Check your expectations prior to spine surgery

I recently did a two-level XLIF on an 83-year-old female who’d been having longstanding back and leg pain.  I’ll call her Patsy. The case went very well and when I saw Patsy the next morning she looked great.  She admitted that she was having quite a bit of back soreness but her leg pain had resolved.  She’d taken hardly any pain medicine overnight and was concerned only with when she was going to be allowed to go home.  (As an aside, I’d say that the best patient to undergo lumbar fusion is a female in her late seventies/early eighties.  These ladies have endured a lot in their lifetimes and have a level of toughness that just isn’t seen in younger patients.  I swear some of them could have these surgeries without anesthesia and not bat an eye!)  I told her that she was making the entire process look easy.  She said, “You know what Dr. Thomas? How you do is all up here” as she pointed to her head.  “I expected it to hurt but I know it’s going to be ok.”  Well said Patsy.  I’d like to put a picture of your smiling face with that quote on a sign in my waiting room.  If only every patient knew how proper expectations play such a pivotal role in outcomes after spine surgery.

Most patients are very happy after their surgery with us, but some just aren’t as happy with their outcome as we’d hope.  Sometimes this is because I didn’t execute either the diagnosis or the surgery properly.  It happens rarely, thankfully, but it does happen.  In many cases, though, a patient’s expectations of the outcome of surgery exceed the actual outcome of the surgery.  This is referred to in the spinal surgery literature as the expectation-actuality discrepancy (EAD).  Several studies have shown that the larger this discrepancy, the lower the patient satisfaction after spine surgery.  Thus, if I can properly manage a patient’s expectations of their postoperative outcomes, they’re more likely to be happy with the results of their surgery.   

Again, much of my time in preoperative discussions is spent clarifying what should and should not be expected after surgery.  There are some unreasonable expectations that come up time and time again:

  1. Patients expect that a minimally-invasive surgery isn’t going to hurt.  I call this the “Laser Spine Institute Effect”.   Patients around here still remember the commercial for the now-defunct Laser Spine Institute showing the patient walking out after spine surgery as if he’d only just had his teeth cleaned.  This commercial created the inaccurate expectation that minimally-invasive spine surgeries just don’t hurt.  We know from a mountain of literature that the muscle-sparing incisions of the minimally-invasive spinal surgery are associate with much less pain (as well as lower risk of infection, faster return to work, shorter hospital stays but who’s counting?)  It’s still going to hurt though.  Despite the tiny incision we can still do a lot to your spine.  Be ready for some degree of discomfort.  Patsy knew she was going to hurt after surgery.  She expected it and thus, isn’t going to let it interfere with her recovery.
  2. Patients expect that with minimally-invasive procedures they’ll get back to full activity right away.  This goes hand-in-hand with the previous misconception and is part of the constellation of symptoms of the “Laser Spine Institute Effect”.  In a widely cited study on patient expectations after spine surgery, Soroceanu et al (2012) found that the biggest EAD was in patients’ expectations about how soon they could return to exercising.  This was a major source of dissatisfaction for patients, even if their surgery was successful by all other measures.  Yes, in time, at least in my practice, you’re going to be able to return to your normal level of physical activity after spine surgery.  Your body needs to recover after surgery, though, so be patient.  Yes…this applies to golf too.
  3. Patients expect all of their pain to improve after spine surgery.  This is a big one.  I practice in a growing retirement community so I see lots of patients with, shall we say, older spines.  These patients have widespread degenerative disc disease and arthritis throughout their entire spine.  This “wear and tear” is inevitable to some degree as patients grow older and contributes to a baseline level of pain and stiffness.  Typically, patients present to me with acute pain that is new and distinct from their baseline level of discomfort.  Examples of this include an unstable spondylolisthesis at L4/5 causing worsening back and leg pain, or disc space collapse and foraminal stenosis at L5/S1 causing “sciatica”.  These are focal problems that are superimposed on the baseline level of painful degenerative changes at other levels in the spine.  The goal of surgery is to address the acute problem causing the severe pain (i.e. fusing the L4/5 or L5/S1 levels in the example above), not to fix everything that is wrong with the spine.  That would be impossible; I can’t give you a 20-year old spine.  Thus, expect your acute pain to be better and to return to your baseline level of discomfort.  (You may get lucky and much of that be addressed too, but don’t count on it.)  
  4. Some patients expect that since they’re in a surgeon’s office there must be some procedure I can offer to help alleviate their pain.  Sometimes this just isn’t the case; not all painful pathology seen on an MRI can be addressed surgically.  So, if surgery won’t help it won’t be offered (the last thing I’d ever want is for a patient to undergo surgery and be no better after surgery than they were before.)  That disappoints some people because they’re desperate, but again, my responsibility is to manage expectations.  I can’t have a patient expect that surgery is going to help when it’s not going to.   (As an aside, unfortunately there are surgeons out there who will prey on desperate patients with unreasonable expectations.  I spend a lot of time making sure that the patient understands and accepts that surgery isn’t the answer so that they don’t just leave my office and go somewhere else.  Because sooner or later, if a patient is persistent enough, they’ll find a surgeon who’ll operate on them.  That’s all I’ll say about that.) 
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Figure 1: You’re going to hurt after surgery but expect to get up and moving right away.  Proper expectations can ensure the best possible outcome after surgery.  

