in multiple dimensions while stratifying the most important expectation based on initial degenerative pathology. In each of the 7 expectation dimensions, presurgical expectations varied across diagnoses with respect to the most important expected change and the magnitude thereof. One can surmise that different expectation dimensions are driven by different factors, and, as a result, individual inquiry into patient preoperative expectations may be beneficial. Overall, our findings are consistent with the heterogeneous clinical symptoms and disability that patients present with when considering spinal surgery. This finding confirms that patient expectations are individualized and that there is no single realm for patient-expected improvement that will dominate or be driven by pathoanatomical diagnosis.

Multiple reports have demonstrated that surgical outcomes can differ by diagnosis; therefore, the preoperative surgical discussion should be adjusted to ensure appropriate expectations for each diagnosis.7 Our findings reinforce the notion that patients may be inherently driven to expect improvement in the area that affects them the most (i.e., their symptoms, not the cause of their symptoms).12 The type of surgery (fusion or nonfusion) had no bearing on which expectation they ranked as the most important, even though fusion surgery may carry a slightly more negative connotation with some patients and outcome has been shown to vary depending on pathoanatomical diagnosis.13

Based on available evidence and personal bias, many surgeons have narrow discussions with patients about improvements in leg or arm pain, while the results of this study show that an equally significant portion of the preoperative discussion should address issues surrounding general health and disability.14–16 Although our data in the current and previous study suggest that arm/leg and back/neck pain are the highest-ranked areas for expectations of improvement, general health and disability are equally important to certain subsets of patients.11 Mancuso et al. have shown previously that, although pain relief was ranked the highest, with 99% of patients having this expectation, 70% sought to maintain personal care and 94% of patients expected to be more mobile.17

Patients with cervical myelopathy ranked general physical capacity and independence in everyday activities as their first and second most important expected change. This may be reflective of dysfunction associated with the patient’s condition but may also be strongly influenced by a discussion with the surgeon focusing more on disability issues and the urgency of surgery to prevent deterioration. Not surprisingly, patients with cervical myelopathy did not consistently rank improvements in arm or neck pain as the most important expected change compared with other dimensions, but more than two-thirds of those patients did expect their neck or arm pain to be better or much better. Although they did not rank these expectations as highly as their counterparts, the issue of neck and/or arm pain should also be addressed in the presurgical consultation with these patients. Very few studies evaluate preoperative patient expectations in cervical myelopathy. While Mancuso et al. evaluated expectations in a cohort of 133 cervical spine surgery patients, only 26% had myelopathy, and the final analysis did not specifically evaluate met or unmet expectations in this subgroup.6,18 Another cross-sectional study revealed that a subgroup of cervical myelopathy patients had similar overall expectation scores to their nonmyelopathy counterparts.19

Patients who were working prior to surgery expected to continue working after surgery and consistently ranked disability statistically significantly lower on disability outcomes than other expectation areas. This finding may represent a subgroup of patients whose symptoms are less functionally severe or they lack occupational insurance or sick leave benefits, or both. Their expectation with surgery was that they would improve, while not ranking issues of disability consistently high since they expected to continue working regardless. There is a potential discrepancy in what constitutes a reasonable expectation for return to work. Lattig et al. identified a significant discrepancy between what patients thought and what surgeons thought were reasonable expectations for returning to work in some capacity.20

Physically active patients did not rank significant improvements in general health as a most important change. It is likely that they are in reasonably good general health at baseline if they are active. In contrast, the obese patient cohort ranked a greater improvement in general functioning and less disability as most important compared with their nonobese counterparts. This finding has not been previously reported and likely highlights an individual desire to become more physically active in general.

Patients with higher levels of baseline pain were more likely to rank improvement in their pain scores postoperatively as the most important expected change; likewise, patients with higher disability scores were more likely to prioritize improvements in independence in everyday activities. These findings are not surprising, since pain is often a patient’s central focus.9,21 The preoperative discussion in these cases should focus more on the specific nature (e.g., constant vs intermittent) and location of the pain and how these specific characteristics might change after surgery. The latter might be dependent on many factors, including the pathoanatomical diagnosis, and it is incumbent on the surgeon to appropriately educate the patient in this regard.

