Fulfillment of Expectations Two Years after Lumbar Spine Surgery
Authors: Lebl Darren , Sama Andrew , Girardi Federico P. , Cammisa Frank P. , Hughes Alex P. , Duculan Roland , Mancuso Carol A. 
Published: April 2016

Background Patients have multiple expectations of lumbar surgery and fulfillment of expectations is an important but infrequently studied outcome. The objective of this study was to compare patients' preoperatively cited expectations with their postoperative ratings of fulfillment of expectations. Methods A longitudinal cohort with 2 year follow-up at a tertiary spine center of 366 patients before and 2 years after surgery was conducted. 422 patients preoperatively completed a valid survey measuring amount of improvement expected from lumbar surgery for 20 items addressing symptoms, function, and mental well-being. Function was measured with the modified Oswestry Disability Index (ODI), and psychosocial variables, including depressive symptoms, were measured with valid scales. Two years after surgery patients were asked how much improvement they actually received for items listed in the survey. The proportion of fulfilled expectations was calculated as the sum of improvement received divided by the sum of improvement expected (0%= expectations completely unfulfilled, 100%=expectations completely fulfilled,  > 100%= expectations surpassed). Additional patient-centered postoperative variables were the ODI and overall satisfaction with the outcome of surgery. Results 401 patients were contacted 2.1 years postoperatively (range 1.9–3.1 years). Of these 366 participated in a postop interview to rate fulfillment of expectations (mean age 55 years, 57% men, 78% degenerative conditions). Mean proportion of fulfilled expectations was 66% (range 0–200%). Greater preoperative expectations were associated with lower proportions of fulfilled expectations postoperatively (p=.002). Other preoperative variables associated with lower proportions of fulfilled expectations were: surgery for a degenerative spine diagnosis [OR 2.8 (1.6–5.0), p=.003]; revision surgery [OR 2.2 (1.4–3.8), p = .006]; more vertebral levels involved [OR 1.5 (1.3–1.8), p < .0001]; more depressive symptoms [OR 2 (1.3–3.10, p = .001]; and not being employed [OR 2.8 (1.8–4.5), p < .0001]. Postoperative variables associated with lower proportions of fulfilled expectations were: less pre-to-postoperative improvement in ODI scores [OR 9 (5–17), p < .0001]; having a postoperative fracture or infection [OR 4.2 (1.5–11.9), p = .007]; and having a subsequent repeat surgery [OR 3.6 (2.1–6.5), p < .0001]. There were no differences based on age, sex, marital status, use of narcotics, and whether a fusion was performed. In multivariable analysis, greater preoperative expectations, not being employed, revision surgery, more levels involved, less improvement in ODI score, and having a subsequent repeat surgery remained associated with lower proportions of fulfilled expectations (p≤.03 for all variables). Overall 73% of patients were satisfied with the results of surgery; the proportion of expectations fulfilled was highly, but not completely, associated with satisfaction (r = .72). Conclusions Fulfillment of expectations varied widely two years after lumbar surgery. Patients with greater preoperative expectations were more likely to have lower proportions of fulfilled expectations postoperatively. Both pre- and postoperative functional and surgical variables were associated with fulfillment of expectations. Fulfillment of expectations and satisfaction were associated but remained distinct patient-centered outcomes.