Expectations Versus Reality in Spine Patients: New Study

How aligned (or not) are expectations versus reality among patients with lumbar degenerative spondylolisthesis who’ve been treated with either decompression alone or decompression with fusion?

To answer that question, a team of investigators from Hospital for Special Surgery (HSS), Showa University Hospital in Tokyo, and Weill Cornell Medicine in New York, designed a new study which addressed factors surrounding patient conversion from ambulatory surgery to observation service (<48 h) or inpatient (>48 h). Their work, “High preoperative expectations and postoperative fulfillment of expectations two years after decompression alone and decompression plus fusion for lumbar degenerative spondylolisthesis,” appears in the June 1, 2023, edition of Spine.

Co-author Federico P. Girardi, M.D., a spine surgeon at HSS, told OTW, “Our group (Carol Mancuso et al) developed and validated an Expectations Survey for lumbar surgery, which we have used in multiple studies assessing outcomes of lumbar surgery. With this survey we have been able to better understand patients’ expectations before surgery and their fulfillment of expectations after surgery. Previously there was no validated method to study this type of patient-centered clinical question.”

The HSS, Showa University and Weill Cornell researchers collected data from 1,096 patients who had one- or two-level lumbar decompression ambulatory surgery at an in-hospital, outpatient surgical facility between January 1, 2019, and March 16, 2020. The study subjects were divided into three groups:

• ambulatory surgery,
• observation service, or
• inpatient.

The investigators found that 641 (58%) patients converted to either observation service (n=486) or inpatient care (n=155).

They determined that the following attributes were independent risk factors for ambulatory surgery conversion to observation service/inpatient:

• age (more than 80 years old),
• high American Society of Anesthesiologists Physical Status grade,
• history of sleep apnea,
• drain use,
• high estimated blood loss,
• long operation,
• late operation start time, and
• a high pain score.

The risk factors for observation service conversion to inpatient were:

• an American Society of Anesthesiologists Physical Status class 3 or higher,
• coronary artery disease,
• diabetes mellitus,
• hypothyroidism,
• steroid use,
• drain use,
• dural tear, and
• laminectomy.

While they found that two years after surgery, fulfillment of expectations was high for both groups, there was more variability in the proportion of expectations fulfilled for the fusion group.

“Patients who had fusion had greater symptomatology and disability compared to those who didn’t have fusion,” explained Dr. Girardi to OTW. “It follows therefore that patients who had fusion would have greater expectations because they had more areas needing improvement.”

“Whether these high expectations were realistic, however, most likely varied among patients and probably contributed to the greater variation in fulfillment of expectations that we found in the fusion group.”

Dr. Girardi added, “Our large longitudinal study contributes to knowledge about lumbar degenerative spondylolisthesis surgery by providing details about the breadth of patients’ expectations and fulfillment of these expectations according to the fusion status, and by providing insights into novel sociodemographic and clinical variables associated with outcomes, specifically help at home, previous arthroplasty, and subsequent lumbar surgery.”

“Understanding these variables can enhance shared decision-making between patients and surgeons and guide the development of interventions to optimize preoperative status and foster realistic expectations of lumbar surgery.”

When OTW asked what role surgeons might play in enhancing modifiable variables, Dr. Girardi noted, “In our study we inquired about help at home (i.e., a proxy for social support) and it was interesting to find that more help at home was associated with greater fulfillment of expectations.”

“Although strongly linked to better health outcomes for multiple health conditions, the role of social support and its contribution to recuperation from lumbar degenerative spondylolisthesis surgery is not well known. Understanding how social support impacts results of lumbar degenerative spondylolisthesis surgery has clinical implications for preoperative planning. Specifically, ascertaining what type of social support is needed (e.g., tangible, emotional) can direct surgeons to tailor interventions to support patients through the recovery period.”

“We also found an association between prior arthroplasty and unfulfilled expectations of lumbar degenerative spondylolisthesis surgery, which has not been described previously.”

“Given that interventions for multiple degenerative musculoskeletal conditions commonly coexist, associations between prior arthroplasty and ratings of lumbar degenerative spondylolisthesis outcomes merit further investigation.”

“In the meantime, spine surgeons can address differences in technical aspects of the surgeries, the recovery process, and the long-term outlook between total joint arthroplasty and lumbar surgery with their patients who have had prior arthroplasty.”