Over 5 million children undergo surgery each year1; however, presurgical factors that impact outcomes after surgery are not well understood. Existing research has largely focused on the impact of presurgical anxiety and coping on postoperative pain. Palermo et al2 found that anticipatory distress and child coping strategies were predictive of acute postoperative pain regardless of surgical and demographic variables. Among studies that have specifically evaluated adolescents with idiopathic scoliosis (AIS) undergoing spinal fusion surgery, 1 study found that presurgical self-image, mental health, and age contributed to a patient’s longitudinal experience with postoperative pain,3 whereas another study found that patients with more vigilant (eg, seeking information about the surgery) preoperative coping strategies experienced better recovery outcomes than those patients with more avoidant (eg, limiting detailed information about the surgery) preoperative coping strategies.4 Although these studies provide important data regarding outcomes related to pain and functioning after surgery, another important dimension to consider is patient satisfaction. Given the evolving nature of health care within the United States that places a premium on optimizing patients’ experiences, there is a need to address how patient characteristics can impact postsurgical satisfaction. Over the past 10 years, there has been an increase in the weight of patient satisfaction on physician compensation; however, measures of patient satisfaction have been criticized for their ambiguity and lack of validity.5–7 The patient factors influencing surgical expectations is likely multifactorial and likely include self-image and mental health status.
The purpose of the present study was to examine how preoperative mental health, self-image, pain, and expectations for spinal appearance predicted postoperative satisfaction in a large prospective cohort of youth with AIS who underwent spinal fusion surgery. Previous research on patient satisfaction has focused primarily on adult subjects or nonsurgical models.8,9 We hypothesized that better preoperative mental health and self-image and lower presurgical pain would be predictive of better satisfaction 2 years postsurgery with presurgical expectations for spinal appearance mediating this relationship.
Data were collected as part of the Prospective Pediatric Scoliosis Study, a multisite, longitudinal study that evaluates existing practices in the surgical intervention for pediatric patients with AIS. Data were collected between 2003 and 2007 and only data from Boston Children’s Hospital were used to have a consistent surgical treatment regimen. Inclusion criteria for this study included a diagnosis of thoracic, thoracolumbar, and/or lumbar idiopathic scoliosis and a spinal fusion with instrumentation. Patients were followed longitudinally at preoperative, 1- and 2-year postoperative timepoints. Of the 260 patients who completed baseline data, 190 patients completed follow-up data at 1 and 2 years. Parent informed consent and child assent for minor patients and consent for patients18 years and older was obtained. Participant responses to follow-up measures were completed either at follow-up appointment or by mail (Table 1).
Expectations for Spinal Appearance
Using the 4-item expectations subscale of the Spinal Appearance Questionnaire (SAQ) 10 we evaluated patient presurgical expecations for the appearance of their spine, shoulders, hips, and waist (eg, “I want to be more even”). A higher score indictes worse expecations and satisfaction. The SAQ has demonstrated reliability and validity.11 The mean for this sample was 15.00 (SD=0.69).
Derived from the Scoliosis Research Society-30 (SRS-30),12 the Mental Health subscale consists of 5-items and assesses general well-being of participants over the course of the last 6 months with higher scores indicative of better outcomes (eg, “During the past 6-month, have you been a very nervous person?”). The mean for this sample was 3.98 (SD=0.60).
Derived from the SRS-30,12 the Self-image subscale consists of 6-items (preoperatively) and assesses health perceptions, social functioning, and physical functioning with higher scores indicative of better outcomes (eg, “How do you look in clothes?” “Do you feel that your back condition affects your personal relationships?”). The mean for this sample was 3.51 (SD=0.60).
Derived from the SRS-30,12 the Pain subscale consists of 5-items and assesses back pain and pain management over the past 6 months with a higher score indicating less pain, less medication use, and less missed work/school days due to pain (eg, “Do you experience back pain at rest?”). The mean for this sample was 4.01 (SD=0.54).
