Preoperative expectations influence patient's decision to undergo surgery and subsequent satisfaction with treatment.1,2 Participation of patients in decision-making can modify expectations; this is particularly true in areas in which surgery is highly discretional, such as lumbar decompressive surgery (LDS) for sciatica.
LDS is offered to patients suffering from sciatica due to lumbar disc herniation or spinal stenosis after failure of conservative management. Outcomes following LDS are variable and 10% to 40% of patients experience persistent postsurgical pain and functional limitations3,4 and require further medical attention or additional surgery.5–10 Given the risks involved in major surgery and the uncertain benefits of LDS, informed choice is a key element of ethical practice in this area. To facilitate informed decision-making and ensure realistic expectations regarding surgery, surgeons must convey to patients the goals of surgery and its limitations.11–14
“Expectation” is a multifaceted term commonly used in surgical research. Quantitatively, “expectation” represents the predictive likelihood of a clinical outcome or the phenomena most commonly explored.15–23 Qualitatively, “expectation” represents the perception of patients and their understanding of information that they need to make informed decisions regarding available treatment options.24–26 Patient expectations are important; postoperative satisfaction is higher when preoperative expectations are met.25,27–29
To date, qualitative studies exploring the preoperative expectations of sciatica patients have been limited and, instead, studies have focused on the postsurgical satisfaction of patients with microdiscectomy,30,31 satisfaction with nonsurgical treatments,32,33 barriers and facilitators for shared decision making,34 recruiting heterogeneous patients, or recruiting patients at different stages of their treatment course.35–37 We undertook a qualitative study to explore sciatica patients’ preoperative expectations and their spine surgeon's perspectives with regards to understanding regarding LDS, postoperative outcomes, and information required for informed decision-making.
MATERIALS AND METHODS
The focus of this qualitative study was to explore the concordance of patients’ and surgeons’ expectations regarding decompression surgery for sciatica. We conducted a descriptive qualitative study using inductive content analysis and semistructured interviews with patients and surgeons. We chose inductive content analysis as this approach is well suited to exploring complex processes and phenomena in areas in which existing knowledge is deemed inadequate. Inductive content analysis allows researchers to create meaningful categories, operational definitions, and enables the organization of data.38,39
We conducted 18 individual interviews between September 2016 and March 2017, using convenience sampling to recruit eligible patients, and their surgeons, from six neurosurgical practices in Hamilton, Ontario. Eligible patients were scheduled for surgical decompression to address symptoms of sciatica, were 18 years or older, and were available for interview 3 to 4 weeks after their surgical consultation but before surgery. An exception was made for one participant who consented to participate in the study preoperatively, but an interview could not be scheduled until 3 days after the surgery had been performed. We considered this patient eligible for the study because we anticipated that memories of the preoperative information received, and expectations were still likely to be accessible, and distortion as a result of postoperative outcomes would be unlikely since the patient was minimally advanced in their rehabilitation process. We excluded patients with acute presentations such as cauda equina syndrome, malignant tumor, or acute infections. The Hamilton Integrated Research Ethics Board approved our study and all the participants provided written informed consent prior to participation.
We developed separate interview guides for patients and surgeons. The patient interview guide focused on patients’ understanding of their condition and surgery, their preoperative expectations, and their decision-making process. The surgeon guide focused on methods used to explain surgery to patients, what surgeons thought were patient's major concerns, and what decision-making process they thought patients employed. Interviews to inform qualitative research continue until the data show saturation, signifying that no new themes emerge from subsequent interviews and the resulting analysis is able to accommodate all relevant viewpoints within the existing data.40 We conducted interviews until thematic saturation was achieved.41–44 We determined saturation through discussion with multiple research team members and sharing information with spine surgeons and patients. Interviews were audio recorded, transcribed verbatim, and team members checked transcripts for accuracy. To maintain the credibility and trustworthiness of the data, member checking45–48 was conducted by sharing the findings of this study with consenting spine surgeons and patients.
Coding and Thematic Analysis
Two teams of reviewers conducted coding and thematic analysis of interview transcripts in duplicate, with a focus on capturing the meanings and concepts of each theme or category. Reviewers labeled data with similar inherent meanings with short phrases or sentences to generate categories. Within each category, reviewers identified the main themes and supporting quotes. Each theme was supported by a subtheme to describe the properties of the theme, thus forming more concrete explanations about the concept. Data were managed with QDA Miner Lite V 1.3.
We interviewed 12 patients and six surgeons, at which point we achieved thematic saturation and stopped recruitment (Tables 1 and 2). All patients had leg dominant symptoms such as pain, numbness, or paraesthesia for at least 2 months. Additionally, most patients reported irritability and low mood due to their pain and functional limitations: “My mood is getting low day by day and now I understand why people with pain are all depressed...the less I do the more I get depressed (P#8).” Thematic analysis informed the perspectives of patients and surgeons in the context of expectations for LDS (Figure 1). We identified three major points of discrepancy between surgeons and patients: understanding the role of surgery, information needs, and decision-making. We also identified notable variations among surgeons in our study.
