Exploring the expectation-actuality discrepancy: a systematic review of the impact of preoperative expectations on satisfaction and patient reported outcomes in spinal surgery

How Minimal Clinically Important Difference and Patient Acceptable Symptom State Relate to Patient Expectations and Satisfaction in Spine Surgery: A Review

This narrative review seeks to enhance our comprehension of how Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS) values in established Patient Reported Outcome Measures (PROMs) for spine surgery correspond with patient preoperative expectations and postoperative satisfaction. Through our literature search, we found that both MCID and PASS serve as dependable indicators of patient expectations. However, MCID may be more susceptible to a floor effect. This implies that PASS may offer a more accurate reflection of how patients anticipate surgery to address their symptoms. Nevertheless, it is crucial to recognize that achieving MCID or PASS may not be an absolute prerequisite for patients to be satisfied with their treatment.

Mental state as a predictor of outcome in spinal stenosis surgery: Four quadrants model integrating patient satisfaction and functional outcome

Introduction

Mental status, characterised by anxiety and depression, significantly influences physical well-being, particularly in patients with spinal stenosis symptoms.

Research question

The prevalence of depression and anxiety in our cohort. The correlation between psychological distress and physical outcome after surgery, including postoperative recovery and satisfaction.

Materials and methods

Questionnaires evaluating anxiety and depression (HADS), functionality (ODI), quality of life (EQ-5D), and perceived recovery (Likert-scale) were sent to a randomly selected cohort of 450 lumbar spinal stenosis patients, with or without spondylolisthesis, who underwent surgery between 2007 and 2013. Results are presented, dichotomised by HADS score (score ≥8 indicating psychologically impaired) and in a Four Quadrants Model integrating functional outcomes and perceived recovery separately for psychologically impaired and non-impaired cases.

Results

Among the 147 included patients, 32 (22%) exhibited anxiety and/or depression (impaired cases). Satisfactory outcome (perceived recovery) was reported in 29.0% of the impaired cases and 78.3% of the non-impaired cases (p < 0.001). The mean postoperative functionality score of the impaired cases was 42.46 ± 16.24, in contrast to 18.48 ± 18.25 for the non-impaired cases (p < 0.001). In the impaired group, only 12.5% achieved both a good functional outcome (ODI ≤24) and satisfactory perceived recovery, compared with 58.4% in the non-impaired group.

Discussion and conclusion

Patients reporting anxiety and/or depression demonstrate an inferior long-term outcome after spinal stenosis surgery compared to non-impaired patients. This clinically relevant difference underscores the importance of addressing depression and anxiety in preoperative counselling to optimize patient satisfaction and functional outcomes.

Preoperative expectations of patients with degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network

BACKGROUND

Despite an abundance of literature on degenerative cervical myelopathy (DCM), little is known about preoperative expectations of these patients.

PURPOSE

The primary objective was to describe patient preoperative expectations. Secondary objectives included identifying patient characteristics associated with high preoperative expectations and to determine if expectations varied depending on myelopathy severity.

STUDY DESIGN

This was a retrospective study of a prospective multicenter, observational cohort of patients with DCM.

PATIENT SAMPLE

Patients who consented to undergo surgical treatment between January 2019 and September 2022 were included.

OUTCOMES MEASURES

An 11-domain expectation questionnaire was completed preoperatively whereby patients quantified the expected change in each domain.

METHODS

The most important expected change was captured. A standardized expectation score was calculated as the sum of each expectation divided by the maximal possible score. The high expectation group was defined by patients who had an expectation score above the 75th percentile. Predictors of patients with high expectations were determined using multivariable logistic regression models.

RESULTS

There were 262 patients included. The most important patient expectation was preventing neurological worsening (40.8%) followed by improving balance when standing or walking (14.5%), improving independence in everyday activities (10.3%), and relieving arm tingling, burning and numbness (10%). Patients with mild myelopathy were more likely to select no worsening as the most important expected change compared to patients with severe myelopathy (p<.01). Predictors of high patient expectations were: having fewer comorbidities (OR -0.30 for every added comorbidity, 95% CI -0.59 to -0.10, p=.01), a shorter duration of symptoms (OR 0.92, 95% CI 0.35-1.19, p=.02), no contribution from "failure of other treatments" on the decision to undergo surgery (OR 1.49, 95% CI 0.56-2.71, p=.02) and more severe neck pain (OR 0.19 for 1 point increase, 95% CI 0.05-0.37, p=.01).

CONCLUSIONS

Most patients undergoing surgery for DCM expect prevention of neurological decline, better functional status, and improvement in their myelopathic symptoms. Stopping neurological deterioration is the most important expected outcomes by patients.

Worse Pain and Disability at Presentation Predicts Greater Improvement in Pain, Disability, and Mental Health in Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion for Degenerative Spondylolisthesis

STUDY DESIGN

Retrospective Review.

OBJECTIVE

To assess the impact of preoperative pain and disability on patient-reported outcome measures (PROMs) following minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Varying preoperative symptom severity in lumbar fusion patients alters perceptions of surgical success.

METHODS

Degenerative spondylolisthesis patients undergoing elective, primary, single-level MI-TLIF were stratified by preoperative symptom severity: Mild (VAS-B<7/ODI<50), Moderate (VAS-B≥7/ODI<50 or VAS-B<7/ODI≥50), and Severe (VAS-B≥7/ODI≥50). PROMs, Patient-reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), ODI, VAS-B, VAS-Leg (VAS-L), and 9-item Patient Health Questionnaire (PHQ-9) were compared at baseline, 6 weeks, and final follow-up (μ=16.3±8.8 mo). Postoperative PROMs, magnitudes of improvement, and minimal clinically important difference (MCID) achievement rates were compared between cohorts through multivariable regression.

RESULTS

A total of 177 patients were included. Acute postoperative pain and narcotic consumption were highest in the severe cohort (P≤0.003). All preoperative PROMs worsened from mild to severe cohorts (P<0.001). All PROMs continued to be significantly different between cohorts at 6 weeks and final follow-up, with the worst scores in the Severe cohort (P≤0.003). At 6 weeks, all cohorts improved in ODI, VAS-B, VAS-L, and PHQ-9 (P≤0.003), with the Moderate cohort also improving in PROMIS-PF (P=0.017). All Cohorts improved across PROMs at the final follow-up (P≤0.044). Magnitudes of improvement in ODI, VAS-B, and PHQ-9 increased with worsening preoperative symptom severity (P≤0.042). The Moderate and Severe cohorts demonstrated higher MCID achievement in ODI, VAS-B, and PHQ-9 rates than the Mild cohort.

CONCLUSIONS

Despite preoperative pain and disability severity, patients undergoing MI-TLIF for degenerative spondylolisthesis report significant improvement in physical function, pain, disability, and mental health postoperatively. Patients with increasing symptom severity continued to report worse severity postoperatively compared with those with milder symptoms preoperatively but were more likely to report larger improvements and achieve clinically meaningful improvement in disability, pain, and mental health.

Patient expectations impact patient-reported outcomes and satisfaction after lumbar fusion

BACKGROUND CONTEXT

Prior studies suggest that patient expectations impact postoperative patient-reported outcomes (PROMs). However, no consensus exists on an appropriate expectations tool.

PURPOSE

To examine the impact of patient expectations using a modified version of the Oswestry Disability Index (ODI) on clinical outcomes and patient satisfaction 1 year after lumbar fusion for degenerative pathologies.

STUDY DESIGN

Prospective longitudinal cohort.

PATIENT SAMPLE

Adults undergoing 1 to 2 level lumbar fusion were identified from four tertiaty spine centers.

OUTCOME MEASURES

ODI, EuroQol-5D, Numeric rating scales for back and leg pain.

METHODS

Preoperatively, patients completed the ODI, as well as a modified ODI reflecting their expected improvement across the 10 ODI items. For example, item 1 in the ODI asks about Pain Intensity at the moment whereas the Expectations ODI asks "One year after surgery, I expect to have…" The difference between this modified ODI score and the baseline ODI score (Baseine ODI minus Expectations ODI) was defined as the Patient Expectation Score. Patients were stratified into tertiles based on their Expectations score into High (HE), Moderate (ME), and Low (LE) Expectations and compared.

RESULTS

There were 30 patients in the HE, 35 in the ME, and 26 in the LE Group, with similar demographics and surgical parameters. Patients in the HE group had worse ODI scores preoperatively (54.96 vs 41.42, p<.001) and were expecting a greater improvement in ODI (43.8 vs 13.5, p<.001). There were fewer patients in the HE group (13, 43%) who reported that they were satisfied with the results compared to either the ME (20, 71%) or LE group (22, 85%, p=.041) despite having similar ODI scores and change in ODI scores 1 year postoperatively.

