Strategies for Closing the Gap Between Expectations and Results

Expectations versus reality. When it comes to the practice of spine or orthopedic surgery…this is one of the most fundamental issues surgeons and their staffs confront.

No surprise, the bigger the gap between pre-op expectations and post-op reality, the harder it is for modern orthopedic and spine practices to thrive.

Researchers from the Hospital for Special Surgery (HSS) and Weill Cornell Medical College in New York designed an interesting study to, first, measure the size of that gap, and then to tease from the data strategies to narrow it—and what they found—a link between large joint arthroplasty and spine fusion surgery, for example, as well as the role that home care plays—may well surprise you.

The study, “High preoperative expectations and postoperative fulfillment of expectations two years after decompression alone and decompression plus fusion for lumbar degenerative spondylolisthesis,” which appeared in the May 2023 edition of The Spine Journal, used a well-validated Expectations Survey to measure pre-op expectations and then matched those scores to the same patient’s post-op Expectations Survey scores.

This was the FIRST time that lumbar decompression patient expectations had been measured in this particular and systematic way.

357 Patients, 20 Expectation Questions, Pre-op and Post-op

In this 357-patient longitudinal cohort study, patients preoperatively completed a 20-item Expectations Survey which measured, among other items:

• “improvement expected” for symptoms,
• physical function,
• psychosocial well-being,
• “improvement received” two years postoperatively,
• Oswestry Disability Index (ODI),
• Short Form Health Survey-12 mental health subscale,
• satisfaction with surgery,
• comorbidities,
• psychosocial status, including social support (i.e., help at home) and
• prior orthopedic surgery (hip/knee arthroplasty).

Demographically, the patients were:

• 67 years of age, on average,
• 61% women,
• 82% diagnosed with single-level lumbar degenerative spondylolisthesis,
• 73% were treated with spine fusion,
• 2 months of follow-up, on average.

When researchers compared patients who had been treated with spine fusion to patients who were not, they found that the non-fusion group experienced more pain, spinal instability, used more opioids, scored higher on the disability scale, and had greater preoperative Expectations Survey scores (69 vs 74).

But, perhaps surprisingly, the proportion of expectations fulfilled postoperatively was high and similar for both groups (.82 vs. .79), but with a greater degree of variability in the fusion treatment group (.32 vs. .40).

The Link Between Prior Joint Arthroplasty and Spine Fusion Outcomes

Study co-author, Dr. Federico Girardi (recent recipient of the Hospital for Special Surgery Lifetime Achievement Award), noted one of the most interesting results from the study was the association between prior arthroplasty and unfulfilled expectations of lumbar degenerative spondylolisthesis surgery.

This, Girardi explained, had not been described previously.

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

“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.”

Better Pre-op Mental Well Being and Social Support

Using a multivariable analysis with the proportion of expectations fulfilled as the dependent variable, the HSS team found that fulfilled expectations were associated with better pre-op mental well-being and existing social support.

Conversely, unfulfilled expectations were associated with prior arthroplasty and subsequent lumbar surgery. The investigators found similar associations for change in ODI and satisfaction.

According to Dr. Girardi, “Patients who had fusion had greater symptomatology and disability compared to those who didn’t have fusion. 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.”

Socio-demographics Key to Successful Outcomes

“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,” explained Dr. Girardi.

“By providing insights into novel sociodemographic and clinical variables associated with outcomes, specifically help at home, previous arthroplasty, and subsequent lumbar surgery and understanding these variables can enhance shared decision-making between patients and surgeons. Furthermore, these insights can guide the development of interventions to optimize preoperative status and foster realistic expectations of lumbar surgery.”

More Help at Home Really Matters

As for what role surgeons might play in enhancing variables associated with better mental well-being—such as more social support—Dr. Girardi told OTW, “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 this 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.”