Variation in Surgical Consultation
The decision to offer surgery to patients was primarily based on medical history, examination, and magnetic resonance imaging findings. There were, however, notable variations in the screening process utilized by surgeons. One surgeon reported that, because he believed they were less likely to benefit, he did not offer surgery to patients with chronic pain syndromes and/or psychological co morbidities such as fibromyalgia, endometriosis, depression, or anxiety: “…I tell patients that surgery will not help them as they have other symptoms…(S#6).” Another surgeon (S#2) worked in collaboration with a physiotherapist with an interest in low back pain. As a result, all patients were screened for surgical candidacy and received information about their surgery prior to their surgical consultation. Another surgeon (S#2) offered nurse-led group education sessions with patients and their family members or friends.
Limited Recall From Presurgery Consultation
All participating surgeons reported using spine models and the patient's magnetic resonance imaging results as visual aids to illustrate the basic anatomy of lumbar disc herniation and spinal stenosis. Surgeons also described informing patients about the risks associated with anesthesia and surgery. When requested to recall the discussion with their surgeons, however, most patients did not have a clear understanding of their upcoming surgery. Moreover, half of the patients were unclear regarding their diagnosis: “my doctor told me, but I can’t remember the name, it's like extrusion (P#1).” Patients were able to recall far fewer complications than surgeons reported discussing; the exception being “paralysis,” which all patients recalled.
Patients also expressed uncertainty about what was required from them postoperatively: “… [the] surgeon only said that I am to do some physiotherapy but did not explain activity modification such as lifting…no information was given that I can recall (P# 8),” and: “I don’t even know if there are serious long-term consequences…[I didn’t] receive information on rehabilitation or what to do after surgery (P#4).”
Patients and surgeons agreed that the amount of information presented during the consultation was excessive. During member checking, surgeons acknowledged that most patients do not leave with a clear understanding of their condition or their upcoming surgery: “In spite of explaining everything with the help of patient images and/or models, I am surprised how little they actually take home” (S#6).
Discrepancy Regarding the Goals of Surgery
All surgeons stressed that the goal of surgery was not to remedy back pain, but to relieve leg pain. More often than not, surgeons reported that patients were overly optimistic about surgery, expecting complete recovery, including their back pain: “…often patients think their symptoms will go away 100%… so that's the expectation I do try to dampen down, because it's not realistic (S#4),” and: “... Saying that 90% of my patients are happy they had surgery… the 90% don’t necessarily get all better, but they’re improved from where they were (S#1).” Results from our patient interviews were consistent with surgeons’ impressions: “the best scenario would be that I don’t have any more back pain…don’t have any more numbness or pain going down my leg… that I just get back to a normal life… (P#5).” During member checking, one surgeon was surprised with these findings: “Most of us tell patients that the surgery is for leg pain… hence, perplexed by comment that they expect low back pain to get better… find it strange that they did NOT understand the condition …(S#3).”
Efforts to Improve Patients’ Understanding
All surgeons permitted patients to ask questions. In situations in which patients were uncertain about undergoing surgery, surgeons encouraged further deliberation: “we talked about a lot of things here… maybe you should go home, contemplate, and think….you don’t have to decide or rush on the spot (S#4).” One surgeon (S#6) called patients the night before surgery to answer any last-minute questions. Patients suggested that surgeons utilize written materials to provide information: “I thought there would be a little bit more information… even in writing, pamphlets just to understand it better… you know you lose your train of thought when somebody is just explaining at you (P#1).” One surgeon reported that attending the consultation with an advocate is helpful: “it turns out the other person who comes (with the patient) …listens and has the best questions (S#2).” On member checking, another surgeon advised they re-enforced information to patients both before and after surgery, but also acknowledged the discussion was directed by what patient's asked them: “…It's something I routinely do the day of surgery and after surgery … If they don’t ask me, I don’t always tell them those details (S#1).”
Nonsurgeon Sources From Which Patients Sought Information
Patients consulted a wide variety of sources of information about their surgery that informed their decisions. The main sources were friends and family, the Internet, and family physicians. For example: “I know there was a probability of my herniation reoccurring, but that was all through my own research (P#2).” Both patients and surgeons expressed concerns regarding the challenges of identifying credible information on the Internet: “…[I’d] like to see this information come from the surgeon as doctor Google is not always a good way to go (P#5).”
Surgeons often expressed concern that family physicians may engender unrealistic expectations in patients. Specifically, when family physicians advised patients they needed surgery to fix their problem, but the surgeons failed to see them as surgical candidates, or vice versa: “Some families’ physicians have already told them…don’t have the surgery, and I find that irritating because why are you sending the guy to a surgeon when you’ve already told them not to have surgery (S#6).” Some surgeons offered second opinion referrals in situations in which they did not deem the patient to be a surgical candidate, but the patient had an expectation that they would be offered surgery.