CONCLUSION

An expectations tool, linked to a disease-specific measure may provide the clinician with a practical method of assessing a patient's expectation of results after treatment and aid in the shared decision-making during the preoperative surgical process.

Longitudinal perioperative patient-reported outcomes in open compared with minimally invasive hysterectomy

BACKGROUND

There are few prospective studies in the gynecologic surgical literature that compared patient-reported outcomes between open and minimally invasive hysterectomies within enhanced recovery after surgery pathways.

OBJECTIVE

This study aimed to compare prospectively collected perioperative patient-reported symptom burden and interference measures in open compared with minimally invasive hysterectomy cohorts within enhanced recovery after surgery pathways.

STUDY DESIGN

We compared patient-reported symptom burden and functional interference in 646 patients who underwent a hysterectomy (254 underwent open surgery and 392 underwent minimally invasive surgery) for benign and malignant indications under enhanced recovery after surgery protocols. Outcomes were prospectively measured using the validated MD Anderson Symptom Inventory, which was administered perioperatively up to 8 weeks after surgery. Cohorts were compared using Fisher exact and chi-squared tests, adjusted longitudinal generalized linear mixed modeling, and Kaplan Meier curves to model return to no or mild symptoms.

RESULTS

The open cohort had significantly worse preoperative physical functional interference (P=.001). At the time of hospital discharge postoperatively, the open cohort reported significantly higher mean symptom severity scores and more moderate or severe scores for overall (P<.001) and abdominal pain (P<.001), fatigue (P=.001), lack of appetite (P<.001), bloating (P=.041), and constipation (P<.001) when compared with the minimally invasive cohort. The open cohort also had significantly higher interference in physical functioning (score 5.0 vs 2.7; P<.001) than the minimally invasive cohort at the time of discharge with no differences in affective interference between the 2 groups. In mixed modeling analysis of the first 7 postoperative days, both cohorts reported improved symptom burden and functional interference over time with generally slower recovery in the open cohort. From 1 to 8 postoperative weeks, the open cohort had worse mean scores for all evaluated symptoms and interference measures except for pain with urination, although scores indicated mild symptomatic burden and interference in both cohorts. The time to return to no or mild symptoms was significantly longer in the open cohort for overall pain (14 vs 4 days; P<.001), fatigue (8 vs 4 days; P<.001), disturbed sleep (2 vs 2 days; P<.001), and appetite (1.5 vs 1 days; P<.001) but was significantly longer in the minimally invasive cohort for abdominal pain (42 vs 28 days; P<.001) and bloating (42 vs 8 days; P<.001). The median time to return to no or mild functional interference was longer in the open than in the minimally invasive hysterectomy cohort for physical functioning (36 vs 32 days; P<.001) with no difference in compositive affective functioning (5 vs 5 days; P=.07) between the groups.

CONCLUSION

Open hysterectomy was associated with increased symptom burden in the immediate postoperative period and longer time to return to no or mild symptom burden and interference with physical functioning. However, all patient-reported measures improved within days to weeks of both open and minimally invasive surgery and differences were not always clinically significant.

Introducing the New Patient Expectations in Spine Oncology Questionnaire

BACKGROUND AND OBJECTIVES

It has been hypothesized that a discrepancy between pretreatment expectations and perceived outcomes is a significant source of patient dissatisfaction. Currently, there is lack in understanding and tools to assess patient expectations regarding the outcomes of treatment for spinal metastases. The objective of this study was therefore to develop a patient expectations questionnaire regarding the outcomes after surgery and/or radiotherapy for spinal metastases.

METHODS

A multiphase international qualitative study was conducted. Phase 1 of the study included semistructured interviews with patients and relatives to understand their expectations of the outcomes of treatment. In addition, physicians were interviewed about their communication practices with patients regarding treatment and expected outcomes. In phase 2, items were developed based on the results of the interviews in phase 1. In phase 3, patients were interviewed to validate the content and language of the questionnaire. Selection of the final items was based on feedback from patients regarding content, language, and relevance.

RESULTS

In phase 1, 24 patients and 22 physicians were included. A total of 34 items were developed for the preliminary questionnaire. After phase 3, a total of 22 items were retained for the final version of the questionnaire. The questionnaire is divided into 3 sections: (1) patient expectations regarding treatment outcomes, (2) prognosis, and (3) consultation with the physician. The items cover expectations related to pain, analgesia requirements, daily and physical function, overall quality of life, life expectancy, and information provided by the physician.

CONCLUSION

The new Patient Expectations in Spine Oncology questionnaire was developed to evaluate patient expectations regarding the outcomes after treatment for spinal metastases. The Patient Expectations in Spine Oncology questionnaire will allow physicians to systematically assess patient expectations of planned treatment and thus help guide patients toward realistic expectations of treatment outcome.

Perceived service adequacy and unmet need after discharge from brain injury rehabilitation

PURPOSE

The present study aimed to quantify the perceived needs and adequacy of realised access to post-acute services in a sample of people with acquired brain injury in the first 6-months after discharge from inpatient rehabilitation. A secondary focus was the influence of access to funding and specialist transitional rehabilitation on unmet needs.

MATERIALS AND METHODS

Participants were 51 adults with a median age of 50 (IQR 35-57) recruited from an inpatient rehabilitation unit in an Australian tertiary hospital. The sample was those who had an acquired brain injury, including 23 who sustained a traumatic injury and 28 who sustained a non-traumatic injury. Measures were collected via telephone at 3- and 6-months, in a prospective observational cohort design using the Needs and Provisions Complexity Scale. A series of logistic regression models were used to determine the effects of participation in a transitional rehabilitation program and funding pathway on adequacy and unmet needs.

RESULTS

Unmet needs for rehabilitation were most commonly reported (60%), followed by unmet needs in relation to health care (40%), social care (35%), personal care (32%) and environment-related (14%). Participants who attended transitional rehabilitation were more likely to indicate unmet health care needs (OR = 6.40, 95% CI = 1.40-29.24, p = 0.02).

CONCLUSIONS

The study highlights the need to look beyond functional impairment when conceptualising appropriate access. Additionally, the present research highlighted the need for greater work into an expectation of services.IMPLICATIONS FOR REHABILITATIONThe majority of people with an acquired brain injury report unmet needs at 6 months post discharge.Present findings support the utility of patient reported measures when considering treatment evaluation with people with ABI, where assessing the personal appraisal of individuals needs may prove to be a key indicator to facilitate optimal service access.There are specific services that needed and not provided including psychological, speech pathology, family carer needs and vocational rehabilitation, and therefore are a key target for ensuring appropriate support is provided.

Usability and performance expectancy govern spine surgeons' use of a clinical decision support system for shared decision-making on the choice of treatment of common lumbar degenerative disorders

Study design

Quantitative survey study is the study design.

Objectives

The study aims to develop a model for the factors that drive or impede the use of an artificial intelligence clinical decision support system (CDSS) called PROPOSE, which supports shared decision-making on the choice of treatment of ordinary spinal disorders.

Methods

A total of 62 spine surgeons were asked to complete a questionnaire regarding their behavioral intention to use the CDSS after being introduced to PROPOSE. The model behind the questionnaire was the Unified Theory of Acceptance and Use of Technology. Data were analyzed using partial least squares structural equation modeling.

Results

The degree of ease of use associated with the new technology (effort expectancy/usability) and the degree to which an individual believes that using a new technology will help them attain gains in job performance (performance expectancy) were the most important factors. Social influence and trust in the CDSS were other factors in the path model. r2 for the model was 0.63, indicating that almost two-thirds of the variance in the model was explained. The only significant effect in the multigroup analyses of path differences between two subgroups was for PROPOSE use and social influence (p = 0.01).

Conclusion

Shared decision-making is essential to meet patient expectations in spine surgery. A trustworthy CDSS with ease of use and satisfactory predictive ability promoted by the leadership will stand the best chance of acceptance and bridging the communication gap between the surgeon and the patient.