Derived from the SRS-30,12 the Satisfaction subscale consists of 3-items (2 that can be assessed before surgery and 1 that can also be assessed after surgery) that measure satisfaction with back management with a higher score indicating increased satisfaction (eg, Would you have the same management again if you had the same condition?). The mean for this sample was 1.64 (SD=0.69).
Data obtained for secondary data analysis for the present study were approved by the Institutional Review Board. Patients completed the questionnaire at the time of the preoperative visit 1 to 3 weeks before the surgery. The questionnaires were completed with parental assistance as necessary for the younger patients or independently by the patient depending on the patients’ level of understanding of the questionnaire. Standard postoperative visits occurred at 1 and 2 years after surgery with completion of the questionnaires at the time of the office visit or by mail. All statistical analyses were carried out using SPSS Software Version 21.
Descriptive statistics were conducted for demographic and study variables. Regression analyses with bootstrapping as outlined by Preacher and Hayes13 (with n=5000 bootstrap samples; http://analyses.com/spss-sas-andmplus-macros-and-code.html) were conducted with 99% bias-corrected confidence intervals to examine the extent to which preoperative expectations for spinal appearance mediated the relations between presurgical mental health and self-image and 2-year postsurgical satisfaction with spinal appearance. In this model, the total effect (weight c, a regression coefficient) of an independent variable (IV) (ie, presurgical mental health and pain) on a dependent variable (DV) (ie, 2-year postsurgical satisfaction with spinal appearance) is composed of a direct effect (weight c′, a regression coefficient) of the IV on the DV and an indirect effect (weight a×b) of the IV on the DV through a proposed mediator (M) (ie, presurgical expectations for spinal appearance). Weight a signifies the effects of the IV on the M, whereas weight b reflects the effect of the M on the DV, controlling for the effects of the IV. Mediation is demonstrated if the bias-corrected confidence intervals do not contain 0.
Preliminary Analyses and Description of the Sample
Of the 260 patients included in this study, 190 patients completed follow-up data at 1 and 2 years postsurgery. We examined baseline differences between patients who completed follow-up data (n=190) and those who did not (n=70) to examine any response or participation bias. There were no significant differences found on age, sex, or race/ethnicity. However, there was a significant difference found on the preoperative pain subscale scores for those who completed follow-up versus those who only had baseline data. Those with postsurgical data reported significantly less preoperative pain (M=4.01, SD=0.54) compared with the group who completed only baseline measures (M=3.72, SD=0.77) (F1,246=10.77, P<0.0.001). For all subsequent analyses, we examined patients who had complete 1 and 2 years postsurgical data points (n=190). Age at the time of surgery for this sample was between 8 and 21 years (M=14, SD=2.29). Patients were predominantly female (72%) and white (82%). The mean preoperative curve angle of the spine was 57.5 degrees (SD=13.09 degrees), which is considered a curve in the severe range. The majority of patients (90%) underwent a posterior surgical approach.
In examining the bivariate correlations between demographic variables, preoperative functioning, surgical variables (eg, major curve, Lenke classification, surgical approach, fusion length), and postoperative satisfaction, there were no significant correlations between any of the surgical variables, as well as for biological sex, age, or presurgical self-image. However, postsurgical satisfaction demonstrated significant modest correlations at P<0.05 with presurgical pain (−0.15), presurgical mental health (−0.18), and presurgical expectations (−0.19) for spinal appearance and thus was used to build the meditational models.
Presurgical mental health was not significantly associated with presurgical expectations (a path) but presurgical expectations were significantly associated with satisfaction 2 years after surgery (b path). When examining the indirect effects, not surprisingly, presurgical mental health did not indirectly impact satisfaction 2 years after surgery through its influence on presurgical expectations (β=0.023, BCCI=−0.02 to 0.10, a×b path). However, presurgical mental health significantly predicted satisfaction 2 years after surgery with poorer preoperative mental health predictive of better post-operative satisfaction (c path) and this relationship remained after controlling for presurgical expectations for spinal appearance (c' path). Interestingly, the relationship between presurgical pain and 2-year postsurgical satisfaction was mediated by presurgical expectations for spinal appearance (confidence interval, 0.01-0.18). All paths in the model were significant. Higher presurgical pain was predictive of higher expectations and better post-surgical satisfaction. Lower presurgical expectations was predictive of better post-surgical satisfaction.
