Elizabeth Hofheinz, M.P.H., M.Ed.
What’s a researcher to think when patients’ pain levels drop, but they remain dissatisfied? New multicenter research has delved into the issue of those who have clinically relevant improvement but are dissatisfied with surgery. The study, “Why are patients dissatisfied after spine surgery when improvements in disability and pain are clinically meaningful?” appears in the October 1, 2020 edition of The Spine Journal.
Co-author Kristin R. Archer, Ph.D., D.P.T. is with the Center for Musculoskeletal Research at Vanderbilt University Medical Center. Dr. Archer told OSN, “Patients were reporting dissatisfaction with their surgery and their recovery. However, these same patients had decreased levels of pain and disability and increased quality of life, which are common patient-reported metrics of success for providers. We were seeing clinically that patients who were dissatisfied also appeared to have higher levels of depressive symptoms both before and after surgery and reported more anxiety about the surgery and their recovery.” 
The researchers worked with data from 34,076 participants undergoing elective surgery for degenerative spine pathology who had clinical improvement in disability or pain. Patient satisfaction was assessed with one item from the North American Spine Society lumbar spine outcome assessment. Each participant completed two assessments for disability, pain, and satisfaction: one at baseline and one 12 months after surgery.
Asked what they learned about psychological distress and spine surgery, Dr. Archer stated, “We learned that patients who reported moderate or extreme psychological distress prior to surgery were more likely to report dissatisfaction with surgery at 1 -year, despite having clinically relevant improvement in pain of disability.”
The good news? There are modifiable factors
“The most important results had to do with the modifiable factors that were associated with dissatisfaction at 1-year. These were preoperative smoking status and psychological distress and failure to return to work and physical activities after surgery. These are important factors for surgeons to consider when both scheduling surgery and planning postoperative care. Preoperative programs to address behavioral self-management that carry over into the early postoperative period may be beneficial for some patients.”
“Also addressing patient expectations about return to work and physical activities that are important to them before surgery is critical to help patients better understand their recovery trajectory. Realistic expectations may help improve patient satisfaction after surgery. In addition, referring patients to postoperative physical therapists that have expertise in behavioral strategies such as patient-centered goal setting and graded activity or experience implementing functional restoration programs may prove helpful for patients who report early dissatisfaction with their physical recovery.”
Holistic, multidisciplinary, etc…the way to go
“A multidisciplinary approach that includes the physical and mental health of the patient is important to consider for surgical success. In addition, assessing patient expectations about return to work and physical activities is an important component of preoperative counseling, which can be monitored postoperatively. Patients unable to meet realistic work and physical activity goals should be referred early to evidence-based rehabilitation programs that incorporate a behavioral approach to patient-centered goal setting.”