The Effectiveness of a Mindfulness-Based Intervention Integrated with Physical Therapy (MIND-PT) for Postsurgical Rehabilitation After Lumbar Surgery: A Protocol for a Randomized Controlled Trial as Part of the Back Pain Consortium (BACPAC) Research Program

BACKGROUND

Improving pain management for persons with chronic low back pain (LBP) undergoing surgery is an important consideration in improving patient-centered outcomes and reducing the risk of persistent opioid use after surgery. Nonpharmacological treatments, including physical therapy and mindfulness, are beneficial for nonsurgical LBP through complementary biopsychosocial mechanisms, but their integration and application for persons undergoing surgery for LBP have not been examined. This study (MIND-PT) is a multisite randomized trial that compares an enriched pain management (EPM) pathway that integrates physical therapy and mindfulness vs usual-care pain management (UC) for persons undergoing surgery for LBP.

DESIGN

Participants from military treatment facilities will be enrolled before surgery and individually randomized to the EPM or UC pain management pathways. Participants assigned to EPM will receive presurgical biopsychosocial education and mindfulness instruction. After surgery, the EPM group will receive 10 sessions of physical therapy with integrated mindfulness techniques. Participants assigned to the UC group will receive usual pain management care after surgery. The primary outcome will be the pain impact, assessed with the Pain, Enjoyment, and General Activity (PEG) scale. Time to opioid discontinuation is the main secondary outcome.

SUMMARY

This trial is part of the National Institutes of Health Helping to End Addiction Long-term (HEAL) initiative, which is focused on providing scientific solutions to the opioid crisis. The MIND-PT study will examine an innovative program combining nonpharmacological treatments designed to improve outcomes and reduce opioid overreliance in persons undergoing lumbar surgery.

A Conceptual Model for Spine Surgery Recovery: A Qualitative Study of Patients' Expectations, Experiences, and Satisfaction

STUDY DESIGN

Qualitative interview study.

OBJECTIVE

The aim was to develop a conceptual model for Spine Surgery Recovery in order to better understand why patients undergo lumbar spine surgery and what factors influence patient satisfaction.

SUMMARY OF BACKGROUND DATA

Quantitative studies have assessed patients' expectations for lumbar spine surgery outcomes, with greater expectation fulfillment leading to higher satisfaction. However, there is limited literature using qualitative methods to understand the patient perspective from the decision to undergo lumbar spine surgery through long-term recovery.

MATERIALS AND METHODS

Semistructured phone interviews were conducted with 20 participants (nine females, mean age ±SD=61.2±11.1 yr) and three focus groups with 12 participants (nine females, mean age ±SD=62.0±10.9 yr). Sessions were audio recorded and transcribed. Two independent researchers coded the transcripts using a hierarchical coding system. Major themes were identified and a conceptual model was developed.

RESULTS

A total of 1355 coded quotes were analyzed. The decision to have lumbar spine surgery was influenced by chronic pain impact on daily function, pain coping, and patient expectations. Results demonstrated that fulfilled expectations and setting realistic expectations are key factors for patient satisfaction after surgery, while less known constructs of accepting limitations, adjusting expectations, and optimism were found by many patients to be essential for a successful recovery. Emotional factors of fear, anxiety, and depression were important aspects of presurgical and postsurgical experiences.

CONCLUSION

Our Spine Surgery Recovery conceptual model provides guidance for future research and clinical practice to optimize treatment and improve overall patient satisfaction. Recommendations based on this model include the assessment of patient expectations and mental well-being throughout postoperative recovery as well as preoperatively to help set realistic expectations and improve satisfaction. Educational, acceptance-based or positive psychological interventions may be potentially beneficial for addressing key factors identified in this model.

Patient and healthcare provider experience and perceptions of a preoperative rehabilitation class for lumbar discectomy: A qualitative study

BACKGROUND

Lumbar disc disease is a leading cause of low back pain. Lumbar discectomy (LD) may be indicated if symptoms are not managed conservatively. Rehabilitation has traditionally been delivered postoperatively; however, there is increasing delivery preoperatively. There are few data concerning perceptions and experiences of preoperative rehabilitation. Exploring experiences of preoperative rehabilitation may help in the development and delivery of effective care for patients.

OBJECTIVES

To develop an understanding of patient and healthcare provider (HCP) experiences, perspectives and preferences of preoperative LD rehabilitation, including why patients do not attend.

DESIGN

A qualitative interpretive approach using focus groups and individual interviews.

METHODS

Data were collected from; a) patients listed for surgery and attended the preoperative rehabilitation (October 2019 to March 2020), b) patients listed for surgery but did not attend rehabilitation, and c) HCPs involved in the delivery of rehabilitation. Data were transcribed verbatim and analysed using thematic analysis.

RESULTS/FINDINGS

Twenty participants were included, twelve patients and eight HCPs. The preoperative class was a valuable service for both patients and HCPs. It provided a solution to staffing and time pressures. It provided the required education and exercise content helping the patients along their surgery pathway. Travel distance, transportation links, parking difficulty and cost, lack of knowledge about the class aims, and previous negative experiences were barriers to patient attendance.

CONCLUSIONS

For most patients and HCPs, the preoperative class was valuable. Addressing the challenges and barriers could improve attendance. Future research should focus on management of patient expectations and preferences preoperatively.

Patient's expectations of surgery for lumbar degenerative spondylolisthesis: analysis by type of surgery and patient factors from the Canadian Spine Outcomes and Research Network (CSORN)

BACKGROUND CONTEXT

Preoperative expectations influence postoperative outcomes. Patients with lumbar degenerative spondylolisthesis have especially high expectations of pain relief and overall functional well-being compared to patients with lumbar stenosis.

PURPOSE

The primary objective was to analyze preoperative expectations of lumbar DS patients with respect to the type of surgery proposed (decompression vs decompression and fusion). Secondarily, we aimed to assess the associations between preoperative expectations and patient and clinical factors as well as postoperative expectations fulfillment.

STUDY DESIGN/SETTING

Patients were prospectively enrolled in a multicenter, prospective cohort study evaluating the assessment and management of degenerative spondylolisthesis utilizing the infrastructure of the Canadian Spine Outcomes and Research Network (CSORN) surgical registry.

PATIENT SAMPLE

Patients with a diagnosis of degenerative spondylolisthesis with symptoms of neurogenic claudication or radiculopathy with or without back pain, unresponsive to nonoperative management over at least 3 months were included. Patients who underwent decompression, decompression and posterolateral fusion or decompression and interbody fusion at Canadian spine centers between January 2015 and September 2021 were included.

OUTCOME MEASURES

The North American Spine Society Lumbar Spine Questionnaire was utilized for expectations measurement. The expectation questionnaire was completed following consent and before surgery and at 1 year.

METHODS

Expectations for pain relief and improvements in overall functional well-being were rated on a scale of 0 to 100. Preoperative expectation in terms of pain relief and functional well-being score were calculated. Multivariate linear regression was used to evaluate the association between expected preoperative patient factors and pain relief and functional well-being. The factors associated with the most important expectation were evaluated using multivariable multinomial logistic regression.

RESULTS

Three hundred fifty-two patients were included with 100 patients undergoing decompression and 252 patients also undergoing fusion. The seven items of preoperative expectations did not differ between the procedure groups nor did expected change. The mean pain relief and overall functional well-being expectation scores did not significantly differ between procedures. Higher expectations were associated with having more comorbidities [β=-2.0 (SE 0.8), p=.020], being physically active [β=8.4 (SE 3.2), p=.010] and having more leg pain [β=1.6 (SE 0.7), p=.015]. Better perceived physical health measured by SF12 PCS was associated with lower expectation of pain relief [β= -0.4 (SE 0.2), p=.039] and functional well-being [β=-0.84 (SE 0.2), p=.001]. Better perceived mental health measured by SF12 MCS was associated with lower expectation of functional well-being [β=-0.8 (SE 0.2), p=.001]. Postoperative expectations fulfillment did not differ between procedures.

CONCLUSION

Preoperative expectations in terms of pain relief and functional well-being were similar between the two most common procedures performed, decompression ± fusion. Secondarily, higher preoperative expectations were associated with greater pain, disability and being physically active. Expectations fulfillment did not differ between procedures.

Poorer surgical outcomes at 2 years postoperatively in patients with lumbar spinal stenosis with long-term preoperative leg numbness: a single-center retrospective study

BACKGROUND

The purpose of this study was to assess whether differences in duration of preoperative leg numbness lead to different surgical outcomes.

METHODS

This study included patients with lumbar spinal stenosis (LSS) who underwent lumbar fusion surgery in our hospital from January 2018 to September 2020. Patients were divided into three groups based on duration of preoperative leg numbness: no numbness (NN) group, short-term numbness (STN) group (leg numbness ≤ 3 months) and long-term numbness (LTN) group (leg numbness > 3 months). The Numerical Rating Scale of leg pain (NRS-LP) and leg numbness (NRS-LN), Oswestry Disability Index (ODI) and Short-Form Health Survey (SF-36) were collected before surgery and at 3, 6, 12 and 24 months postoperatively.

