Lower back pain is complex, requiring accurate diagnosis and careful consideration of treatment options. Mechanical problems, such as a muscle strain from heavy lifting or twisting, a sudden jolt in a car accident, a herniated disc from stress on spinal bones or joint degeneration due to osteoarthritis, are typical causes of lower back pain. Most patients do not require surgery and are treated with medications to relieve pain and reduce inflammation. Surgical options are considered for back pain that does not respond to other therapies.

“There have been tremendous advances in spine surgery over the past 20 years, including minimally invasive and robotic approaches, new implants and bone grafting methods,” says Federico P. Girardi, MD, an attending orthopaedic surgeon at HSS. “However, despite clinical assessment and improvements seen on postoperative imaging, some patients report they are not doing well compared to others with similar conditions who received the same surgeries. That has been very frustrating for surgeons because our goal is to optimize patient outcomes.”

“Patients decide to pursue lumbar spine surgery to relieve symptoms, improve their quality of life and avoid further disability,” says Carol A. Mancuso, MD, FACP, a general internist and clinical epidemiologist at HSS. “Unrealistically high or low expectations are problematic, predisposing patients to poor outcomes if they become discouraged with recovery, abandon rehabilitation or ignore recommended lifestyle modifications that reduce disease progression.”

To understand the gap between expectations and patient-reported outcomes, Dr. Girardi, Dr. Mancuso and colleagues developed the HSS Lumbar Spine Surgery Expectations Survey in 2013 with input from hundreds of patients on the surgical outcome factors that matter most to them. The comprehensive, validated tool evaluates patients’ expectations for symptom relief, resuming activities, and importantly, psychological well-being, which previous surgeon-oriented surveys did not capture. The HSS Lumbar Spine Surgery Expectations Survey is one of several patient-centered tools developed by Dr. Mancuso and HSS researchers used worldwide and considered the gold standard for measuring patients’ expectations with orthopedic surgery.

For their recent study, published online ahead of print on November 4, 2020 in the journal Spine, Dr. Girardi, Dr. Mancuso and colleagues asked 402 patients and their surgeons to preoperatively assess their expectations of patient-reported surgical outcomes using the HSS Lumbar Spine Surgery Expectations Survey. The researchers surveyed patients again, two years after surgery, to evaluate the degree of fulfillment of their expectations.

Patients participating in the study were 55 years of age, on average. Most had a degenerative spine condition and had experienced symptoms for a year or longer. About one-quarter had undergone previous spine surgery, and one-third were taking opioids to relieve leg and back pain. The extent of surgical procedures spanned from the removal of a single, herniated disc to more complex operations such as a five-level anterior-posterior decompression, instrumentation and fusion.

Responses to the HSS Lumbar Spine Surgery Expectations Survey generate a score on a scale of 0 to 100, where a higher score indicates higher expectations. Patients’ average preoperative score in the study was 73 (ranging from 20 to 100), much higher than surgeons’ average score of 57 (ranging from 16 to 100).

Next, the investigators determined whether surgeons or patients’ presurgical expectations more closely predicted postoperative fulfillment of those expectations as reported by patients. The proportion of expectations fulfilled was .79 for patients, indicating that they were satisfied overall. Dr. Mancuso’s previous research found that a ratio of .6 or higher corresponds with satisfaction with surgical results. However, the surgeons’ ratio was 1.01, meaning that their predictions for patient-reported outcomes were highly accurate and more accurate than patients’ presurgical estimates. In 73 percent of cases, surgeons either predicted patients’ reported outcomes exactly, or patients surpassed surgeons’ expectations.

“HSS spine surgeons very accurately predicted patient-reported outcomes two years after surgery, indicating that they are adept at integrating complex clinical, surgical and psychological factors that matter most to patients,” says Dr. Mancuso. “Getting this right is an indicator of providing high-quality and high-value care.”

Overall, surgeons and patients agreed on the same areas of improvement. However, expectations for the degree of improvement differed. Surgeons expected surgery would lead to a little, moderate, or a lot of improvement, based on their clinical expertise treating hundreds of patients. However, 84 percent of patients had higher expectations than their surgeons, often expecting complete improvement. The investigators interviewed patients about the source of their expectations and discovered they had amplified their surgeons’ guidance with information they obtained from family, friends, coworkers and the internet.

“Our study underscores that there is room for improvement in patient education and that patients should rely on their surgeon’s expertise when forming expectations of lumbar spine surgery,” Dr. Girardi says. “At HSS, we recognize that expectations for surgical outcomes are affected by many factors and develop evidence-based, individualized treatment plans. Patients need to realize that anecdotal stories from social contacts or the internet are often not relevant to their situation.”

According to the article, HSS internist and lead investigator Carol A. Mancuso, MD, FACP said the questionnaire could improve patient care by providing a template for patients to discuss the range of impact of this injury.