Patients with increasing depressive mood had decreased odds of ranking pain as the most important expected change. It has been shown previously that patients with higher degrees of preoperative distress, as measured by the Distress and Risk Assessment Method questionnaire, which includes the Zung depression scale, have lower satisfaction scores postoperatively. This finding may be related to lower preoperative patient expectations. The association of depression with specific preoperative expectations has been scantly assessed in the literature.22,23 The results of our study suggest that depressive moods may have independent effects on preoperative expectations regarding pain.

Limitations of this study are as previously outlined and primarily involve timing of the administration of the questionnaires.11 Patient questionnaires are recorded at varying times after the initial surgical consultation, once the patient has provided consent for both surgery and the registry. Patients are likely, however, to research their condition in a variety of ways.17 The day that the decision is made to undergo surgery is stressful, and there are likely competing, often disorganized thoughts for each patient. Patient expectations from surgery may change significantly from the consultation, versus the visit in which they provide their consent, to the day of surgery. Representative preoperative expectations are likely more accurate immediately prior to surgery, after the patient has reflected on the surgical visit and researched their planned surgical procedure.

Another limitation tempering the interpretation of the results is the smaller odds ratios found in the multinomial regression analysis. Although numerous patient characteristics were found to be statistically significant, their clinical impact on expectations is difficult to interpret. This finding limits the message of this work in that diagnosis (with the exception of myelopathy) has a lower likelihood than other patient characteristics of significantly impacting preoperative expectations. There is no uniform approach, form, or video used to outline patient expectations. The discussions around expectations after surgery were solely at the discretion of the treating surgeon.

Conclusions

In this study, while most patients expected improvements in multiple domains, the degenerative pathoanatomical diagnosis did not significantly influence patient expectations. With the exception of patients with cervical myelopathy, individual patient factors such as age, baseline pain, disability, obesity and depressive symptoms, and work and activity status were independently associated with what patients expected from surgery, not their pathoanatomical diagnosis. Surgeons should make efforts to understand and address patient-specific expectations across different diagnoses and for any given proposed elective spine procedure. Encouraging a personalized approach based on patient characteristics rather than surgeon-based expectations for a given diagnosis may lead to a better understanding of what patients expect for their surgical outcome. This would provide a preoperative opportunity to discuss differences between patient and surgeon expectations of surgical outcome.

Disclosures

Dr. Glennie: support of non–study-related clinical or research effort from Medtronic. Dr. Nicholls: honoraria from DePuy Synthes. Dr. Johnson: clinical or research support for the study described from Stryker. Dr. Fisher: consultant for Medtronic and NuVasive; royalties from Medtronic; and fellowship support paid to institution from Medtronic and AO Spine. Dr. Manson: consultant for and support of non–study-related clinical or research effort from Medtronic Canada. Dr. Rampersaud: royalties from Medtronic.

Author Contributions

Conception and design: Glennie, Canizares, Perruccio, Nataraj, Phan, Johnson, McIntosh, Fisher, Manson, Thomas, Rampersaud. Acquisition of data: Glennie, Canizares, Abraham, Nicholls, Nataraj, Phan, Attabib, Johnson, McIntosh, Ahn, Fisher, Manson, Thomas, Rampersaud. Analysis and interpretation of data: Glennie, Canizares, Fisher, Thomas, Rampersaud. Drafting the article: Glennie, Nicholls, Fisher, Manson, Rampersaud. Critically revising the article: Glennie, Canizares, Perruccio, Abraham, Nicholls, Nataraj, Phan, Johnson, Fisher, Manson, Thomas, Rampersaud. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Glennie. Statistical analysis: Canizares, McIntosh, Manson, Thomas, Rampersaud. Administrative/technical/material support: Canizares, Perruccio, Abraham, Attabib, Richardson, Thomas, Rampersaud. Study supervision: Rampersaud.

References

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    • Crossref
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    Soroceanu A, Ching A, Abdu W, McGuire K. Relationship between preoperative expectations, satisfaction, and functional outcomes in patients undergoing lumbar and cervical spine surgery: a multicenter study. Spine (Phila Pa 1976).2012;37(2):E103E108.