I want you to do really well after surgery.  Much of your success depends on my framing your expectations of surgery so that you understand what a reasonable outcome of the surgery should be.  This can be challenging because while I want you to fully understand what you’re getting into, I also don’t want to paint such a gloomy picture that you become discouraged heading into surgery.  It’s a balancing act between making you believe you’re going to do well and tempering your expectations about the outcome.   You’re going to hurt, you’re going to have to lay low for a while and we might not be able to make you feel like you did when you were in your twenties.  In the end, though, you’ll be happy with your outcome because you understand what you’re getting into.  

Thanks for reading!

 J. Alex Thomas, M.D.

 Sources:

 Soroceanu A, Ching A, Abdu W, McGuire K. Relationship between preoperative expectations, satisfaction, and functional outcomes in patients undergoing lumbar and cervical spine surgery: a multicenter study. Spine (Phila Pa 1976). 2012;37(2):E103-E108. 

Why patients don’t get better after spinal surgery (it’s not always my fault.)

Ok.  I’m going to admit this for you right here and right now: my patients don’t always get better after surgery.  It’s a crazy thought, I know.  But it’s true.  Despite my best efforts to control all variables to ensure that things go smoothly, things can go awry and the patient doesn’t get better (and sometimes gets worse).  Generally speaking there are two categories of variables that must be managed to ensure success in spine surgery.  First, there are the variables that are dependent on me, the surgeon.  These variables stem from the technical, physical and psychological challenges of spine surgery.  I have to correctly diagnose the patient; I have to know the anatomy and technical nuances of the surgical procedure; I have to plan for the patient-specific anatomy of the case; I have to get a good night sleep before my OR day so that I can focus on the case; I have to maintain a level of fitness in order to handle the physical demands of surgery (yes, spine surgery can be quite physically taxing), etc.  No problem.  This is what I signed up for and I’m up for the challenge.  I can manage these variables better than most.  I do want to say one thing about the psychological stress of these cases.  I want every one of my patients to have the best possible outcome.  That itself weighs on my psyche enough.  But when things don’t go as planned and a patient has a poor outcome (I feel as if I hurt them) it can take months for my conscience and confidence to recover.   This isn’t a therapy session though.  I love what I do and overall I think that I handle the stress of it pretty well (my wife is blocked from posting comments on Spinal (con)Fusion, by the way.) 

Here’s what drives me crazy about taking care of spine patients though.  I can control all of the variables on my end and execute perfectly and the patient STILL doesn’t get better.  There isn’t always a direct correlation with my success in the OR and the patient’s outcome.  Why?  Patient-dependent variables, which often are out of my control, also affect outcomes in spine surgery.   Here, I offer a few of the ways patients don’t hold up their end of the doctor-patient relationship.

1)  Patients don’t want to get better.  Ok, so this is a very broad and potentially very damning characterization of some patients.   You could say obese patients or smokers don’t have the discipline to better themselves and thus don’t want to maximize their chances of success after spinal surgery.  As tempting as it is, though, we can’t blame patients for being obese or for smoking.  Both of these are diseases that many patients are incapable of managing on their own.  So while I do think patients in this country should take more responsibility for their own health, we shouldn’t automatically assume that they don’t want to get better because of their weight or their bad habits.    

What I’m referring to here is a more pernicious subset of patients who are actively trying to not get better, the landmines in the minefield that is my clinic.  These patients usually have some sort of secondary gain that they’re after that leads them to consciously or subconsciously fail to improve after surgery.  Maybe they were injured on the job and want to live off of a worker’s compensation claim.  Maybe they don’t want to be in the military anymore.  Maybe they were in a car accident (not their fault) and their lawyer is telling them they can get more money if they appear more severely injured.  Maybe they want more attention from their spouse.  Maybe they just want oxycodone.  You wouldn’t believe what I’ve seen.   And before you come after me for being insensitive, check the literature.  There are dozens of studies correlating secondary gain with poor outcomes in spine surgery. Thankfully as I’ve moved along in my career I’ve gotten better at spotting patients like these and will avoid ever offering them surgery.  That’s the art of spine surgery.