Read the full article at beckersspine.com

Additional Coverage:

• Physical Therapy Products: Questionnaire Measures Impact of Brachial Plexus Injury

The research and the copyrighted questionnaire were published in the Journal of Bone & Joint Surgery today.

The brachial plexus is a network of nerves that extends from the spinal cord in the neck, under the collarbone and down the arm. These nerves control the shoulder, arm, elbow, wrist and hand. A brachial plexus injury (BPI) can be life-altering. People often suffer from severe, unrelenting pain and can lose the use of their arm and hand.

"A brachial plexus injury has a profound impact on quality of life," said Carol A. Mancuso, MD, a senior scientist at HSS and lead investigator. "Patients are usually young adults who sustained trauma, such as from a motor vehicle accident or sports injury."

Dr. Mancuso and orthopedic surgeons specializing in complex nerve reconstruction surgery for BPI sought to develop a questionnaire to thoroughly understand the injury’s impact on patients. "The sudden nature of the injury can lead to a realm of psychological challenges, such as emotional distress, loss of independence, and depression, that can overwhelm patients and potentially hamper recovery," said Dr. Mancuso, who specializes in developing surveys and questionnaires at HSS. "Capturing these psychological elements is necessary to thoroughly understand disability and recovery from this complex condition."

"The questionnaire is important because it moves beyond the surgeon’s interpretation of the outcomes of surgery and gets to the heart of patient needs, expectations, and functional satisfaction," said Scott W. Wolfe, MD, director of the Center for Brachial Plexus and Traumatic Nerve Injury at HSS. "It probes the emotional as well as the physical impact of the injury and realizes data that is not identified in any other outcome measure."

Dr. Mancuso developed the questionnaire based on patient input, with preoperative and postoperative versions. Patients with BPI who were undergoing or had already undergone surgical reconstruction were enrolled during routine office visits at HSS.

The study had three phases. Phase 1 included interviews with patients using open-ended questions addressing the impact of BPI and improvement expected before surgery (preoperative patients) or received (postoperative patients). Phase 2 involved assembling a draft questionnaire and administering it twice to establish test-retest reliability. Phase 3 involved selecting final items, developing a scoring system, and assessing validity. Patient scores using the questionnaire were assessed in comparison with scores of the Disabilities of the Arm, Shoulder and Hand (DASH) and RAND-36 measures.

The HSS preoperative and postoperative surveys both include questions rating the severity of BPI symptoms; assess difficulty with activities of daily living, such as getting dressed; address psychological issues, such as depression; and ask how the injury has affected school or work. The preoperative questionnaire also assesses how much improvement patients expect from treatment, while the postoperative version asks how much improvement patients believe they received from surgery or another treatment.

Dr. Mancuso noted that the questionnaire has the potential to improve patient care. "First, it provides a template from which patients can discuss the spectrum of physical and emotional effects of BPI with their surgical team. This, in turn, offers providers the opportunity to comprehensively address patients’ needs directly or through a referral," she said. "Second, the questionnaire fosters discussion of realistic outcome expectations, which are necessary to maintain motivation and ensure long-term participation in rehabilitation. This also enables patients to make appropriate plans for school or work activities."

"We will be able to tell what matters most to patients and then see if we achieved their goals," said Steve K. Lee, MD, director of research, Center for Brachial Plexus and Traumatic Nerve Injury. "Other outcomes measurements were not specific enough to this unique, complex patient population."

Dr. Wolfe noted, "The questionnaire will, without a doubt, improve patient care by aligning surgical and treatment alternatives with patient needs and expectations."

In addition, the survey plays a role in assessing outcomes of highly specialized nerve reconstruction surgery to repair brachial plexus injury, according to Dr. Mancuso. "The questionnaire provides a valid and standardized method for clinicians and researchers to document and compare patient-reported outcomes from specific or novel surgical interventions."

This work was supported by the J.W. Kieckhefer Foundation, the Howard J. Golden Family Research Fund, and a Richard Menschel institutional award.

Institutions that wish to receive a copy of the questionnaire, which is copyrighted, are invited to contact Dr. Mancuso via email: MancusoC@hss.edu.

About the Center for Brachial Plexus and Traumatic Nerve Injury at HSS

The Center for Brachial Plexus and Traumatic Nerve Injury at Hospital for Special Surgery is a national resource for men and women of all ages, providing diagnostic and reconstructive options for patients with injuries to or dysfunction of the peripheral nerve and brachial plexus. Using a multidisciplinary approach, the center utilizes the expertise of a wide range of health care professionals including orthopedic surgeons, physiatrists, neurologists, radiologists, psychiatrists, rheumatologists, pain management specialists, physical therapists and anesthesiologists, so that patients can benefit from a coordinated treatment experience. For more information, visit: http://www.hss.edu/brachialplexuscenter