RESULTS

178 patients were included in this study. At 24 months postoperatively, NRS-LP was significantly higher in LTN than in NN [NN vs. STN vs. LTN: 0 (0,1) vs. 0 (0,1) vs. 1 (0,1)] (p = 0.033). NRS-LN in STN [2 (1,3)] was significantly lower than in LTN [3 (2,3)] (p < 0.001). SF-36 was significantly lower in LTN than in other two groups (NN vs. STN vs. LTN: 86.10 ± 6.02 vs. 84.09 ± 5.59 vs. 78.93 ± 6.57) (p < 0.001). ODI was significantly higher in LTN than in other two groups [NN vs. STN vs. LTN: 18 (15,22) vs. 18 (16,20) vs. 21 (19,24)] (p = 0.001).

CONCLUSIONS

Patients with LSS with long-term preoperative leg numbness have poorer outcomes at 2 years postoperatively. Surgical intervention should be performed before persistent leg numbness for more than 3 months to obtain a better prognosis.

Effectiveness of a rectal cancer education video on patient expectations

AIM

Discrepancy between patient expectations and outcomes can negatively affect patient satisfaction and quality of life. We aimed to assess patient expectations of bowel, urinary, and sexual function after rectal cancer treatments, and whether a preoperative education video changed expectations.

METHODS

A total of 45 patients were assessed between January 2018 and January 2021 in a tertiary care hospital in Vancouver, Canada. Patients included were rectal cancer patients who had neoadjuvant chemoradiation and were listed for low anterior resection but had not yet had surgery. Following surgical consultation but before surgery, a questionnaire assessing expectations of lifestyle after treatments was administered. Patients then watched an educational video and repeated the questionnaire to assess for changes in expectations.

RESULTS

Patient scores indicated expectation that control of bowel movements, urination, and sexual function would sometimes be problematic, but had a range from occasionally problematic to good function. Significant change after the video was seen in the expectation of needing medications for bowel control, and 44%-69% of individual patient answers changed from prevideo to post-video, depending on the question. The education video was scored as helpful or very helpful by 82% of patients.

CONCLUSIONS

Patients have varying expectations of problematic control of bowel, urinary, and sexual function following rectal cancer treatments. A pretreatment education video resulted in a trend toward changed expectations for functional outcomes in most patients. Further educational modalities for patients may provide more uniform expectations of function and increase patient satisfaction after rectal cancer treatments.

Total laryngectomy negatively impacts sinonasal and olfactory-specific quality of life

PURPOSE

The purpose of this study is to characterize deficits in olfactory-specific and sinonasal-specific QoL after total laryngectomy (TL) with validated patient reported outcome measures.

METHODS

Thirty patients who had a TL were prospectively enrolled. Patient demographics, as well as scores from the Questionnaire of Olfactory Disorders Negative Statements (QOD-NS) and the Sino-nasal Outcome Test-22 (SNOT-22) were collected. Univariate analysis was performed to assess associations between patient characteristics and QoL scores.

RESULTS

The average QOD-NS score was 37.9 ± 11.4 (<38.5 is considered abnormal) and average SNOT-22 score was 32.0 ± 3.8 (>20 indicates a moderate/severe impact on QoL). The abnormal QOD-NS group had a greater percentage of former smokers compared to the normal group (77.8% vs. 58.1%; P = 0.56) and more median days from surgery compared to the normal group (904 vs. 477 days; P = 0.24).

CONCLUSIONS

Olfactory dysfunction associated with TL results in blunting of olfactory-specific QoL.

Fulfillment of Patient Expectations After Spine Surgery is Critical to Patient Satisfaction: A Cohort Study of Spine Surgery Patients

BACKGROUND

Patient satisfaction is an important indicator used to monitor quality of care and outcomes after spine surgery.

OBJECTIVE

To examine the complex relationship between preoperative expectations, fulfillment of expectations, postsurgical outcomes, and satisfaction after spine surgery.

METHODS

In this national study of patients undergoing elective surgery for degenerative spinal conditions from the Canadian Spine Outcomes and Research Network Registry, we used logistic regression to examine the relationships between patient satisfaction with surgery (1-5 scale), preoperative expectation score (0 = none to 100 = highest), fulfillment of expectations, and disability and pain improvement.

RESULTS

Fifty-eight percent of patients were extremely satisfied, and 3% were extremely dissatisfied. Expectations were variable and generally high (mean 79.5 of 100) while 17.3% reported that none of their expectations were met, 49.8% reported that their most important expectation was met, and 32.9% reported that their most important expectation was not met but others were. The results from the fully adjusted ordinal logistic model for satisfaction indicate that satisfaction was higher among patients with higher preoperative expectations (odds ratio [OR] [95% CI]: 1.11, [1.04-1.19]), reporting important improvements in disability (OR [95% CI]: 2.52 [1.96-3.25]) and pain (OR [95% CI]: 1.64 [1.25-2.15]) and reporting that expectations were fulfilled (OR = 80.15, for all expectations were met). The results were similar for lumbar and cervical patients.

CONCLUSION

Given the dominant impact of expectation fulfillment on satisfaction level, there is an opportunity for improving overall patient satisfaction by specifically assessing and mitigating the potential discrepancies between patients' preoperative expectations and likely surgical outcomes. The findings are likely relevant across elective surgical populations.

The Relation of Patient Expectations, Satisfaction, and Outcome in Surgery of the Cervical Spine: A Prospective Study

STUDY DESIGN

We performed a prospective nonblinded single center observational study.

OBJECTIVE

To investigate the relationship between expectations, outcome, and satisfaction with the outcome in patients undergoing cervical spine stabilization surgery.

SUMMARY OF BACKGROUND DATA

In modern healthcare, patient-reported outcome measures and patient satisfaction have become an important aspect of quality control. Therefore, outcome benchmarks for specific diseases are highly desired. Numerous studies have investigated patient-reported outcome measures and what constitutes satisfaction in degenerative lumbar spine disease. In cervical spine surgery, it is less clear what drives the postoperative symptom burden and patient satisfaction and how this depends on the primary diagnosis and other patient factors.

METHODS

This was a prospective, single center, observational study on patients undergoing cervical spine stabilization surgery for degenerative disease, trauma, infection, or tumor. Using the visual analogue scale for neck and arm pain, the neck disability index (NDI), the modified Japanese Orthopedic Association Score (mJOA) and patient-reported satisfaction, patient status and expectations before surgery, at discharge, 6 and 12 months after surgery were evaluated.

RESULTS

One hundred five patients were included. Score-based outcome correlated well with satisfaction at 6 and 12 months. Except for low NDI expectations (≥15 points) that correlated with dissatisfaction, expectations in no other score were correlated with satisfaction. Expectations did influence the outcome in some subgroups and meeting expectations resulted in higher rates of satisfaction. Pain reduction plays an important role for satisfaction, independently from the predominant symptom or pathology.

CONCLUSION

Satisfaction correlates well with outcome. Meeting expectations did influence satisfaction with the outcome. The NDI seems to be a valuable preoperative screening tool for poor satisfaction at 12 months. In degenerative pathology, pain is the predominant variable influencing satisfaction independently from the predominant symptom (including myelopathy).

LEVEL OF EVIDENCE

5.

Updates on enhanced recovery after surgery for radical cystectomy

Enhanced Recovery after Surgery (ERAS) is a multimodal pathway that provides evidence-based guidance for improving perioperative care and outcomes in patients undergoing surgery. In 2013, the ERAS society released its original guidelines for radical cystectomy (RC) for bladder cancer (BC), adopting much of its supporting data from colorectal literature. In the last decade, growing interest in ERAS has increased RC-specific ERAS research, including prospective randomized controlled trials (RCTs). Collective data suggest ERAS contributes to improved complication rates, decreased hospital length-of-stay, and/or time to bowel recovery. Various institutions have adopted modified versions of the ERAS pathway, yet there remains a lack of consensus on the efficacy of specific ERAS items and standardization of the protocol. In this review, we summarize updated evidence and practice patterns of ERAS pathways for RC since the introduction of the original 2013 guidelines. Novel target interventions, including use of immunonutrition, prehabilitation, alvimopan, and methods of local analgesia are reviewed. Finally, we discuss barriers to implementing and future steps in advancing the ERAS movement.