2)  We aren’t good at accurately measuring if a patient is in fact better.  In spine surgery we rely on patient reported outcomes (PROs) measured before and after surgery to assess the patient’s response to the surgery.    PROs generally fall into two categories: those that measure pain severity and those that measure level of disability.   The visual analog scale (VAS) is the most common tool used to assess a patient’s pain level (see figure 1).  In this scale the patient is asked to rate their back or leg pain on an 11-point scale where 0 is no pain and 10 is the worst pain imaginable.  While VAS is useful on a superficial scale, I find that patients’ responses are widely variable thus making the test unreliable.  I frequently will see that a patient has rated their pain a 10/10 on their intake paperwork but when I walk into the exam room they’re sitting comfortably reading a book.  If this is how the patient self-assesses their pain how can I know for sure that the patient in fact got better?  The problem is that pain is so subjective and influenced by so many factors that it’s just hard to quantify objectively.     

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Figure 1: Visual Analog Scale (VAS) for reporting pain. 

Common measures of disability include the Oswestry Disability Index (ODI) and the Short-Form 36 Health Survey (SF-36).  Both of these are quite thorough but again are subject to variability.  The ODI, for example, asks the patient to rate their quality of sleep, sex life and social life.  In my opinion, these are things that are open to wide interpretation (you ask someone about this stuff on a Friday versus a Monday and the answers may vary!).  With so much variability in patients’ responses on VAS and ODI it can be difficult to determine to what extent the patient actually improved after surgery.  Obviously these PROs leave room for improvement.  These days we’re finding that by combining several PRO modalities we can get a more accurate representation of a patient’s progress.

3)  Patients don’t remember how bad they were and thus don’t realize that in fact they’re better.  Recall bias is a well-known entity in medical research.  When asked to recall facts or conditions in the past, research subjects are notoriously inaccurate.  The same applies to spine patients.  A 2017 study out of the Mayo Clinic found significant limitations in how well patients recalled their preoperative VAS scores when asked to recall them a year later. (Aleem et al, 2017)  Also, more than 40% of patients couldn’t remember if it was their back or leg that hurt them more before surgery.  How can a patient tell me if they’re better after my surgery if they don’t remember what was hurting before the surgery. 

Along the same lines, patients may have improper expectations about their surgery and thus may be disappointed in their outcome even when it’s a good outcome.  For example, often patients with lumbar stenosis and spondylosis present with both back and leg pain.  When I consent them for surgery I explain to them that the minimally-invasive laminectomy that I’m recommending will only relieve their leg pain (by fixing the stenosis) and not their back pain.  Some patients don’t hear that though.  After surgery they’ll come back in and tell me that surgery didn’t help them at all.  The exchange goes something like this:

     Me: “Mr. Smith, you’re two weeks out from your laminectomy.  How’s it going?”

     Mr. Smith: “Horrible.  Surgery didn’t help me doc.  You said you were gonna fix me but I’m no better.”

     Me: “Oh no! Tell me where you hurt?”

     Mr. Smith: “My back hurts, Doc.  You said you were going to help my pain.  What happened?”

     Me: “Well how do your legs feel?  Prior to surgery you told me that you couldn’t even walk to the mailbox because your legs hurt so badly.  

     Mr. Smith: “My legs?  Oh they’re great.  Leg pain was gone when I woke up from surgery.  I walked 2 miles this morning. But my back still hurts.”

     Me: (internally) Sigh

I understand why some patients may not fully absorb what I’m telling them.  They’re scared and distracted when the prospect of surgery becomes a reality.   Prospective patients should be mindful of this, though, and make every effort to listen to and process what their surgeon is telling them.   On my end I’m working on ways to ensure that patients hear what I’m telling them so that they can have accurate expectations about their surgery.  This includes detailed handouts discussing surgery as well as audio/video recordings of preoperative conversations that the patient can refer back to when they’re home with their families.  The most well-informed patients will have the most accurate expectations of surgery and thus are most likely to report that they’re better after surgery.

4)  Patients just don’t get better.  Unfortunately some patients, through no fault of their own or the surgeon, just don’t get better.  As much as we like to think we doctors know everything, we don’t.  I think that we just don’t understand every etiology of back pain.  Is it the degenerated disc?  Is it the facet joint?  Has the brain just learned the pain?  There’s just so much we don’t know.  We do our best to make an accurate diagnosis, assess the patient and prescribe an accurate treatment and yet sometimes even that’s not enough for the patient.  This may be the most frustrating thing about what I do.  All I can do is look at myself in the mirror in the morning and swear that I’m just going to do my best for my patients.  Hopefully it’s enough. 

Ok so maybe there wasn’t much technical information in this post.  That’s OK.  Hopefully by hearing my candid thoughts on the matter you’ll be better equipped when talking to your surgeon about the surgery he’s recommending.  Ultimately I love taking care of my patients and just want them to have the best possible outcome after their surgery.  We’re in it together.  If we both do our parts you, the patient, are going to do fabulously after your surgery.   

 

Thanks for reading!

J. Alex Thomas, M.D.

Sources:

Aleem IS, Duncan J, Ahmed AM, Zarrabian M, Eck J, Rhee J, et al.: Do Lumbar Decompression and Fusion Patients Recall Their Preoperative Status? Spine (Phila Pa 1976) 42:128–134, 2017.