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

Introduction Patients have multiple expectations of cervical spine surgery that encompass physical and psychological well-being. Assessment of 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. Materials and Methods A longitudinal cohort study with 2 year follow-up at a tertiary spine center was conducted of 133 patients before and 2 years after surgery.150 patients preoperatively completed a valid survey measuring amount of improvement expected from cervical surgery for 20 items addressing symptoms, function, and mental well-being. Function was measured with the Neck Disability Index (NDI), 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 NDI and overall satisfaction with the outcome of surgery. Results 149 patients were contacted 2.1 years postoperatively (range 1.9–2.7 years). Of these 133 participated in a postop interview and rated fulfillment of expectations (mean age 54 years, 62% men, 67% had radiculopathy, 26% had myelopathy, and 7% had other conditions). Mean proportion of fulfilled expectations was 78% (range 0–216%). Greater preoperative expectations were associated with lower proportions of fulfilled expectations postoperatively (p = .001). Having revision surgery also was associated with a lower proportion of fulfilled expectations (58% versus 82%, p = .03). Postoperative variables associated with lower proportions of fulfilled expectations were less pre-to-postoperative improvement in NDI scores (51% versus 91%, p < .0001) and more depressive symptoms (31% versus 88%, p < .0001). Prolonged dysphagia after surgery (i.e., to more than 6 months) also was associated with a lower proportion of fulfilled expectations (60% versus 80%). There were no differences based on age, sex, use of narcotics, or number of vertebral levels involved. Although preoperative expectations were higher in patients with radioculopathy versus myelopathy, the percent of fulfilled expectations was similar (77% versus 81%, p = .61). Overall 83% of patients were satisfied with the results of surgery; the proportion of expectations fulfilled was highly, but not completely, associated with satisfaction (r = .61). Conclusions Fulfillment of expectations varied widely two years after cervical spine surgery but most expectations were fulfilled. 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.