Patient Attitude Predicts Outcome of Neck Surgery for Pain

Daniel M. Keller, PhD

April 22, 2011

April 22, 2011 (Denver, Colorado) — Expectations of the success of anterior cervical discectomy for pain relief appear to correlate with clinical outcomes. Patients who preoperatively expected no pain after surgery reported less pain on a visual analogue scale of neck or arm pain and more satisfaction with the results compared with patients who expected some residual pain, Alan Villavicencio, MD, senior partner at Boulder Neurosurgical Associates in Colorado, announced here at the American Association of Neurological Surgeons (AANS) 79th Annual Meeting.

The prospective study presented included 79 patients undergoing 1- to 3-level anterior cervical discectomy and fusion surgery. Before surgery, patients rated their expected postoperative pain and completed visual analogue scale neck/arm pain (0 - 10 scale), neck disability index, and SF-36 health survey physical component scale and mental component scale (MCS) scores. The SF-36 is a measure of a patient's own assessment of his or her health and well-being. Higher scores indicate an assessment reflecting better health and/or well-being.

Participants were categorized into 2 groups: those who expected complete resolution of their pain (n = 44), and those who expected some postoperative pain (n = 35). Preoperative patient demographics and clinical parameters were similar between the 2 groups. Postoperatively, patients completed the same clinical parameter ratings as before surgery, and they reported their satisfaction with the surgical results. The mean follow-up was 38.8 months (range, 7 - 59 months).

All postoperative measures showed significant improvement compared with the preoperative state, regardless of expectations. However, Dr. Villavicencio said patients' expectations were borne out after surgery. "When we analyzed the net expectations, there was statistically significant difference in what they expected," he said. "If they expected to have pain postoperatively, they usually did, and if they didn't expect to have pain postoperatively, they usually didn't."

Once the investigators controlled for patients' respective preoperative scores, those patients who expected no pain reported less postoperative neck or arm pain (P < .02), higher SF-36 MCS (P = .04), and higher satisfaction with their surgical outcomes (P = .007) when compared with the group of patients who expected some remaining pain. Higher preoperative SF-36 MCS predicted lower postoperative neck pain (P = .003) and neck disability index (P = .004) scores and higher SF-36 physical component scale (P = .002), SF-36 MCS (P = .001), and satisfaction (77 vs 59 on a 0 - 100 scale; P = .03) scores.

Dr. Villavicencio said that to his knowledge, this study is the first to prospectively analyze the effects of both preoperative pain expectations and SF-36 mental component scores and postoperative patient satisfaction. Given the almost 39-month average follow-up, he said, "The outcomes that we have published are sustained."

"The results of the study do not suggest artificially or unrealistically increasing patient expectations," he warned, "but [they] do emphasize the importance of mental health and optimism in patients." He noted that psychosocial factors are known to be very strong predictors of postoperative outcome. "I think it has to do with motivation.... Those people that really want to get better and are motivated and expect to do well, will do so eventually," he said.

When asked how his findings may be used clinically, Dr. Villavicencio told Medscape Medical News, "It's good to encourage patients to have optimistic outcomes. I don't think it's good to give them false hope, but if you encourage optimistic outcomes, then I think they do better.

"I always explain to patients that I'm not actually making them any younger. They're still going to be 70 years old, if that's how old they are when they go into the operating room. So if I'm doing back surgery, then they're still going to have back pain now and again, just like any 70-year-old person."

Alon Mogilner, MD, PhD, director of functional and restorative neurosurgery for the North Shore–Long Island Jewish Health System and Hofstra Medical School in Great Neck, New York, and past-president of the AANS Pain Section, said the results of the study made good sense to him.

"There are multiple factors for surgical outcomes, and many of them are really expectational, emotional, and mental. So I'm not surprised. I'm surprised at the degree of it, though, because...there should be an objective improvement [from surgery,] whether or not your expectations are there," he said.

Dr. Mogilner suggested looking into the phenomenon more deeply; for example, categorizing the location of the pain. "My feeling is neck pain vs arm pain would have a different group of patients because these operations improve arm pain significantly, but neck pain questionably, so I think if they had subcategorized it, I think the data would be stronger," he commented to Medscape Medical News.

Dr. Villavicencio has received research and other financial or material support from Medtronic. He is a shareholder in Lanx. Dr. Mogilner is a consultant to and has received honoraria from Medtronic and has received research support from Medtronic and St. Jude Medical.

American Association of Neurological Surgeons (AANS) 79th Annual Meeting: "The Effects of Preoperative SF-36 Mental Component Summary Scores and Patient Pain Expectations on Clinical Outcomes Following Anterior Cervical Discectomy and Fusion." Presented April 12, 2011.


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