Discrepancies Between Patient and Surgeon Expectations of Surgery for Sciatica

A Challenge for Informed Decision Making?

Yasir Rehman, MD, MSc, PhD (C); Muzammil Syed, BSc; Wojtek Wiercioch, MSc, PhD; Nadia Rehman, BDS; Brian Drew, MD, FRCS; Aleksa Cenic, MD, FRCS; Kesava Reddy, MD, FRCS; Naresh Murty, MD, FRCS; Edward Kucher, MD, FRCS; Brett Dunlop, MD, FRCS; Gordon H. Guyatt, MD, MSc, FRCP; Jason W. Busse, DC, PhD; Lisa Schwartz, PhD; Meredith Vanstone, PhD

Disclosures

Spine. 2019;44(10):740-746. 

In This Article

Abstract and Introduction

Abstract

Study Design: Qualitative study.

Objective: The objective of this study was to compare the perceptions of patients and surgeons regarding the risks and benefits of lumbar decompressive surgery for sciatica following a consultation meeting.

Summary of Background Data: Evidence regarding pain improvement in patients following lumbar decompressive surgery for sciatica is inconsistent. Given this inconsistency, patients choosing to undergo lumbar decompressive surgery must accept the risks associated with the surgery despite uncertainty regarding benefits. This raises questions as to the nature of informed decision-making for patients choosing to undergo surgery for sciatica.

Methods: We undertook a qualitative descriptive study with 12 adult lumbar decompressive surgery candidates and six of their spine surgeons and analyzed data using inductive content analysis.

Results: Our analysis revealed that most patients were satisfied with the consultation despite limited understanding of lumbar decompressive surgery. We found discrepancies between patients' preoperative expectations and understanding of information provided by surgeons and what surgeons believed they had conveyed. Surgeons and patients disagreed on how much information is needed about postsurgical activity modifications and long-term outcomes to make a decision about whether or not to undergo surgery, with patients desiring more information. As a result, for most patients, the decision-making process extended beyond the information provided by surgeons and incorporated information from family members, friends, family doctors, and the internet.

Conclusion: Our results highlight misunderstandings between patients and surgeons, particularly in regard to prognosis and activity modifications. Since this information is important for patients choosing whether to undergo a surgical intervention, our study provides guidance to improve informed decisions about sciatica and, potentially, other elective surgeries.

Level of Evidence: 4

Introduction

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 limitations[3,4] 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.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....