Establishing the minimal clinically important difference for the PROMIS Physical domains in cervical deformity patients

INTRODUCTION

Patient Reported Outcome Measurement Information System (PROMIS) instruments have been shown to correlate with established patient outcome metrics. The aim of this retrospective study was to determine the MCID for the PROMIS physical domains of Physical Function (PF), Pain Intensity (PI), and Pain Interference (Int) in a population of surgical cervical deformity (CD) patients.

METHODS

Surgical CD patients ≥ 18 years old with baseline (BL) and 3-month (3 M) HRQL data were isolated. Changes in HRQLs: ΔBL-3M. An anchor-based methodology was used. The cohort was divided into four groups: 'worse' (ΔEQ5D ≤ -0.12), 'unchanged' (≥0.12, but < -0.12), 'slightly improve' (>0.12, but ≤ 0.24), and 'markedly improved' (>0.24) [0.24 is the MCID for EQ5D]. PROMIS-PF, PI and Int at 3M was compared between 'slightly improved' and 'unchanged'. ROC computed discrete MCID values using the change in PROMIS that yielded the smallest difference between sensitivity ('slightly improved') and specificity ('unchanged'). We repeated anchor-based methods for the Ames-ISSG classification of severe deformity.

RESULTS

140 patients were included. EQ5D groups: 9 patients 'worse', 53 'unchanged', 20 'slightly improved', and 57 'markedly improved'. Patients classified as 'unchanged' exhibited a PROMIS-PF improvement of 2.9 ± 17.0 and those 'slightly improved' had an average gain of 13.3 ± 17.8. ROC analysis for the PROMIS-PF demonstrated an MCID of +2.26, for PROMIS-PI of -5.5, and PROMIS-Int of -5.4. In the Ames-ISSG TS-CL severe CD modifier, ROC analysis found MCIDs of PROMIS physical domains: PF of +0.5, PI of -5.2, and Int of -5.4.

CONCLUSIONS

MCID for PROMIS physical domains were established for a cervical deformity population. MCID in PROMIS Physical Function was significantly lower for patients with severe cervical deformity.

Mental Health Associated With Postoperative Satisfaction in Lumbar Degenerative Surgery Patients

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To assess the association between preoperative and postoperative mental health status with postoperative satisfaction in lumbar degenerative surgery patients.

SUMMARY OF BACKGROUND DATA

Poor preoperative mental health has been shown to negatively affect postoperative satisfaction among spine surgery patients, but there is limited evidence on the impact of postoperative mental health on satisfaction.

MATERIALS AND METHODS

Adult patients undergoing surgery for lumbar degenerative conditions at a single institution were included. Mental health was assessed preoperatively and 12 months postoperatively using Patient-Reported Outcomes Measurement Information System Depression and Anxiety scores. Satisfaction was assessed 12 months postoperatively using North American Spine Society Patient Satisfaction Index. The authors evaluated associations between mental health and satisfaction with univariate and multivariable logistic regression to adjust for confounders. Preoperative depression/anxiety level was corrected for postoperative depression/anxiety level, and vice versa. Statistical significance was assessed at α=0.05.

RESULTS

A total of 183 patients (47% male individuals; avg. age, 62 y) were included. Depression was present in 27% preoperatively and 29% postoperatively, and anxiety in 50% preoperatively and 31% postoperatively. Ninteen percent reported postoperative dissatisfaction using the North American Spine Society Patient Satisfaction Index. Univariate analysis identified race, family income, relationship status, current smoking status, change in pain interference, and change in physical function as potential confounders. In adjusted analysis, odds of dissatisfaction were increased in those with mild postoperative depression (adjusted odds ratio=6.1; 95% confidence interval, 1.2-32; P=0.03) and moderate or severe postoperative depression (adjusted odds ratio=7.5; 95% confidence interval, 1.3-52; P=0.03). Preoperative and postoperative anxiety and preoperative depression were not associated with postoperative satisfaction.

CONCLUSIONS

Following lumbar degenerative surgery, patients with postoperative depression, irrespective of preoperative depression status, have significantly higher odds of dissatisfaction. These results emphasize the importance of postoperative screening and treatment of depression in spine patients with dissatisfaction.

LEVEL OF EVIDENCE

Level III-nonrandomized cohort study.

Expectations of treatment outcomes in patients with spinal metastases; what do we tell our patients? A qualitative study

Background

Realistic pre-treatment expectations are important and have been associated with post-treatment health related quality of life (HRQOL). Patient expectations are greatly influenced by physicians, as they are the primary resource for information. This study aimed to explore the communication practices of physicians regarding treatment outcomes for patients with spinal metastases, and physician experiences with patients’ pre-treatment expectations.

Methods

An international qualitative study using semi-structured interviews with physicians routinely involved in treating metastatic spine disease (spine surgeons, radiation and medical oncologists, and rehabilitation specialists) was conducted. Physicians were interviewed about the content and extent of information they provide to patients with spinal metastases regarding treatment options, risks and treatment outcomes. Interviews were transcribed verbatim and analyzed using a thematic coding network.

Results

After 22 interviews data saturation occurred. The majority of the physicians indicated that they currently do not establish patients’ pre-treatment expectations, despite acknowledging the importance of these expectations. Spine surgeons often believe that patient expectations are disproportionate. Physicians expressed they manage expectations by detailing the most common risks and providing a broad but nonspecific overview of treatment outcomes. While the palliative intent seems clear to the physicians, their perception is that the implications of a palliative treatment remains elusive to most patients.

Conclusion

This study highlights the current gap in patient-physician communication regarding expectations of treatment outcomes of patients with spinal metastases. These results warrant further research to improve communication practices and determine the effect of patient expectations on patient reported outcomes in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08993-0.

Future-Proofing Startups: Stress Management Principles Based on Adaptive Calibration Model and Active Inference Theory

In this paper, the Adaptive Calibration Model (ACM) and Active Inference Theory (AIT) are related to future-proofing startups. ACM encompasses the allocation of energy by the stress response system to alternative options for action, depending upon individuals’ life histories and changing external contexts. More broadly, within AIT, it is posited that humans survive by taking action to align their internal generative models with sensory inputs from external states. The first contribution of the paper is to address the need for future-proofing methods for startups by providing eight stress management principles based on ACM and AIT. Future-proofing methods are needed because, typically, nine out of ten startups do not survive. A second contribution is to relate ACM and AIT to startup life cycle stages. The third contribution is to provide practical examples that show the broader relevance ACM and AIT to organizational practice. These contributions go beyond previous literature concerned with entrepreneurial stress and organizational stress. In particular, rather than focusing on particular stressors, this paper is focused on the recalibrating/updating of startups’ stress responsivity patterns in relation to changes in the internal state of the startup and/or changes in the external state. Overall, the paper makes a contribution to relating physics of life constructs concerned with energy, action and ecological fitness to human organizations.

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

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.

Psychomotor Predictive Processing

Psychomotor experience can be based on what people predict they will experience, rather than on sensory inputs. It has been argued that disconnects between human experience and sensory inputs can be addressed better through further development of predictive processing theory. In this paper, the scope of predictive processing theory is extended through three developments. First, by going beyond previous studies that have encompassed embodied cognition but have not addressed some fundamental aspects of psychomotor functioning. Second, by proposing a scientific basis for explaining predictive processing that spans objective neuroscience and subjective experience. Third, by providing an explanation of predictive processing that can be incorporated into the planning and operation of systems involving robots and other new technologies. This is necessary because such systems are becoming increasingly common and move us farther away from the hunter-gatherer lifestyles within which our psychomotor functioning evolved. For example, beliefs that workplace robots are threatening can generate anxiety, while wearing hardware, such as augmented reality headsets and exoskeletons, can impede the natural functioning of psychomotor systems. The primary contribution of the paper is the introduction of a new formulation of hierarchical predictive processing that is focused on psychomotor functioning.

A Qualitative Descriptive Study of Patient Experiences of Pain Before and After Spine Surgery

OBJECTIVE

The purpose of this study was to describe the preoperative and postoperative experiences of spine surgery from the patient's perspective to help inform behavioral health services provided before, during, and after hospitalization.

SETTING

Single urban academic tertiary care hospital.

METHODS

Semistructured interviews with 14 adults who underwent spine surgery. Interview transcriptions were analyzed using content analysis by three investigators to identify emergent themes.

RESULTS

Three broad domains with associated themes emerged from the analysis: 1) preoperative experience-preparation, worries, and expectations; 2) recovery process-activity and pain management strategies; and 3) postoperative support in recovery-family and social support.

