Patients' Expectations Before, and Their Experiences After Spinal Surgery, Regarding Pain, Rehabilitation and Quality of Life
Conditions: Expectations, Surgery, Pain, Quality of Life
Sponsor: Zealand University Hospital

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Patients' expectations before, and their experiences after spinal 
surgery, regarding pain, rehabilitation and quality of life. 
 
Josephine Zachodnik 1,4, Kasper H. Thybo 2,4, Peter Muhareb Udby3, Anja Geisler 1,4,5, Magnus 
Sandberg 4. 
 
Affiliations 
1 Department of Anesthesiology, Zealand University Hospital, Zealand Region of Denmark,      
Denmark 
2 Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, 
Copenhagen, Denmark 
3 Department of Orthopaedic, Zealand University Hospital, Zealand Region of Denmark, Denmark 
4 Faculty of Medicine, Department of Health Sciences, Lund University, Sweden  
5 Faculty of Health and Medical Science, University of Copenhagen, Denmark 
 
Corresponding author: 
Josephine Zachodnik 
Department of Anesthesiology 
Zealand University Hospital 
 
Lykkebækvej 1, 4600 Køge 
Denmark 
Email: jzc@regionsjaelland.dk 
Telephone: +45 47 32 63 16 
 

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Primary investigator 
Name: 
Josephine Zachodnik 
Title: 
PhD student, RN. 
Department of Anesthesiology, Zealand University Hospital, Zealand Region of 
Denmark, Denmark 
Co-investigators: 
Name:  
Kasper Thybo 
Title:  
MD, PhD 
Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University 
Hospital, Copenhagen, Denmark 
Name: 
Peter Muhareb Udby 
Title: 
MD, DC, PhD 
Spine Unit, Department of Orthopaedics, Zealand University Hospital, Zealand 
Region of Denmark, Denmark 
Name: 
Anja Geisler 
Title: 
Associate Professor, Head of research, CCRN, PhD  
Department of Anesthesiology, Zealand University Hospital, Zealand Region of 
Denmark, Denmark 
Name: 
Magnus Sandberg 
Title: 
Associate Professor, RN  
Faculty of Medicine, Department of Health Sciences, Lund University, Sweden 
 
 
 

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Background 
Surgery can be an overwhelming and often a life-changing experience for patients. To mitigate this 
experience a patient-centered approach can be beneficial 1. Patient-centered care is defined as 
providing care that is "respectful of and responsive to individual patient preferences, needs and 
values, and which ensures that patient values guide all clinical decisions" 1. Patient-centeredness 
should be considered in discussions about the value of surgical treatment for the patient and the 
expectations regarding the process of postoperative rehabilitation, especially considering the 
patient's definition of a successful outcome 1. The meaning of rehabilitation may vary between 
stakeholders involved in surgery, including patients, surgeons, anesthetists, nurses, and hospital 
administrators 2. Studies addressing strategies to improve rehabilitation, such as minimally invasive 
surgery and enhanced recovery pathways, commonly focus on measures such as complication rates, 
gastrointestinal activity, physical function, and duration of hospital stay 2. These parameters are 
mostly relevant to clinicians and administrators, but they do not reflect the complexity of the 
rehabilitation process or include the patient`s perspective and expectations.  
In musculoskeletal practice, patients’ expectations have been reported as a valuable predictor for 
treatment outcomes in patients with acute and chronic pain 3. Patients with higher expectations 
regarding the treatment report better outcomes than those with lower expectations 3. Previous 
studies have investigated the relationship between expectations and postoperative satisfactions in 
patients undergoing spinal surgery 4, and some evidence suggest patients’ expectations also impact 
rehabilitation after surgery 5,6. 
Patients undergoing spinal surgery usually suffer from moderate to severe pain during the 
perioperative and postoperative period 7, which is associated with developing persistent pain 8 and 
compromises patients’ quality of life. 
Lumbar disc herniation is one of the most common musculoskeletal diseases which, in some cases, 
can compromise patients’ quality of life, and the most common operations performed on the spine 9. 
A previous study has shown that persistent pain after surgery for lumbar disc herniation is 

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negatively associated with psychological and physical well-being, and the overall quality of life is 
decreased 10.  
We hypothesize that interviewing patients in a semi-structured manner would give unique 
perspectives on what is important to patients, as opposed to what is important to researchers. 
Further, we hypothesize that patients’ preoperative expectations for spinal surgery can affect 
postoperative rehabilitation. Gaining in-depth understanding of the process of recovery from the 
patients´ perspectives can, ultimately, guide patient-centered care and future research. 
Aim 
The purpose of this study is twofold:  
1) to investigate how expectations predict patients' pain, rehabilitation and quality of life after spinal 
surgery. 
2) to explore the patients' expectations before, and their experiences after, spinal surgery regarding 
pain, rehabilitation and quality of life.  
  
