A positive attitude does not always lead to positive results in lumbar spine surgery

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A positive attidude can sometimes set patients up for disappointment

According to a new study presented at the 31st Annual Meeting of the North American Spine Society (NASS), high expectations of pain improvement before a common back surgery are actually associated with less pain improvement after surgery.

“While a positive attitude can be terrific for overall wellness, this study suggests that a patient’s high expectations about pain relief from lumbar surgery could actually set them up for some disappointment,” says Scott Kreiner, a physiatrist and 2016 NASS Annual Meeting Program Chair. “For the very best outcomes, it is critical that spine specialists do a thorough job of educating patients and managing their expectations.”

The study, “Greater Expectations of Pain Improvement Are Associated with Less Actual Pain Improvement after Lumbar Surgery” was selected as one of the “Best Papers” at the NASS meeting.

In a single-centre prospective cohort study, 422 patients experiencing pain underwent lumbar surgery. Patients had the following characteristics: mean age 56 years, 55% men, 78% degenerative diagnosis, 44% taking opioids, and median back (7) and leg (6) pain intensities. Prior to their surgery, patients completed a validated survey that included an item that specifically asked about expected pain improvement with response options of “complete,” “a lot,” “a moderate amount,” and “a little.”

Patients also rated back and leg pain intensity on a 0–10 scale and completed a survey for depressive symptoms. Clinical information included diagnosis, number of vertebral levels involved, and whether this was revision surgery. Most expected “a lot” (44%) or “complete” (45%) pain improvement. At a two-year follow-up, patients were asked a global question about how much pain improvement they received, with response options of “complete,” “a lot,” “a moderate amount,” “a little,” and “no improvement.” Patients also rated the intensity of current back and leg pain (0–10), and reported on any subsequent spine surgery.

Regarding postop actual pain improvement, 11% reported “no improvement” and 89% reported at least some improvement (28% “a little” to “moderate” improvement, 44% “a lot,” and 17% “complete” improvement). In multivariable analysis, patients had less improvement if they expected greater pain improvement (OR 1.4), had symptoms longer (OR 1.6), had a positive screen for depression (OR 1.7), were having revision surgery (OR 1.6), had surgery at L4 or L5 (OR 2.5), had a degenerative diagnosis (OR 1.6), had a subsequent surgery (OR 2.8), and had less decrease in back (OR 1.3) and leg pain intensity (OR 1.1) (p<0.5 for all comparisons).

While most patients had improvement in back pain two years postop, the amount of actual improvement often was less than the amount expected by patients. This was particularly true for patients who expected “complete” pain relief, which most likely was an unrealistic expectation for their clinical scenario. Less improvement was associated with multiple demographic and clinical variables, including greater preoperative expectations for pain relief. “Expecting greater pain improvement pre-op is associated with patients’ rating of less pain improvement postop. Expecting complete pain improvement, in most cases, is unrealistic,” says study lead author Federico P Girardi, from the Hospital for Special Surgery, New York City, USA. “Given that expectations are potentially modifiable, this study supports addressing pain-related expectations with patients prior to surgery through discussions with surgeons and through formal patient education.”

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