    • Crossref
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    Mancuso CA, Duculan R, Cammisa FP, et al. Fulfillment of patients’ expectations of lumbar and cervical spine surgery. Spine J. 2016;16(10):11671174.

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    Crawford CH III, Carreon LY, Bydon M, et al. Impact of preoperative diagnosis on patient satisfaction following lumbar spine surgery. J Neurosurg Spine. 2017;26(6):709715.

    • Crossref
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    Fehlings MG, Tetreault LA, Kurpad S, et al. Change in functional impairment, disability, and quality of life following operative treatment for degenerative cervical myelopathy: a systematic review and meta-analysis. Global Spine J. 2017;7(3)(suppl):53S69S.

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    Witiw CD, Mansouri A, Mathieu F, et al. Exploring the expectation-actuality discrepancy: a systematic review of the impact of preoperative expectations on satisfaction and patient reported outcomes in spinal surgery. Neurosurg Rev. 2018;41(1):1930.

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    Ailon T, Tee J, Manson N, et al. Patient-reported outcomes following surgery for degenerative spondylolisthesis: comparison of a universal and multitier health care system. Spine J. 2019;19(1):2433.

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    Canizares M, Gleenie RA, Perruccio AV, et al. Patients’ expectations of spine surgery for degenerative conditions: results from the Canadian Spine Outcomes and Research Network (CSORN). Spine J. 2020;20(3):399408.

    • Crossref
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  • 12

    Stoll T, Huber E, Bachmann S, et al. Validity and sensitivity to change of the NASS questionnaire for patients with cervical spine disorders. Spine (Phila Pa 1976).2004;29(24):28512855.

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    Glassman SD, Carreon LY, Djurasovic M, et al. Lumbar fusion outcomes stratified by specific diagnostic indication. Spine J. 2009;9(1):1321.

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    Abraham P, Rennert RC, Martin JR, et al. The role of surgery for treatment of low back pain: insights from the randomized controlled Spine Patient Outcomes Research Trials. Surg Neurol Int. 2016;7(1):38.

    • Crossref
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    Mancuso CA, Duculan R, Cammisa FP, et al. Sources of patients’ expectations of lumbar surgery. Spine (Phila Pa 1976).2019;44(5):318324.

  • 18

    Mancuso CA, Cammisa FP, Sama AA, et al. Development of an expectations survey for patients undergoing cervical spine surgery. Spine (Phila Pa 1976).2013;38(9):718725.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Mancuso CA, Duculan R, Stal M, Girardi FP. Patients’ expectations of cervical spine surgery. Spine (Phila Pa 1976).2014;39(14):11571162.

  • 20

    Lattig F, Fekete TF, OʼRiordan D, et al. A comparison of patient and surgeon preoperative expectations of spinal surgery. Spine (Phila Pa 1976).2013;38(12):10401048.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Mannion AF, Junge A, Elfering A, et al. Great expectations: really the novel predictor of outcome after spinal surgery?. Spine (Phila Pa 1976).2009;34(15):15901599.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Abtahi AM, Brodke DS, Lawrence BD, et al. Association between patient-reported measures of psychological distress and patient satisfaction scores after spine surgery. J Bone Joint Surg Am. 2015;97(10):824828.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Rehman Y, Muzammil S, Wiercioch W, et al. Discrepancies between patient and surgeon expectations of surgery for sciatica: a challenge for informed decision making?. Spine (Phila Pa 1976).2019;44(10):740746.

    • Crossref
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Illustrations from Walker et al. (pp 80–90). © Barrow Neurological Institute, Phoenix, Arizona.
  • 1

    Rönnberg K, Lind B, Zoëga B, et al. Patients’ satisfaction with provided care/information and expectations on clinical outcome after lumbar disc herniation surgery. Spine (Phila Pa 1976).2007;32(2):256261.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Leinweber KA, Columbo JA, Kang R, et al. A review of decision aids for patients considering more than one type of invasive treatment. J Surg Res. 2019;235:350366.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Bourne RB, Chesworth BM, Davis AM, et al. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not?. Clin Orthop Relat Res. 2010;468(1):5763.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Pucher PH, Johnston MJ, Archer S, et al. Informing the consent process for surgeons: a survey study of patient preferences, perceptions, and risk tolerance. J Surg Res. 2019;235:298302.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Soroceanu A, Ching A, Abdu W, McGuire K. Relationship between preoperative expectations, satisfaction, and functional outcomes in patients undergoing lumbar and cervical spine surgery: a multicenter study. Spine (Phila Pa 1976).2012;37(2):E103E108.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Mancuso CA, Duculan R, Cammisa FP, et al. Fulfillment of patients’ expectations of lumbar and cervical spine surgery. Spine J. 2016;16(10):11671174.