Patient's Decision-making Process for Surgery
All the patients reported that opting for surgery was their own decision, which was based on their pain, functional limitations, as well as failure of prior treatment: “it was pretty simple—I wanted to get better and the only way to get better was to have the surgery (P#11).”
In this qualitative study of patients’ and surgeons’ expectations about LDS, most patients expected complete recovery, including resolution of their back pain, which surgeons considered to be unrealistic and not the message they tried to convey during the consultation. Surgeons mostly provided information about the surgery, the success rate of the surgery, and the possible complications associated with surgery. Patients, however, desired more information pertaining to postoperative activity modifications and long-term outcomes. In cases where information was lacking, additional information was sought by patients from external sources to help reassure them of their decision. The decision to undergo LDS was mainly based on pain, functional limitations, and failure of previous treatments that patients experienced.
Some patients acknowledged the possibility that their surgeon could have given them information about their postoperative activity modifications, but they had forgotten. Additional barriers included the copious amount of information given to patients during consultations, often compounded by their psychological and physical distress. Our findings reveal a discernible gap between the understanding of patients and explanations provided by their surgeons. To help alleviate this problem, patients suggested written material that they could take home, to read later and enhance their comprehension.
Patient's decision to undergo surgery was not necessarily based on their understanding of the risks and benefits associated with the procedure. Rather, the majority of patients opted to undergo surgery because of the debilitating pain and poor quality of life that they were experiencing. Moreover, patients were put at ease when their surgeon advised high success rates from surgery, which may have diminished their desire to understand other important information pertaining to the procedure.
Strengths and Limitations
To ensure methodological rigor, we discussed our findings in terms of credibility and transferability34 and used triangulation, including as regular discussion with the senior investigator, checking verbatim transcripts, as well as reaching consensus on thematic analysis. Our study was limited to a small sample; however, during our interview process we reached data saturation. Thus, we considered the data collected as sufficient and comprehensive.33 Previous qualitative studies of surgical patients,11,49–52 and low back pain and sciatica patients31,53–57 have performed similar numbers of interviews (range = 8 to 13).
Relation to Prior Research
The key findings of our study align with previous studies that explored expectations of patients with other musculoskeletal disorders,21,22,58–61 discrepancy between patients understanding and the information provided by surgeons in other surgical procedures,51,56–58 optimism before surgical procedures,51 and the participation of patients in decision-making.13,14,35,36,49,62–65 As with surgeries for other musculoskeletal disorders, the significance of establishing realistic expectations in preoperative LDS patients is multifold. Previous research has demonstrated that fulfillment of presurgical expectations has predictive value.27–29,66 If patients expect complete resolution of their pain after surgery, they are less likely to be satisfied with the results.
As LDS is an elective surgical procedure with available alternative treatment options to relieve leg pain, management should be based on patient's values and preference.35,37,67,68 Our results revealed that although patients relied on spine surgeons’ opinion to undergo LDS, they also sought information from other sources. In concordance with other studies,69,70 the patients in our study typically consulted family members, friends and their family physician to help inform their decision. Most patients in our study desired information in written formats as a means to reinforce their understanding. Strategies such as evidence-based patient decision aids, including videos19,70–72 and patient information booklets,73 have been reported to be effective methods for dissemination of information in spine surgeries and other elective surgeries such as total knee arthroplasty and total hip arthroplasty.11,12,27,52,74,75
Implications for Practice and Research
Understanding preoperative perceptions and expectations that patients have can serve to identify and address important barriers, and as a result, facilitate communication about LDS between spine surgeons and patients. Merely attending preoperative consultations may not suffice in meeting the emotional and psychological needs of patients. Furthermore, establishing realistic expectations of surgery is important in order to facilitate informed decision making, and improve postoperative satisfaction.
Our findings suggest strategies to enhance shared decision-making between patients and spine surgeons. Moreover, open collaboration between patients and their health care providers can provide patients with more realistic expectations about outcomes pertaining to their procedure; expectations that are achievable and that will facilitate decision-making based on sound understanding.65 Future research is needed to develop and validate models of communication that enhance shared decision-making and effective sharing of information between surgeons and patients, and, to explore the association between effectiveness of preoperative communication and long-term outcomes.Key PointsOur results showed discrepancies between patients’ understanding and information provided by surgeons, and most patients addressed gaps in their understanding by seeking out additional sources of information.It was often difficult for patients to assimilate information about their diagnosis, surgical procedure, and expected outcomes during the consultation. Most patients wanted information in written format to reinforce their understanding.Improved communication between patients and their surgeon is important to provide realistic expectations about lumbar decompression for sciatica and optimize informed decision-making by patients.
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