CONCLUSIONS

The results of this qualitative descriptive study can be used to guide future perioperative behavioral health services for patients undergoing spinal surgery. Establishing realistic expectations of spine surgery and a comprehensive pain management plan are essential for adequate preoperative preparation. Furthermore, family involvement in the preoperative preparation for surgery is important for support of the patient during the recovery process.

Pre-treatment expectations of patients with spinal metastases: what do we know and what can we learn from other disciplines? A systematic review of qualitative studies

Background

Little is known about treatment expectations of patients with spinal metastases undergoing radiotherapy and/or surgery. Assuming that patients with spinal metastases share characteristics with patients who had spinal surgery for non-cancer related conditions and with advanced cancer patients, we performed a systematic review to summarize the literature on patient expectations regarding treatment outcomes of spinal surgery and advanced cancer care.

Methods

A comprehensive search was performed in MEDLINE, EMBASE and PsycINFO for studies between 2000 and sep-2019. Studies including adult patients (> 18 years), undergoing spinal surgery or receiving advanced cancer care, investigating patients’ pre-treatment expectations regarding treatment outcomes were included. Two independent reviewers screened titles, abstracts and full-texts, extracted data and assessed methodological quality.

Results

The search identified 7343 articles, of which 92 were selected for full-text review. For this review, 31 articles were included. Patients undergoing spinal surgery had overly optimistic expectations regarding pain and symptom relief, they underestimated the probability of functional disability, and overestimated the probability of (complete) recovery and return to work. Studies highlighted that patients feel not adequately prepared for surgery in terms of post-treatment expectations. Similarly, advanced cancer patients receiving palliative treatment often had overly optimistic expectations regarding their survival probability and cure rates.

Conclusions

Patients tend to have overly optimistic expectations regarding pain and symptom relief, recovery and prognosis following spinal surgery or advanced cancer care. Pretreatment consultation about the expected pain and symptom relief, recovery and prognosis may improve understanding of prognosis, and promote and manage expectations, which, in turn, may lead to better perceived outcomes.

Trial registration

PROSPERO registration number: CRD42020145151.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07683-7.

Patient Expectations of Adult Spinal Deformity Correction Surgery

BACKGROUND

There is a growing interest in examining preoperative expectations as a potential predictor of postoperative outcome. However, it has never been studied in the setting of adult spinal deformity (ASD). This study aims to characterize patient expectations before ASD surgery and examine the relationship between preoperative expectation and postoperative patient-reported outcomes (PROs).

METHODS

Analysis of prospectively collected clinical and PRO data was performed on patients who underwent ASD surgery. Inclusion criteria were age >18 years, a diagnosis of ASD, >3 vertebral level instrumentation, and completed pre- and postoperative surveys. The preoperative expectation survey included expectations of surgical outcome, pain reduction, complications, and the duration of postoperative recovery. Relationships between patient expectations and PROs were assessed.

RESULTS

Twenty-seven patients who underwent operative management of ASD met the inclusion criteria. In their preoperative survey, 66% of patients expected highly successful surgery, whereas 22% had a moderate expectation of complications. Patients anticipated an average 71% reduction in back pain (range 42%-100%) and 68% reduction in leg pain (range 0%-100%). Patients who met their expectations of leg pain reduction had significantly greater satisfaction scores than those who did not. There were moderate-to-strong positive correlations between preoperative expectation and observed improvement in back pain, leg pain, and mental health.

CONCLUSIONS

While substantial variability in patient expectation exists for the surgical management of ASD, patients anticipated a positive outcome with a significant reduction in pain. Greater postoperative satisfaction was associated with patients who met the expected improvement in leg pain. Preoperative expectation was positively correlated with change in pain and mental health scores.

Why are patients dissatisfied after spine surgery when improvements in disability and pain are clinically meaningful?

BACKGROUND CONTEXT

Studies have found that most patients are satisfied after spine surgery, with rates ranging from 53% to 90%. Patient satisfaction appears to be closely related to achieving clinical improvement in pain and disability after surgery. While the majority of the literature has focused on patients who report both satisfaction and clinical improvement in disability and pain, there remains an important subpopulation of patients who have clinically relevant improvement but report being dissatisfied with surgery.

PURPOSE

To examine why patients who achieve clinical improvement in disability or pain also report dissatisfaction at 1-year after spinal surgery.

STUDY DESIGN

Retrospective analysis of prospective data from a national spine registry, the Quality Outcomes Database.

PATIENT SAMPLE

There were 34,076 participants undergoing elective surgery for degenerative spine pathology who had clinical improvement in disability or pain.

OUTCOME MEASURES

Satisfaction with surgery was assessed with 1-item from the North American Spine Society lumbar spine outcome assessment. Participants with answer choices other than "treatment met my expectations" were classified as dissatisfied.

METHODS

Patients completed a baseline and 12-month postoperative assessment to evaluate disability, pain, and satisfaction. Clinical improvement was defined as patients who achieved a 30% or greater improvement in spine-related disability (Oswestry/Neck Disability Index) or extremity pain (11-point Numeric Rating Scale) from baseline to 12-month after surgery. A generalized linear mixed model was used to predict the odds of the patient being dissatisfied 1-year after surgery from demographic, clinical and surgical characteristics, postoperative complications and revision, and return to work and previous physical activity. Random effects were included to model the effect of both site and surgeon on dissatisfaction. Sensitivity analyses were conducted on samples who achieved 30% or greater improvement in (1) disability only, (2) axial (back/neck) pain only, (3) extremity (leg/arm)pain only, (4) both disability and axial pain, and (5) both disability and extremity pain. Results showed the same pattern of findings across all samples.

RESULTS

Twenty-eight percent of patients were classified as dissatisfied with their spine surgery and 72% classified as satisfied. For patients with clinical improvement in disability or extremity pain at 1-year, significant predictors of higher odds of dissatisfaction included baseline psychological distress, current smoking status, workers compensation claim, lower education, higher ASA grade, lumbar versus cervical procedure, and increased axial pain, major complication within 30 days, and revision surgery within 12-months. The most important contributors to dissatisfaction were return to work and return to previous physical activity, with the odds of dissatisfaction being over 2 times and 4 times higher for these variables. Site and surgeon explained 3.8% of the variance in dissatisfaction, with more of the variance attributed to site than to surgeon.

CONCLUSIONS

Several modifiable factors, including psychological distress, current smoking status, and failure to return to work and physical activity, helped explain why patients report being dissatisfied with surgery despite clinical improvement in disability or pain. The findings of this study have the potential to help providers identify at-risk patients, set realistic expectations during preoperative counseling, and implement postoperative management strategies. A multidisciplinary approach to rehabilitation that includes functional goal setting or restoration may help to improve patients psychological distress as well as return to work and previous physical activity after spine surgery.

Experiences From the Patient Perspective on Spinal Cord Stimulation for Failed Back Surgery Syndrome: A Qualitatively Driven Mixed Method Analysis

INTRODUCTION

When neither pharmacological therapies nor alternative interventions provide sufficient pain relief, spinal cord stimulation (SCS) can be used to treat Failed Back Surgery Syndrome (FBSS). Although it seems reasonable that quality of life (QoL)- and psychosocial-related factors contribute to the outcome of SCS since pain is a multidimensional experience, few qualitative studies have explored the expectations of SCS and experiences on SCS to treat FBSS from the patient perspective.

OBJECTIVES

The aim of this study was to qualitatively and quantitatively map the FBSS patients' experiences with SCS and the effects of SCS on low back pain caused by FBSS.

MATERIALS AND METHODS

A qualitative study with in-depth semi-structured interviews, assisted by the Brief Pain Inventory (BPI)-questionnaire.

RESULTS

Seven themes regarding patients' experiences, subdivided into 15 categories, were identified, including an understudied theme within this field of research, Spiritual Well-Being. "Acceptance" and "coping" emerged as pre-eminent motifs throughout these themes. Moreover, the realization of patients' expectations were variable throughout the presented themes. According to the BPI Questionnaire, four out of 13 patients (31%) had significant pain relief (≥50%). Seven out of 13 (54%) reported a ≥50% increase regarding enjoyment of life.

CONCLUSION

Multiple QoL- and psychosocial-related themes are related to SCS-outcomes. In order to improve SCS-outcomes for both short- and long-term, these themes should be implemented as a multidimensional approach, both prior to implantation as during follow-up.

