Surgery for lumbar radiculopathy or claudication is generally elective and done to alleviate pain and improve function. The decision to undergo surgery is related to how the patient and surgeon perceive the likely risks and benefits associated with the operation. While it is impossible to perfectly predict outcomes with surgical and non-operative treatment, patients can be advised on the probability of outcomes and complications as well as the typical recovery periods. Prior literature has suggested that patients retain only a small portion of the information conveyed to them at an office visit and oftentimes do not comprehend even relatively basic concepts pertaining to their condition, planned treatment, and likely outcomes. In order to better understand the decision-making leading up to lumbar decompressive surgery, Dr. Rehman and colleagues from McMaster University in Ontario performed a qualitative study in which they interviewed 12 patients after the decision was made to undergo surgery and before they underwent the operation. They also interviewed their six surgeons. Using inductive content analysis, they classified the content of the interviews into broad themes and compared patient and surgeon experiences around the decision-making process as well as their expectations. The authors documented that the patients had relatively limited recall about their condition, treatment, and recovery. The surgeons also felt that patients had a relatively limited understanding despite their efforts to convey information using aids like spine models and MRI images. Patients also believed that decompressive surgery would improve both their leg and back pain, while the surgeons were adamant that they informed patients that only their leg pain was likely to improve. While all patients went through a consent process in which risks were discussed, they tended to remember only serious—and very rare—complications such as paralysis. Patients tended to consult family, friends, and the internet to gather more information, accurate or not. They reported making the decision to proceed with surgery based on the severity of their symptoms and not a careful calculation regarding the risks and benefits of surgery.
The authors have done a nice job performing a qualitative study on a topic that can probably only be studied using such methods. Efforts to evaluate the decision-making process using validated outcome measures such as decisional conflict scales would have likely missed much of the content that was captured with the qualitative approach. The results of this study come as no surprise to surgeons who go through this process with patients on a daily basis. Patients generally arrive in a state of distress and are simply looking for a way to relieve their pain. While shared decision making experts extoll the virtues of an arithmetic calculation based on likely risks, benefits, and ultimate utility of surgery, such a process is foreign and unsatisfying to most patients. Many patients want a surgeon to recommend the treatment most likely to help them and expect that the surgeon has done the "calculations" behind such a recommendation. There is a subset of patients who do engage in the traditional, semi-quantitative shared decision-making process, and surgeons need to be able to judge their patients in terms of what type of decision support they require. The current paper did not record and analyze the actual content of the office visit at which the decision to proceed with surgery occurred, and that could have added some more objective data about what was conveyed and what was absorbed. Those details may actually matter little, as patient perceptions and expectations are what shape satisfaction with outcomes. Even if the surgeon did an excellent job explaining the condition, planned treatment, and likely outcomes, if the patient did not understand or retain the information, it will not shape their expectations or satisfaction. Studies such as these should serve as good reminders to surgeons that patient expectations may not be realistic, and multiple conversations before and after surgery are likely necessary to bring their expectations in line with reality.
Please read Dr. Rehman's article on this topic in the May 15 issue. Does this change how you view the surgeon's role in setting patient expectations? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor