The prognostic importance of patient pre-operative expectations of surgery for lumbar spinal stenosis
Introduction
The purpose of this study was to examine the prognostic value of pre-operative expectations of lumbar spinal stenosis surgery on post-surgical outcomes at 6 months. Using Social Learning Theory as a framework, we examined the impact of realistic and unrealistic expectations, and their interaction with baseline function, on patients' long-term outcome.
Spinal stenosis is a disabling condition, commonly manifesting in the 6th or 7th decade of life, which results from compression of nerve roots by degenerative spinal processes 1, 2. Conservative treatments seldom yield sustained benefits 3, 4, 5. Hence, many symptomatic patients face surgery. In the United States, from 1983 to 1987 the number of lumbar laminectomies performed on elderly patients with lumbar spinal stenosis (LSS) increased 25% [6]. Rates for arthrodesis (fusion), which is sometimes performed concurrently to enhance the stability of the spine, have increased nineteen-fold in patients with lumber spinal stenosis between 1979 and 1990 [7]. However, despite the widespread use of these procedures, approximately one third of patients fail to benefit substantially from surgery for lumbar spinal stenosis 8, 9and little is known about predictors of outcome.
A large body of literature on psycho-educational preparation for surgery has identified some key psychological predictors of outcome, including: anxiety [10]; depression 11, 12; coping strategies 13, 14, 15; and, sense of control 16, 17. Despite increasing recognition of the role of psychosocial variables in surgical outcome 18, 19, the prognostic influence of pre-operative expectations in LSS surgery has not been evaluated. The few studies of expectations of technical procedures such as surgery, have focused mainly on the relationships between expectations and satisfaction [20]and have not assessed the impact of incorporating patients' expectations of surgery during the pre-operative counselling session on surgical outcomes.
Lumbar spinal stenosis surgery is an excellent intervention in which to test the impact of expectations on post-surgical outcomes such as function, because functional outcomes may be based in part on patient self-management and participation in rehabilitation, which in turn may be influenced by expectations. Counselling may be able to help patients develop more realistic expectations of surgical outcomes and may enhance their ability to fulfil their potential. Counselling may also help patients prepare for post-operative psychosocial sequelae; increase their ability to advocate for needed services and develop a network of support.
Social Learning Theory 21, 22, 23, 24has been used to understand and intervene in health behaviors which influence outcomes. According to this theory, health behavior is a dynamic phenomenon in which behaviors, personal factors (including cognitions) and the environment all interact. Underlying this theory is the assumption of reciprocal determinism. The person's behavior and the environment constantly influence one another. In the case of a surgical intervention to improve function, a patient may alter his/her environment to enhance the opportunity for exercise, which in turn may increase his/her ability to function and provide an incentive to do more activities independently.
Social Learning Theory identifies three key concepts for explaining and predicting behavior change: incentives, outcome expectations and efficacy expectations. Behavior is influenced by the patient's beliefs concerning the likelihood of the consequences of his/her actions as well as by expectations of personal mastery. Expectations may also arise from similar experiences or from observing others in similar situations. For instance, how a friend or relative performed who had the same surgery.
Using this theory as a framework, we would expect that pre-operative expectations for outcomes, together with the values patients assign to particular outcomes (expectancies) would be helpful in determining the degree to which patients persevere in a desired set of activities, such as those required for effective rehabilitation. Ideally, patients would expect a level of post-operative functional gain that is obtainable, given their baseline function, and would expect these changes within a reasonable timeframe (in the case of LSS surgery between 3 and 6 months). Together these expectations could allow patients to establish incremental goals which are attainable and develop interim support strategies. As patients achieve each incremental goal, their confidence is likely to improve, enabling them to persevere in the rehabilitation process and achieve greater functional results. Patients with unrealistic expectations, either for magnitude or speed of recovery, might become discouraged and fail to perceive and achieve their potential. We would expect patients with moderate expectations of improvement to be more likely to set incremental goals and persevere in the face of obstacles than patients with either very high or very low expectations of pain relief and functional improvement. For example, patients who walk one block pre-operatively and who expect to be able to walk 1 mile within 3–6 months post-operatively, will likely function better and be more satisfied than patients who are limited to in-home activities pre-operatively and expect to walk 1 mile within the same 3–6 month timeframe. It is essential then that providers identify patients' expectations of surgery and assist patients in setting realistic goals.
Section snippets
Design
Data were collected as part of a prospective, multicenter study of outcomes of surgery in a cohort of LSS patients described elsewhere [25]. The data analyzed here were collected pre-operatively and at 6 months.
Subjects and recruitment
Subjects with LSS were recruited from the Brigham and Women's Hospital (Boston, MA), the Spine Institute of New England (Burlington, VT), the University of Iowa Hospitals and Clinics (Iowa City, IA), and the Beth Israel Hospital (Boston, MA), from January 1989 to June 1993. Eligibility
Hypotheses
It was hypothesized that patients with high pre-operative function would expect to function better at 6 months than patients with low pre-operative functioning. It was further hypothesized that patients with moderate expectations of post-operative improvements in function or pain would do better than those that expected large or small improvements.
Statistical methods
Linear regression was used to model the effect of expectations on global function (SIP), physical function (walking capacity), satisfaction with
Recruitment
From January 1989 to June 1993, 305 eligible patients were invited to participate, of whom 257 (84%) completed the baseline questionnaires. At 6 months, 2 patients had died, and 228 of the remaining patients completed the surveys at 6 months (87%). There were no significant differences on baseline measures between the 228 patients who completed the data at 6 months and those who dropped out.
Baseline features
This study population consisted of primarily white (97%), elderly patients (mean age 69 years; SD=9).
Discussion
The purpose of this study was to examine the prognostic value of pre-operative expectations of lumbar spinal stenosis surgery on post-surgical outcomes at 6 months. It was hypothesized that patients with moderate expectations (those who expect reasonable changes within a reasonable timeframe) would experience higher levels of post-operative function and greater pain relief than patients with either very high or very low pre-operative expectations.
Patients on average reported improved
Practice implications
Expectations are directly influenced by a patient's baseline function and are indirectly influenced by observation and/or discussions with individuals who have undergone the surgery or who are considered experts (e.g. surgeons). As the clinical encounter is the place where provider–patient discussions occur, it is important for providers to elicit patients' pre-operative expectations of surgery and clearly relate the extent to which surgery is likely to enhance physical function and reduce
Acknowledgements
This work was performed as part of Dr Iversen's doctoral research at the Harvard School of Public Health. Original data collection was supported by NIH Grant (AR36308), partial support was provided by the National Arthritis Foundation [Doctoral Dissertation Grant (MDI); Investigator Award (JNK)]. We thank Drs. Leon Grobler, Stephen Lipson, James Weinstein and Gregory Brick for their participation in the primary study, Drs. E. Francis Cook, Thomas Inui and Karen Emmons for their guidance, and
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