Patient Participation With a Mobile Phone Application for Objective Activity Assessment Before and After Spinal Fusion

Background 

Evolution within spine surgery is driven by a surgeon’s desire for expertise and significant improvement in their patients’ quality of life. As surgeons move away from using subjective patient-reported outcome (PRO) surveys, there must be an alternative objective metric in its place. Modern iPhone (Apple Inc., Cupertino, CA) technology can be used to capture daily activity in a simple, non-user biased manner. These health data can be used to analyze objective functional status in conjunction with PRO surveys to measure surgical outcomes.

Methods 

Patients who underwent an awake transforaminal lumbar interbody fusion (TLIF) between 2014 and 2018 at our institution were identified. Patients were consented and instructed to download the application “QS Access” (Quantified Self Labs, San Francisco, CA). Following data collection, we analyzed the demographic information of patients who were reached to gauge participation and feasibility of data exportation.

Results

A total of 177 patients who underwent an awake TLIF at our institution were contacted. Of those who answered, 41 (44.6%) agreed to participate and 51 (55.4%) declined to participate. When comparing those who either participated or declined, there were no significant differences in age (p=0.145), sex (p=0.589), or ethnicity (p=0.686).

Conclusion 

Our pilot study examined the patient participation in the novel usage of Apple "Health" data, queried from "QS Access" (Quantified Self Labs), to objectively measure relative patient functional status surrounding spinal fusion. We demonstrated that a smartphone-based application was mostly well received by our patient cohort and has the potential to be used as an objective operative metric moving forward. 

Returning to Work Within Two Years After First-Time, Single-Level, Simple Lumbar Discectomy: A Multifactorial, Predictive Model

Purpose Continued inability to work has societal and individual consequences. Thus, the factors associated with sustained return to work after lumbar discectomy should be identified. Prior studies of the biopsychosocial factors associated with sustained RTW were primarily based on patient-reported outcome data and have shown conflicting results because of small study samples. In patients undergoing first-time, single-level, simple lumbar discectomy, we describe the time to sustained return to work within 2 years after surgery using outcome data from a national database and identify the pre- and peri-operative factors associated with sustained return to work within 2 years by developing and validating a predictive multivariable model. Methods The time to a sustained return to work within the study period was described using a Kaplan-Meier plot. A temporal validated Cox proportional hazards model examined associations between biopsychosocial factors and return to work. Results In the derivation cohort made up by 351 operated patients who were on sick-leave for more than 3 weeks around the time of surgery, 62% returned to work (median 15 weeks). The probability of sustained return to work was associated with a high education level, positive expectations towards future labor market attachment, pre-operative stable labor market attachment, pre-operative higher physical quality of life, and less disability. Conclusions Through the development and validation of a predictive model, this study identifies a number of patient-related factors associated with sustained return to work after lumbar discectomy, while revealing that most disease-related clinical findings were not associated with the outcome.

Development of a Risk Prediction Model With Improved Clinical Utility in Elective Cervical and Lumbar Spine Surgery

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

We present a universal model of risk prediction for patients undergoing elective cervical and lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Previous studies illustrate predictive risk models as possible tools to identify individuals at increased risk for postoperative complications and high resource utilization following spine surgery. Many are specific to one condition or procedure, cumbersome to calculate, or include subjective variables limiting applicability and utility.

METHODS

A retrospective cohort of 177,928 spine surgeries (lumbar (L) Ln = 129,800; cervical (C) Cn = 48,128) was constructed from the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Cases were identified by Current Procedural Terminology (CPT) codes for cervical fusion, lumbar fusion, and lumbar decompression laminectomy. Significant preoperative risk factors for postoperative complications were identified and included in logistic regression. Sum of odds ratios from each factor was used to develop the Universal Spine Surgery (USS) score. Model performance was assessed using receiver-operating characteristic (ROC) curves and tested on 20% of the total sample.

RESULTS

Eighteen risk factors were identified, including sixteen found to be significant outcomes predictors. At least one complication was present among 11.1% of patients, the most common of which included bleeding requiring transfusion (4.86%), surgical site infection (1.54%), and urinary tract infection (1.08%). Complication rate increased as a function of the model score and ROC area under the curve analyses demonstrated fair predictive accuracy (lumbar = 0.741; cervical = 0.776). There were no significant deviations between score development and testing datasets.

CONCLUSION

We present the Universal Spine Surgery score as a robust, easily administered, and cross-validated instrument to quickly identify spine surgery candidates at increased risk for postoperative complications and high resource utilization without need for algorithmic software. This may serve as a useful adjunct in preoperative patient counseling and perioperative resource allocation.

LEVEL OF EVIDENCE

3.

Patients' expectations of spine surgery for degenerative conditions: results from the Canadian Spine Outcomes and Research Network (CSORN)

BACKGROUND

Understanding patient expectations is a critical component of patient-centered care; however, little is known about which expectation(s) are most important to patients as they relate to their sense of postoperative success.

PURPOSE

To investigate patient's preoperative expectations of change in symptoms, function, and well-being resulting from surgical intervention and to examine the associations between sociodemographic, lifestyle, health status, and clinical characteristics with patient outcome expectations STUDY DESIGN: Observational cross-sectional study.

SAMPLE

Preoperative data from the Canadian Spine Outcomes and Research Network national registry of patients of patients (n=4,333) undergoing surgery for degenerative spinal conditions between 2012 and 2017.

OUTCOME MEASURES

Patients reported their expectations as a result of the surgery (0 [no change], 1 [somewhat better], 2 [better] or 3 [much better]) for seven items: leg/arm pain, back/neck pain, independence in everyday activities, sporting activities/recreation, general physical capacity, frequency and quality of social contacts, and mental well-being. Patients also reported the single most important change expected.

METHODS

Data on demographic, lifestyles, health status, clinical factors, and reasons for having surgery were also collected. Factor analysis was used to examine the multidimensionality of expectations. Multivariate linear regression was used to examine factors associated with expectations.

RESULTS

Over 80% of patients reported expectation for improvements (at least somewhat better) in all items with the exception of social contacts (75.8%). Expectations are multidimensional; a two factor structure emerged indicating two expectation dimensions (pain relief and overall functional well-being). Two expectation scores were calculated corresponding to the two dimensions (0-100), with higher scores reflecting higher expectations. The mean±standard deviation pain relief expectation score was 78.5±24.7 and the mean overall functional well-being expectation score was 69.7±24.4. In multivariate analysis, the variables associated with these dimensions either differed or differed in degree of influence. For example, higher pain and disability scores, thoracolumbar location and diagnosis of spondylolisthesis were associated with higher expectations in both dimensions, while longer disease duration was only associated with lower overall functional well-being expectations. The top three most important expected change items were pain (improvement of leg or arm pain (29.1%)/improvement in back/neck pain (26.0%)), improvement in general capacity/function (21.0%), and improvement of independence in everyday activities (15.9%). Rankings of the most important expected change were similar across sociodemographic, lifestyle, health status, and clinical variables examined.

CONCLUSIONS

Our findings highlight the need to identify and address specific individual expectations as part of the shared decision-making and presurgery education process.

A Review of Clinical Trials in Spinal Cord Injury Including Biomarkers

Acute traumatic spinal cord injury (SCI) entered the arena of prospective, randomized clinical trials almost 40 years ago, with the undertaking of the National Acute Spinal Cord Study (NASCIS) I trial. Since then, a number of clinical trials have been conducted in the field, spurred by the devastating physical, social, and economic consequences of acute SCI for patients, families, and society at large. Many of these have been controversial and attracted criticism. The current review provides a critical summary of select past and current clinical trials in SCI, focusing in particular on the findings of prospective, randomized controlled trials, the challenges and barriers encountered, and the valuable lessons learned that can be applied to future trials.

Exploring the Relationship between Perceived Ease of Use and Continuance Usage of a Mobile Terminal: Mobility as a Moderator

As the number of mobile terminal users has increased worldwide, research on continuance usage of a mobile terminal (CUMT) has received wide attention to facilitate the sustainability of development of mobile application providers. However, different results of the relationship between perceived ease of use (PEU) and continuance usage toward information technology were found in prior studies, and studies that mainly focus on their linear relationship cannot provide an explanation of the different results. The purpose of this study was to explore the relationship between PEU and CUMT to examine the intriguing possibility that a curvilinear relationship can be found. This study proposed a model with a moderator of mobility based on the environment–behavior relationship theory and expectation disconfirmation theory. The research model was tested with 311 respondents collected in China through hierarchical regressions method. The results empirically indicate that mobility moderates the relationship between PEU and CUMT and show a linear relationship under high levels of mobility and a U-shaped relationship under low levels of mobility. At a low PEU stage, PEU negatively and significantly influences the behavior of CUMT, while, at a high PEU stage, there is a positive relationship between PEU and CUMT. This paper provides a detailed explanation of this behavior in the mobile Internet context. This paper discusses theoretical contributions and practical implications for the sustainable development of mobile application providers as well as the limitations of the study and future research directions.