  • 7

    Crawford CH III, Carreon LY, Bydon M, et al. Impact of preoperative diagnosis on patient satisfaction following lumbar spine surgery. J Neurosurg Spine. 2017;26(6):709715.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Fehlings MG, Tetreault LA, Kurpad S, et al. Change in functional impairment, disability, and quality of life following operative treatment for degenerative cervical myelopathy: a systematic review and meta-analysis. Global Spine J. 2017;7(3)(suppl):53S69S.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Witiw CD, Mansouri A, Mathieu F, et al. Exploring the expectation-actuality discrepancy: a systematic review of the impact of preoperative expectations on satisfaction and patient reported outcomes in spinal surgery. Neurosurg Rev. 2018;41(1):1930.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Ailon T, Tee J, Manson N, et al. Patient-reported outcomes following surgery for degenerative spondylolisthesis: comparison of a universal and multitier health care system. Spine J. 2019;19(1):2433.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Canizares M, Gleenie RA, Perruccio AV, et al. Patients’ expectations of spine surgery for degenerative conditions: results from the Canadian Spine Outcomes and Research Network (CSORN). Spine J. 2020;20(3):399408.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Stoll T, Huber E, Bachmann S, et al. Validity and sensitivity to change of the NASS questionnaire for patients with cervical spine disorders. Spine (Phila Pa 1976).2004;29(24):28512855.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Glassman SD, Carreon LY, Djurasovic M, et al. Lumbar fusion outcomes stratified by specific diagnostic indication. Spine J. 2009;9(1):1321.

  • 14

    Awad JN, Moskovich R. Lumbar disc herniations: surgical versus nonsurgical treatment. Clin Orthop Relat Res. 2006;443:183197.

  • 15

    Chen BL, Guo JB, Zhang HW, et al. Surgical versus non-operative treatment for lumbar disc herniation: a systematic review and meta-analysis. Clin Rehabil. 2018;32(2):146160.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Abraham P, Rennert RC, Martin JR, et al. The role of surgery for treatment of low back pain: insights from the randomized controlled Spine Patient Outcomes Research Trials. Surg Neurol Int. 2016;7(1):38.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Mancuso CA, Duculan R, Cammisa FP, et al. Sources of patients’ expectations of lumbar surgery. Spine (Phila Pa 1976).2019;44(5):318324.

  • 18

    Mancuso CA, Cammisa FP, Sama AA, et al. Development of an expectations survey for patients undergoing cervical spine surgery. Spine (Phila Pa 1976).2013;38(9):718725.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Mancuso CA, Duculan R, Stal M, Girardi FP. Patients’ expectations of cervical spine surgery. Spine (Phila Pa 1976).2014;39(14):11571162.

  • 20

    Lattig F, Fekete TF, OʼRiordan D, et al. A comparison of patient and surgeon preoperative expectations of spinal surgery. Spine (Phila Pa 1976).2013;38(12):10401048.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Mannion AF, Junge A, Elfering A, et al. Great expectations: really the novel predictor of outcome after spinal surgery?. Spine (Phila Pa 1976).2009;34(15):15901599.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Abtahi AM, Brodke DS, Lawrence BD, et al. Association between patient-reported measures of psychological distress and patient satisfaction scores after spine surgery. J Bone Joint Surg Am. 2015;97(10):824828.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Rehman Y, Muzammil S, Wiercioch W, et al. Discrepancies between patient and surgeon expectations of surgery for sciatica: a challenge for informed decision making?. Spine (Phila Pa 1976).2019;44(10):740746.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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