The most critical question most patients ask when we discuss lumbar fusion is their chance of success.
Historically, this was a very difficult question to answer. Surgeons have known the main indications for lumbar fusion, which mostly include: lumbar spondylolisthesis (slippage of one vertebral body over another), recurrent disc herniation, or the inability to perform a given surgery without causing the spine to become unstable. However just because a patient has one of these conditions does not guarantee surgical success. Making an x-ray look better after surgery does not automatically translate to a happy patient. The results of spine surgery trials vary greatly, ranging from less than a 20% chance of improvement to upwards of 80% chance of improvement. Would you undergo an operation if the success could range anywhere between 20-80%?
It’s easy to attribute success to the surgeon or facility. I routinely hear patients claim, “my surgeon is the best”, or, “everyone does well at that hospital”. Similarly, I routinely hear surgeons claim, “I am the best”, or hospitals claim, “our facility is the best”.
Recent research suggests, that while a surgeon or hospital may be slightly better than one another, success in lumbar fusion may be highly attributable to patient-related factors and if the surgery is being performed minimally invasively (discussed in prior blogs).
The Spine Surgical Care and Outcomes Assessment Program (Spine SCOAP) was designed to help identify patient characteristics and modifiable risk factors that may predict the best outcomes. Groups least likely to improve from lumbar fusion include a non-surgical spine disease, smoking status, history of prior surgery, preoperative opiate use and preoperative disability score, amongst other variables. In patients with a higher predicted chance of improvement, there was little variation in outcome when considering a surgeon or hospital. There even was little variation between academic and community-based centers.
If surgeons and patients want to avoid operations where there is less than a 50% chance of improvement, a significant amount of patients should probably avoid surgery. This is a difficult concept for many to grasp because many symptomatic patients feel surgery is their only remaining option, even if they are poor surgical candidates.
Another factor in predicting outcome comes down to how the outcome is measured. Performance-based measure reflects an objective score, which a doctor can quantify in a patient. We can reasonably rate how weak a patient’s muscle tests or weak a reflex responds, and compare those results before and after surgery. Perception-based measures, on the other hand, reflect patient judgment in how they feel. A surgeon simply relies on the patient’s symptom reporting for this. Patient-surgeon perspectives do not always agree, with a mismatch in perceived outcomes up to about 24%. There has been an evolution from purely objective measures towards the patient’s perspective, which means it is very important for the patient and surgeon to discuss the patient’s expectations to gauge postoperative satisfaction. Additionally, patients sometimes have a difficult time remembering exacting how they felt prior to surgery. Studies assessing how much patients remember from a preoperative visit show their recall is about 21%
