94. The effect of preoperative expectations and postoperative fulfillment of expectations on dissatisfaction after spine surgery for patients with good clinical outcomes

BACKGROUND CONTEXT Expectations of elective spine surgery can be a major determinant in the decision to undergo surgery, where prediction of future condition may affect treatment choices and perceptions of postoperative outcomes. There is interest in understanding why patients with an objectively “good clinical outcomes” are still dissatisfied with their surgical outcomes. PURPOSE To examine why patients who achieved clinical improvement in disability or pain still report dissatisfaction at 12-months after elective cervical/lumbar spinal surgery. We aimed to investigate the association between preoperative expectations, fulfilled expectations, and preoperative depression, with dissatisfaction at 12-month postoperative. STUDY DESIGN/SETTING Retrospective analysis of prospectively collected registry data at a single center. PATIENT SAMPLE Patients undergoing elective cervical/lumbar spine surgery for degenerative reasons were enrolled in a spine registry. Only patients with a "good clinical outcome" were included, defined as a 30% improvement from baseline in disability or back/leg pain. OUTCOME MEASURES Dissatisfaction at 12-months. METHODS Patient demographics, clinical/surgical data, and patient reported outcomes including PROMIS-29 and the 20-item HSS Cervical and Lumbar Spine Surgery Expectations Survey were collected from medical records and patient self-report preoperatively and 3 and 12 months after surgery. Analysis was conducted using 3 multivariable proportional odds regression models predicting dissatisfaction at 12-months. The exposure variables were preoperative expectations (Model 1), expectations fulfilled at 3-months postop (Model 2), and preop + fulfilled expectations at 3-months postop (Model 3) entered in the models using nonlinear effects. Covariates in all models included patient demographics, clinical and surgical characteristics, preop PROMIS depression, and preop disability score. RESULTS Of 540 patients who had a "good clinical outcome defined earlier, 33% of patients reported being dissatisfied with the outcome of their spine surgery. The mean preoperative expectations score was M=75±19 and mean proportion of expectations fulfilled at 3mo was M=80±36. Regression analyses revealed that preoperative expectations were an independent predictor of dissatisfaction when controlling for other variables (Figure 1). Preoperative expectations had a significant nonlinear relationship with dissatisfaction. Patients with lower preoperative expectations were more likely to be dissatisfied with their surgical outcome, however the relationship inverted around 80, with the highest expectations (above this threshold) being associated with higher odds of dissatisfaction. Expectations fulfilled postoperatively were also found to be an independent predictor of dissatisfaction when controlling for covariates. Expectations fulfilled postoperatively were the strongest predictor of dissatisfaction in Models 2 and 3. Preoperative PROMIS depression was a significant predictor of dissatisfaction among those with a “good clinical outcome” across all three models. CONCLUSIONS In a sample of patients with “good clinical outcomes” after elective cervical/lumbar spine surgery, unrealistically high preoperative expectations were significantly associated with postoperative dissatisfaction. Additionally, fulfilled expectations after surgery was the strongest predictor of satisfaction; however, risk factors such as preoperative depression also explained why patients reported being dissatisfied with surgery despite having clinically meaningful improvement in disability or pain. These results emphasize the importance that even if surgery achieves its desired effect, if preoperative expectations are not aligned with reality, patients will be dissatisfied. Future research would be important to better understand what a "reasonable” expectation for improvement is after surgery, depending on a patient's individual characteristics. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.