Effect on leg pain is biggest factor for patients considering sciatica surgery

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Pravesh Gadjradj

The effect on leg pain is the most important factor for patients when it comes to deciding whether or not to undergo surgery for sciatica. This is according to a recent study, which was published in the Journal of Neurosurgery: Spine by Pravesh Gadjradj (Weill Cornell, Brain and Spine Centre, New York, USA) et al, and which also found that not all potential advantages of minimally invasive spine surgery—such as scar size and no need for general anaesthesia—are necessarily perceived as advantages by patients themselves.

According to the study researchers, these findings suggest that spine surgeons “should propose surgical techniques for sciatica, not only based on own ability and proposed eligibility, but also based on patient preferences” as part of a shared decision making process.

The study aimed to determine the relative preference weights patients apply to various attributes of lumbar discectomy, determine if patient preferences change after surgery, identify preference heterogeneity for choosing surgery for sciatica, and calculate patient willingness to pay for other attributes.

A discrete choice experiment (DCE) was conducted among patients with sciatica caused by lumbar disc herniation. A questionnaire was then given to patients prior to surgery and to an independent sample of patients who had already undergone surgery. Patients were required to choose between two surgical techniques or to opt out from 12 choice sets with alternating characteristic levels: waiting time for surgery, out-of-pocket costs, size of the scar, need of general anaesthesia, need for hospitalisation, effect on leg pain, and duration of the recovery period.

A total of 287 patients were included in the DCE analysis, which found that all attributes, except scar size, had a significant influence on the overall preferences of patients. The effect on leg pain was found to be the most important factor in the decision for a surgical procedure (chosen by 44.8%). The potential out-of-pocket costs for the procedure (28.8%), wait time (12.8%), need for general anaesthesia (7.5%), need for hospitalisation (4.3%), and the recovery period (1.8%) were also highlighted.

Preferences were independent of the scores on patient-reported outcome measures and baseline characteristics. Three latent classes could be identified with specific preference patterns. Willingness-to-pay was the highest for effectiveness on leg pain, with patients willing to pay €3,133 for a treatment that has a 90% effectiveness instead of 70%.

Speaking to Spinal News International, Gadjradj said: “The idea of conducting this study arose when I was a medical student attending an outpatient clinic where minimally invasive lumbar disc surgery was offered. Patients were often counselled about the advantages and disadvantages of minimally invasive surgery and often the use of local anaesthesia instead of general anaesthesia or the option to undergo surgery in an outpatient clinic setting, were presented as advantages to the patient.

“To me as a student, both of these seemed advantageous to the surgeon, but not to me if I was a patient with sciatica. Therefore, we tried to capture these patient preferences in as unbiased a way as possible, with advanced research methodology provided by the Erasmus Choice Modelling Centre.

“The findings of this study did surprise my colleague physicians, who were more tenured spine surgeons, but did not actually surprise me as it in fact confirmed my hypothesis. As the popularity of full-endoscopic lumbar disc surgery increases, and the evidence increases showing equivalence in leg pain reduction between endoscopic surgery and conventional open microdiscectomy, the importance of other factors such as out-of-pocket costs, wait time to surgery and need for general anaesthesia, could be tie-breakers from a patient perspective when choosing a specific procedure.”


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