Satisfaction With Pain After Spine Surgery: What Residual Pain Level Do Spine Surgery Patients Find Acceptable?
Patient satisfaction will continue to become an important metric in healthcare
Commentary by Tamas F. Fekete, MD —Brian Etier, MD — Anne F. Mannion, PhD
The acceptable pain level after surgery for disc herniation is ≤2 and for other degenerative pathologies is ≤3 on a 10-point scale, according to findings from a cross-sectional study involving nearly 7,000 patients. The findings suggest that achievement of an acceptable level of pain may be a better target for denoting surgical success among patients undergoing surgery for painful degenerative lumbar disorders than more complex health-related quality of life measures, the study authors wrote in the April issue of The Spine Journal.
“Our study shows that a simple measure, like pain intensity on 0-10 scale, can indicate whether patients are happy with the results [of lumbar spine surgery],” said lead author Tamas F. Fekete, MD, Consultant Spine Surgeon, Spine Center, Schulthess Klinik, Zurich, Switzerland.
“Studies in days gone by used pain scales only, but for various reasons over the years a more complex assessment of health-related quality of life has become popular,” Dr. Fekete explained. “This has led to an ever increasing rise of the administrative burden for both patients and medical professionals (filling in and analyzing long and often multiple questionnaires). Most degenerative disorders of the spine cause pain primarily. Hence, it makes sense to (re)focus on this aspect of patient-reported outcomes measures,” Dr. Fekete said.
“Fekete et al have tried to quantify the acceptable level of pain following lumbar spine surgery in a large cross sectional study,” commented Brian Etier, MD, lead author of another recently published study on patient satisfaction scores in spinal surgery, as discussed below.
“The authors concluded that most spine interventions decrease pain, and a pain level goal can be set at 2 or 3 depending on the procedure,” said Dr. Etier. “The clinical implications of this study are helpful in guiding surgeons and patients on surgical expectations. Furthermore, subsequent research can use the ‘acceptable symptom state’ to denote a successful outcome following surgery.”
Findings Based on 12-Month Postoperative Data
The study is based on 12-month postoperative data from patients who underwent surgery for degenerative disorders of the lumbar spine. Patients completed the Core Outcome Measures Index (COMI) questionnaire that contains, among other items, two graphic rating scales (0-10) for back pain and leg pain (the higher score was used in the analysis) and the following question concerning the acceptability of symptoms: “If you had to spend the rest of your life with the symptoms you have now, how would you feel about it?” The question was answered on a 5-point Likert scale from “very satisfied” to “very dissatisfied,” and the top two categories (somewhat/very satisfied) were considered an acceptable state.
Nearly Half of Patients Somewhat Satisfied With Symptom State
At 12 months, 47% of the 6,248/6,943 patients (90%) completed the questionnaire. Of these, 47% reported being at least somewhat satisfied with their symptom state, ranging from 44% among patients with degenerative deformity to 53% among patients with degenerative spondylolisthesis.
“The cutoff indicating a satisfactory symptom state was ≤2 points for patients who underwent surgery for disc herniation (sensitivity: 76%; specificity: 88%) and ≤3 points for all other conditions (sensitivity: 79%–84%; specificity 81%–85%),” the authors wrote. Sensitivity analyses suggested that a score of ≤3 points was the most common cutoff for the various disorder subgroups.
Related Study Shows Factors Linked to Patient Satisfaction in Spinal Surgery
In related research by Dr. Etier et al, two factors were found to be significantly associated with increased patient satisfaction scores after orthopaedic spine surgery: pain and patients feeling the provider spent enough time with them.
“In fact, patients who felt the provider ‘definitely’ spent enough time with them had an almost 60% increase in satisfaction,” said Dr. Etier, who was an orthopaedic surgery resident at University of Alabama at Birmingham at the time that this study was conducted. He is currently a fellow in the orthopaedic sports medicine program at the University of Virginia in Charlottesville.
Findings May Help in Design of Future Pain Studies
“A very important aspect of the study is that it may help in designing future pain studies,” said senior author Anne F. Mannion, PhD, who is Senior Research Fellow at the Spine Center of the Schulthess Klinik. “Definition of a threshold above which pain is not ‘acceptable’ can help to define patient groups with predominant leg or back pain, or whether a patent qualifies for participation in a pain study (ie, does the patient have sufficiently high pain at baseline?) or whether leg pain or back pain is considered to predominate.”
“Achievement of an acceptable pain level is also a more stringent criterion to define success,” Dr. Mannion said. “Success is when the patient not only feels better after surgery, but also feels good. Seeing as only a very low proportion of the patients will become pain free, it stimulates us to put more effort into improving our treatment methods. The pain score alone gives a good reflection of how happy the patients are after surgery. Using a simple score like pain allows us to compare [outcomes from] different medical fields: other orthopedic disciplines, rheumatology, just to mention a few.”
Findings May Aid in Patient Education Before Surgery
In addition, Dr. Fekete believes that the findings also can help spine surgeons educate patients about expected outcomes of surgery.
“Telling patients that they won’t be completely pain free may help patients to create a more realistic expectation before surgery. It also helps the surgeon to interpret the ‘level of suffering’ of a patient prior to surgery. Sometimes patients request surgery at a low pain level,” Dr. Fekete said.
“Spine surgeons can look at both of these studies to educate patients,” Dr. Etier said. “Pain has proven to be an important metric in patient satisfaction and patient’s acceptable symptom state. Surgeons can also improve patient satisfaction by increasing the perceived amount of time spent with patients. Surgeons should pace the dialogue, recognize the patient's concern, ask open-ended questions, and sit with the patient.”
“Patient satisfaction will continue to become an important metric in healthcare. These two studies are helpful in defining the characteristics and associated factors of a satisfied patient,” Dr. Etier concluded.