Expectations drive patient preferences for treatment of spine problems

Nov 17 2008

For patients with low back pain caused by a herniated disk, expectations of good results without surgery are the main factor affecting the preference for nonsurgical treatment, reports a study in the November 15 issue of Spine.

The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health, a leading provider of information and business intelligence for students, professionals, and institutions in medicine, nursing, allied health, pharmacy and the pharmaceutical industry.

However, once patients overcome their reluctance to undergo surgery, they strongly prefer surgical treatment - generally for reasons that are "clinically sensible," according to the new study, led by Dr. Jon D. Lurie of Dartmouth Medical School, Lebanon, N.H.

As part of a larger trial comparing the results of surgical versus nonsurgical treatment, the researchers studied preferences and expectations for treatment in 740 patients with pain and other symptoms caused by herniated disks in the lower back (lumbar spine). The current study included only those patients who had declined to be randomly assigned to surgery or nonsurgical treatment.

Before discussing treatment alternatives with a spine specialist, the patients completed a questionnaire asking whether they preferred surgical or nonsurgical treatment, and about the results they expected. Factors affecting patient preferences were analyzed, along with the relationship between treatment preferences and expectations.

Expectations Are Strongest Reason for Treatment Preferences
Overall, 67 percent of the patients preferred surgical treatment for their herniated disk problem. Twenty-eight percent said they preferred nonsurgical treatment; the remaining six percent were unsure.

Patients preferring surgery were more certain of their choice: 53 percent stated a "definite preference," compared to 18 percent of those preferring nonsurgical treatment. Patients who preferred surgery were younger, less educated, and had higher rates of unemployment or disability.

A preference for surgery was related to other patient characteristics as well, including higher levels of pain, more problems with functioning, and more back pain-related disability. They had had back pain for a longer time and were more likely to be using strong pain-relieving drugs (opiates).

However, the factor most strongly related to treatment choice was the expectation that nonsurgical treatment would be effective. In other words, patients who thought that treatment without surgery would improve their symptoms tended to prefer nonsurgical treatment, regardless of their other characteristics.

Patients Must Cross 'Threshold' before Preferring Surgery
Patient expectations have an important but complex relationship with treatment results. For example, if expectations are unrealistically high, patients may be disappointed with the results. On the other hand, patients who expect good results may be more motivated to improve or follow their recommended treatment more closely—or may improve because of a "placebo effect." Patients' preferences for a certain type of treatment have an important effect on their expectations of the results.

The new study suggests that, among patients with herniated disks, those who expect to improve without surgery are more likely to prefer nonsurgical treatment. There is a "certain reluctance threshold" that needs to be crossed for patients to prefer surgery, Dr. Lurie and colleagues write: "When the expected benefits were equal, patients tended to prefer nonoperative treatment due to higher perceived risks of surgery." When discussing treatment options for low back pain, doctors should make sure that patients have accurate expectations regarding the treatment results.

After crossing the threshold, patients tend to have a strong preference for surgery. Dr. Lurie and colleagues note that most of the characteristics of patients preferring surgery seem "clinically sensible." They write, "Those with more severe, longer lasting symptoms and those with greater symptoms are more likely to prefer surgery…and in fact, this group is probably more likely to benefit from surgery."

About Spine
Recognized internationally as the leading journal in its field, Spine is an international, peer-reviewed, bi-weekly periodical that considers for publication original articles in the field of spine. It is the leading subspecialty journal for the treatment of spinal disorders. Only original papers are considered for publication with the understanding that they are contributed solely to Spine . According to the latest ISI Science Citation Impact Factor, Spine ranks highest among general orthopaedic journals and subspecialty titles. Visit the journal website at http://www.spinejournal.com