Surgeons have a lower preference for back surgery than family doctors

Jan 29 2010

Surgeons are less likely than family physicians or patients to view surgery as the preferred treatment option for low back pain, according to a study in the January 1 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, and pharmacy.

For patients with back pain, quality-of-life issues are the main factor affecting treatment preferences—which has important implications for shared decision-making between patients and their doctors, according to the new study led by Dr. S. Samuel Bederman at University of Toronto.

Family Doctors Have Highest Preferences for Surgery
The researchers presented hypothetical back pain scenarios to surgeons (orthopedic surgeons and neurosurgeons), family physicians, and patients with back and/or leg pain. The scenarios reflected key factors related to back pain: walking ability, pain duration, pain severity, neurological symptoms, factors inducing pain, and pain location. Each group rated their preference for surgery in each scenario, and the factors affecting preferences were analyzed.

Perhaps unexpectedly, surgeons had the lowest overall preferences for surgery, while family physicians had the highest preference for surgery. For orthopedic surgeons, the preference for surgery was somewhat lower than for neurosurgeons. Both the family doctors and patients had a higher preference for surgery than either group of surgeons.

The factors affecting preferences for surgery varied as well. For surgeons, the most important factor was the location of pain. In particular, they preferred surgery for patients with pain predominantly in the leg, rather than the back. Surgery provides better results in patients with problems affecting the spinal nerve roots, which tend to cause leg pain.

Revealing Differences in Reasons for Preferences
In contrast, for family physicians, the most important factor affecting preferences for surgery was neurological symptoms, followed closely by walking ability and pain severity. Family doctors may be unaware of which factors affect the chances of good outcomes from back surgery, the researchers suggest.

For patients, the most important factors were pain severity, walking ability, and pain duration. "All of these symptoms are highly related to quality of life and have little direct bearing on outcomes following surgery," Dr. Bederman and co-authors write.

When other treatments have failed, surgery can help patients with moderate to severe lower back pain. Family physicians play an important role in sending back pain patients for surgical evaluation. However, few studies looked at the factors considered by primary care doctors consider in referring patients for possible spinal surgery. The final decision is generally made through a shared process between the patient, family physician, and surgeon.

The new results suggest that, in various scenarios, surgeons have a lower preference for surgery than family physicians. In addition, the factors that surgeons feel are most important—especially the location of pain—don't match those considered most important by family doctors.

The study also highlights the importance of quality-of-life factors—especially pain severity and duration and walking ability—in affecting patients' treatment preferences. Dr. Bederman and colleagues hope their findings will help in "aligning" the opinions of patients and doctors, thus improving the shared decision-making process and promoting more accurate patient expectations of the results of surgery. "This can directly result in a significant improvement in patient satisfaction with the healthcare process and even overall health status following treatment," the researchers write.