Expectations of Pain Improvement and Actual Pain Improvement: A Prospective Comparison for 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

Introduction Patients undergo lumbar spine surgery because they expect improvement in pain and function. Traditionally, pain outcomes have been measured with numerical scales that capture pain intensity. Fulfillment of the expectation for pain improvement is another outcome that captures additional components of pain. This study compared patients' preoperative expectation of pain improvement with their actual pain improvement two years after surgery and identified variables associated with postoperative pain and unfulfilled expectations of pain improvement. Methods Several days before surgery patients completed a multi-item expectations survey specific to lumbar spine surgery that is valid and reliable. One item asked patients how much pain improvement they expected with response options ranging from “complete improvement” to a “little improvement.” Patients also rated pain intensity on a numerical scale (0 (none), 10 (worst)) and completed standard surveys for psychological well-being and disability due to lumbar pain. Two years after surgery patients were asked how much pain improvement they actually received with response options ranging from “complete improvement” to “no improvement.” Patients were not reminded of their preoperative responses. They also reported current back and leg pain intensity with the numerical scale. Results In total, 422 patients (87% of those eligible) completed the follow-up a mean of 2.2 years after surgery; mean age was 56 years, 55% were men, 78% had a degenerative spine condition, 44% were taking opioids, and median back and leg pain intensities were 7 and 6, respectively. Most patients expected a lot (44%) or complete (45%) pain improvement preoperatively. Regarding postoperative pain improvement at two years, 11% reported no improvement, 28% reported a little to moderate improvement, 44% reported a lot of improvement, and 16% reported complete improvement. In multivariable analysis, patients were more likely to report less improvement if, before surgery, they expected greater pain improvement (OR 1.4; CI 1.1–1.9; p=.001), had symptoms longer (OR 1.6; CI 1.0–2.5; p=.06), had a positive screen for depression (OR 1.7; CI 1.2–2.5; p=.005), were having revision surgery (OR 1.6; CI 1.0–2.6; p=.04), had surgery at L4 or L5 (OR 2.5; CI 1.3–4.7; p=.004), and had a degenerative diagnosis (OR 1.6; CI 1.0–2.6; p=.05). They also had less pain improvement if they had a subsequent (repeat) surgery (OR 2.8; CI 1.7–4.7; p < .0001) and had less decrease in back (OR 1.3; CI 1.2–1.3; p < .0001) and leg pain (OR 1.1; CI 1.0–1.1; p=.004) based on the numerical scale. The proportions of patients who had their expectation fulfilled were 23% for those who expected complete improvement, 60% for those who expected a lot, 60% for those who expected moderate, and 71% for those who expected a little improvement. The variables associated with an unfulfilled expectation in multivariable analysis were greater preoperative expectations (OR 6.0; CI 3.9–9.2; p < .0001), a positive screen for depression (OR 1.9; CI 1.2–3.1; p=.01), surgery at L4 or L5 (OR 3,6; CI 1.6–8.5; p=.003), repeat surgery (OR 3.6; CI 1.8–7.5; p=.0005), and less decrease in back (OR 1.2; CI 1.2–1.4; p < .0001) and leg (OR 1.1; CI 1.0–1.1; p=.02) pain based on the numerical scale. Discussion Back pain is common two years after lumbar spine surgery with most patients having less improvement in pain then they expected preoperatively. Postoperative lumbar pain is a complex phenomenon due to an interrelated network of clinical, technical, and psychological variables. Surgeons should preoperatively ascertain patients' expected level of pain relief and particularly council those who expect complete improvement in pain.