Methods 
Design 
Prospective observational cohort study, where qualitative and quantitative data is collected. The 
study will illuminate the research question by using quantitative and qualitative approaches. No 
formal sample size calculation is performed since this is a prospective cohort study exploratory by 
nature. 
Location of the study 
The study will be conducted at the Department of Anesthesiology, Zealand University Hospital, 
Koege, from 01.09.2023 – 31.08.2024. 
Participants  
All patients at Zealand University Hospital, who meet the inclusion criteria, undergoing spinal 

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surgery during 1 year, will be invited to participate in the quantitative part of the study. We estimate 
that 300 patients will be eligible for the quantitative part. For the qualitative part, we will include 10 
- 15 patients undergoing spinal surgery.  
Inclusion criteria 
Patients must meet all the following criteria to be suitable for inclusion in the study. 
Patients > 18 years, undergoing elective spinal surgery at Zealand University Hospital, Koege. 
Patients able to read and understand Danish. 
Exclusion criteria 
Patients meeting one or more of the following criteria are ineligible for inclusion in the study. 
Patients with cognitive deficits, such as dementia or who are mentally disabled and cannot 
cooperate with the study based on the investigator`s judgement. Patients with alcohol and drug 
dependence based on the investigator`s judgement. 
Procedure for patients who withdraw from the trial  
In accordance with the Declaration of Helsinki 11, patients have the right to withdraw from the study 
at any time for any reason. It will be recorded in the patient’s Case Report Form if a reason is given. 
 
Data collection and analysis  
For the quantitative part the following background characteristics will be collected in a CRF: sex 
(male/female), age (years), Body Max Index (BMI), preoperative opioid consumption (yes/no), civil 
status (response alternatives), job situation (response alternatives), and capable of working (yes/no). 
Questionnaires will be used for collection of data regarding pre-operative expectations (Treatment 
Expectation Questionnaire (TEX-Q) 12), pain (Verbal rating scale (VRS)) functional level 
(Oswestry Disability Index (ODI) 13) and quality of life (WHO Quality of Life – BREF  
(WHOQOL-BREF) 14) and will be collected at baseline. Data regarding pain, functional level, and 
quality of life, will also be collected postoperatively. All questionnaires have been validated except 
the TEX-Q, which validation is under preparation. 

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The analyses will primarily focus on functional level and quality of life postoperatively as a 
function of preoperatively expectations. Other analyses will explore covariates as determinates of 
preoperative expectations and functional recovery. Data will be analyzed with multiple regression 
in SPSS. Results will be described with mean values and standard deviation of the mean value, or 
with median and inter-quartile range as appropriate. A 5% level of significance will be used. 
Relevant parametric or non-parametric methods will be used, depending on distribution of data. 
For the qualitative part, data regarding pre-operative expectations, and their experiences 3 months 
post-operatively, will be collected using interviews. The interviews will be conducted using semi-
structured questions, which will be designed prior to the interviews. Patients will be enrolled several 
days before surgery and will be interviewed during an in-person interview. The interviews will be 
recorded using an IPAD and in rooms suitable for asking emotional questions. The interviews will 
afterward be transcribed and analyzed by the investigators using inductive qualitative content 
analysis as described by Graneheim and Lundman 15. The data will then be divided into meaning 
units, condensed meaning units, codes and themes and discussed by the authors until consensus has 
been obtained. 
Ethical considerations 
In this study, there will be no changes in the patient's treatment. 
Written consent will be obtained from the participants after oral information, according to 
regulations of the local Research Ethics Committee and The Danish Data Protection Agency. The 
patients included in the study will not have an immediate benefit from participating, but in the 
future, the results of the study may be useful for other patients. The study will be conducted in 
accordance with the principles of the Declaration of Helsinki 11.  
Protection of patient data 
Information will be treated confidentially and in the reporting of test results, patients will be 
anonymous at all times and the persons responsible for this trial are bound to confidentially. 
The primary investigator will create an identification list of all patients who have been given trial 
numbers. The list will contain patients` full name and CPR number stored in the template “Team 

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site SharePoint”.  
The IPAD used for the interviews will only be used for research purposes and will be locked away 
until the interviews have been transcribed. All transcribed material and results will be stored in the 
template “Team site SharePoint”, a closed document library to store all files related to a specific 
project. 
Data will be stored according to The Danish Data Protection Agency. 
Financial situation 
The primary investigator is employed at Zealand University Hospital, Koege and has no financial 
benefit from the study.  
The investigators have no financial interest in the study.  
Data registration and rules for the control of investigation procedures  
The study will be conducted in accordance with the applicable rules on clinical trials involving 
people in respect of quality control and quality management, and will follow Good Clinical 
Practice.   
The investigator and co-investigators at Zealand University Hospital, Koege are responsible for 
managing and archiving data in accordance with current regulations. The data belongs to Josephine 
Zachodnik. 
The study will be reported to The Danish Data Protection Agency, Research Ethics Committee and 
Clinical Trials.gov 
 
 
 

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Publication of results  
Data from this study will form the basis of at least 2 manuscripts to be submitted for publication 
with the following order of authors; 
The quantitative study: 
 Josephine Zachodnik 
 Kasper Thybo 
 Peter Udby 
 Magnus Sandberg 
 Anja Geisler 
The qualitative study: 
 Josephine Zachodnik 
 Kasper Thybo 
 Peter Udby 
 Anja Geisler 
 Magnus Sandberg 
Other authors may be added during the work if relevant. Josephine Zachodnik will always be the first 
author.  
 
 
 

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