Patient-reported allergies predict postoperative outcomes and psychosomatic markers after spine surgery

BACKGROUND CONTEXT

Prior studies have shown that patient-reported allergies can be prognostic of poorer postoperative outcomes.

PURPOSE

The objective of this study was to investigate the correlation between self-reported allergies and outcomes after cervical or lumbar spine surgery.

STUDY DESIGN/SETTING

This is a retrospective cohort study at a single tertiary care institution.

PATIENT SAMPLE

The patient sample included all patients undergoing cervical or lumbar spine surgery from 2009 to 2014.

OUTCOME MEASURES

The primary outcome measure was change in the EuroQol-5 Dimensions (EQ-5D) after surgery. Secondary outcomes included changes in the Pain Disability Questionnaire (PDQ) and in the Patient Health Questionnaire-9 (PHQ-9), achievement of the minimal clinically important difference (MCID) in these measures, and cost of admission.

METHODS

Before and after surgery, EQ-5D, PDQ, and PHQ-9 were recorded for patients with available data. Paired Student t tests were used to compare changes in these measures after surgery. Multivariable linear and logistic regressions were used to assess the relationship between the log transformation of the total number of allergies and outcomes.

RESULTS

A total of 592 cervical patients and 4,465 lumbar patients were included. The median number of reported allergies was two. The EQ-5D index increased from 0.539 to 0.703 for cervical patients and from 0.530 to 0.676 for lumbar patients (p<.01 for both). Patients experienced significant pain improvement by the PDQ (80.1-58.2 for cervical patients and 79.4-58.1 for lumbar patients, p<.01). Using multivariable logistic regression, the log transformation of the number of allergies predicted significantly higher odds of achieving the PDQ MCID (odds ratio [OR]=2.09, 95% confidence interval [CI] 1.05-4.15, p=.02, for cervical patients; OR=1.30, 95% CI 1.03-1.68, p=.03, for lumbar patients). However, this relationship was not durable for patients with follow-up exceeding 1 year. The log transformation of the number of allergies for lumbar patients predicted a significantly increased cost of admission (β=$3,597, p<.01) and trended toward significance among cervical patients (β=$1,842, p=.10).

CONCLUSIONS

Patient-reported allergies correlate with subjective improvement in pain and disability after spine surgery and may serve as a marker of postoperative outcomes. The relationship between allergies and PDQ improvement may be secondary to the short-term expectation-actuality discrepancy, as this relationship was not durable beyond 1 year.

Minimum Clinically Important Difference in SF-36 Scores for Use in Degenerative Cervical Myelopathy

STUDY DESIGN

Post-hoc analysis of 606 patients enrolled in the AOSpine CSM-NA or CSM-I prospective, multicenter cohort studies.

OBJECTIVE

The aim of this study was to determine the minimum clinically important difference (MCID) in SF-36v2 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores in patients undergoing surgery for degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

There has been a shift toward focus on patient-reported outcomes (PROs) in spine surgery. However, the numerical scores of PROs lack immediate clinical meaning. The MCID adds a dimension of interpretability to PRO scales; by defining the smallest change, a patient would consider meaningful.

METHODS

The MCID of the SF-36v2 PCS and MCS were determined by distribution- and anchor-based methods comparing preoperative to 12-month scores. Distribution-based approaches included calculation of the half standard deviation and standard error of measurement (SEM). Change in Neck Disability Index (NDI) served as the anchor: "worse" (ΔNDI>7.5); "unchanged" (7.5≥ΔNDI>-7.5); "slightly improved" (-7.5≥ΔNDI>-15); and "markedly improved" (ΔNDI ≤-15). Receiver operating characteristic (ROC) analysis was performed to determine the change score for the MCID with even sensitivity and specificity to distinguish patients who were "slightly improved" versus "unchanged" on the NDI.

RESULTS

The MCID for the SF-36v2 PCS and MCS were 4.6 and 6.8 by half standard deviation and 2.9 and 4.3 by SEM, respectively. By ROC analysis, the MCID was 3.9 for the SF-36v2 PCS score and 3.2 for the SF-36v2 MCS score. Using a cutoff of 4 points, the SF-36v2 PCS had a sensitivity of 72.2% and specificity of 68.1%, and MCS 61.9% and 64.6%, respectively, in separating patients who were "markedly improved" or "slightly improved" from those who were "unchanged" or "worse."

CONCLUSION

We found the MCID of the SF-36v2 PCS and MCS to be 4 points. This will facilitate use of the SF-36v2 as an outcome in future studies of DCM.

LEVEL OF EVIDENCE

3.

General Health Adverse Events Within 30 Days Following Anterior Cervical Discectomy and Fusion in US Patients: A Comparison of Spine Surgeons' Perceptions and Reported Data for Rates and Risk Factors

STUDY DESIGN

Survey study and retrospective review of prospective data.

OBJECTIVES

To contrast surgeons' perceptions and reported national data regarding the rates of postoperative adverse events following anterior cervical discectomy and fusion (ACDF) and to assess the accuracy of surgeons in predicting the impact of patient factors on such outcomes.

METHODS

A survey investigating perceived rates of perioperative complications and the perceived effect of patient risk factors on the occurrence of complications following ACDF was distributed to spine surgeons at the Cervical Spine Research Society (CSRS) 2015 Annual Meeting. The equivalent reported rates of adverse events and impacts of patient risk factors on such complications were assessed in patients undergoing elective ACDF from the National Surgical Quality Improvement Program (NSQIP).

RESULTS

There were 110 completed surveys from attending physicians at CSRS (response rate = 44%). There were 18 019 patients who met inclusion criteria in NSQIP years 2011 to 2014. The rates of 11 out of 17 (65%) postoperative adverse events were mildly overestimated by surgeons responding to the CSRS questionnaire in comparison to reported NSQIP data (overestimates ranged from 0.24% to 1.50%). The rates of 2 out of 17 (12%) postoperative adverse events were mildly underestimated by surgeons (range = 0.08% to 1.2%). The impacts of 5 out of 10 (50%) patient factors were overestimated by surgeons (range relative risk = 0.56 to 1.48).

CONCLUSIONS

Surgeon estimates of risk factors for and rates of adverse events following ACDF procedures were reasonably nearer to national data. Despite an overall tendency toward overestimation, surgeons' assessments are roughly appropriate for surgical planning, expectation setting, and quality improvement initiatives.

Patient expectations for management of chronic non-cancer pain: A systematic review

Background

Chronic pain is a major economic and social health problem. Up to 79% of chronic pain patients are unsatisfied with their pain management. Meeting patients’ expectations is likely to produce greater satisfaction with care. The challenge is to explore patients’ genuine expectations and needs. However, the term expectation encompasses several concepts and may concern different aspects of health‐care provision.

Objective

This review aimed to systematically collect information on types and subject of patients’ expectations for chronic pain management.

Search strategy

We searched for quantitative and qualitative studies. Because of the multidimensional character of the term “expectations,” the search included subject headings and free text words related to the concept of expectations.

Data extraction and synthesis

A framework for understanding patients’ expectations was used to map types of expectations within structure, process or outcome of health care.

Main results

Twenty‐three research papers met the inclusion criteria: 18 quantitative and five qualitative. This review found that assessment of patients’ expectations for treatment is mostly limited to outcome expectations (all 18 quantitative papers and four qualitative papers). Patients generally have high expectations regarding pain reduction after treatment, but expectations were higher when expressed as an ideal expectation (81‐93% relief) than as a predicted expectation (44‐64%).

Discussion and conclusions

For health‐care providers, for pain management and for pain research purposes, the awareness that patients express different types of expectations is important. For shared decision making in clinical practice, it is important that predicted expectations of the patient are known to the treating physician and discussed.

Structure and process expectations are under‐represented in our findings. However, exploring and meeting patients’ expectations regarding structure, process and outcome aspects of pain management may increase patient satisfaction.

The evolution of our measurement of patient treatment expectations

Commentary On: Mancuso CA, Duculan R, Cammisa FP, Sama AA, Hughes AP, Lebl DR, et al. Fulfillment of patients' expectations of lumbar and cervical spine surgery. Spine J 2016:16:1167-74 (in this issue).