Given the evolving nature of health care in the United States, where patient satisfaction is becoming increasingly tied to physician reimbursement,5 it is necessary to examine potential barriers to long-term satisfaction. By assessing preoperative factors that could later contribute to satisfaction with surgical outcomes, surgeons can proactively target these issues to positively impact postsurgical care.
The present study examined how presurgical mental health, pain, and self-image among adolescents with idiopathic scoliosis could impact satisfaction with management 2 years after undergoing spinal fusion surgery. The mediating role of presurgical expectations for spinal appearance was also examined. Unexpectedly, presurgical self-image was not related to postsurgical satisfaction. Further research should be conducted exploring the role self-image has on postsurgical outcomes. Findings indicate that both presurgical mental health and pain are predictive of postsurgical satisfaction scores. Contrary to our hypotheses, we found that worse pre-operative mental health and higher presurgical pain was predictive of better post-surgical satisfaction. While it was initially hypothesized that better presurgical functioning would serve as a buffer for better surgical outcomes, it seems that patients with poorer preoperative mental health prior to surgery may have been more negatively impacted by their curve and therefore were more highly satisfied when it was corrected. Similarly, patients with higher presurgical pain may have had more to gain from surgery, thus improving their satisfaction. However, when examining the mediating role of presurgical expectations for spinal appearance, this variable only mediated the relationship between presurgical pain and postsurgical satisfaction; it did not mediate the relationship between presurgical mental health and postsurgical satisfaction, indicating that both mental health and presurgical expectations exert their own influence on postsurgical satisfaction with management. However, it was found that patients with follow-up data versus those with only baseline had significantly lower pain before surgery. It is possible that this model may operate differently among patients who report higher levels of preoperative pain and future research should examine that.
Findings suggest that it is important for surgeons performing spinal fusion surgery to monitor presurgical mental health and pain along with identifying those patients who have exceedingly high expectations for their appearance. Interdisciplinary collaboration with a mental health provider could prove quite useful to screen patients and implement intervention efforts tailored at targeting pain and mental health as well as realistic expectations before undergoing spinal fusion surgery.
This study should be viewed in light of its limitations. First, data collection for this study ended in 2007. As presurgical education, surgical techniques, and postoperative care may have changed since that time, it is unclear how potential differences in care may impact postsurgical satisfaction. Data from more recent data sets should be analyzed. However, given that for this sample, there were no significant correlations between surgical variables and predictors and outcomes, it is likely that mental health and high expectations for surgical outcomes will still be important to consider as these are traits intrinsic to the individual patient and may not necessarily be impacted by surgical variables. This study only examined patients with idiopathic scoliosis undergoing spinal fusion surgery, so it will be useful to examine this model with other diverse surgical samples in the future. The SRS-22 preoperative measures used in this study were available using the Prospective Pediatric Scoliosis Study and do not reflect the most comprehensive means of assessing preoperative mental health, pain, self-image, expectations, and satisfaction; however, it may be an effective screening tool. We would suggest that a score of <4 on the SRS subscales may indicate less than optimal functioning and referral to a staff psychologist or social worker. The current findings suggest that further evaluation of these factors is warranted as they do appear to potentially influence postsurgical satisfaction. In addition, research has suggested that youth aged 8 to 16 demonstrated difficulties understanding the questions in the SAQ.14 Given that the mean age of our sample was 14 and that parents of younger patients assisted with completion of the data, we do not think that the validity of this measure was a concern; however, it is possible that some patients may have had difficulty answering these questions.
In an era of health care reimbursement that is shifting toward payment for performance, defining successful surgical outcomes hinges not only on traditional biometrics but also patient satisfaction. Optimizing patient satisfaction after surgery involves consideration of preoperative pain, mental health status, and managing appearance expectations.
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