What Factors Are Important to Patients When Deciding Between Minimally Invasive or Open Surgery for Posterior Lumbar Fusion?

Lead author, Hwee Weng Dennis Hey, FRCSEd (Orth), FAMS (Orth), MCI, eludidates common concerns that influence patient decision-making and informed consent. Choll W. Kim, MD, PhD, comments.

Research on whether minimally invasive surgery (MIS) for lumbar spine fusion is more advantageous than open surgery has been the topic of much debate. While studies suggest less blood loss and fewer infections with MIS, this approach may take longer and be more technically demanding.
Professionals having a roundtable discussion.Patient education and shared decision-making can be complex. Photo Source:123RF.com.Given the lack of consensus on which approach may be best, patient education and shared decision-making can be complex. New findings suggest that patient preference may be influenced by many factors during consent-taking, as reported in the August issue of The Spine Journal.

“Our study demonstrated that patients change their decisions between MIS and open approaches frequently during the process of consent-taking,” said lead author Hwee Weng Dennis Hey, FRCSEd (Orth), FAMS (Orth), MCI, Consultant, Orthopaedic and Spine Surgery, University Orthopaedics, Hand and Reconstructive Microsurgery Cluster, National University Health System in Singapore. “This is likely due to the different weight each patient gives to the advantages and disadvantages of MIS or open surgery.”

“The most common concerns influencing patients’ final decision are radiation and cosmesis,” Dr. Hey told SpineUniverse. “As a result, consent-taking should be conscientious such that patients are adequately informed. Radiation and cosmesis should be given more emphasis.”

Cross Sectional Study of Patients with Lumbar Spondylolisthesis

The findings are based on a cross-sectional study of 54 patients (mean age, 55.8 years) collected over a 3-month period at a single institution in Singapore. These patients were indicated for transforaminal lumbar interbody fusion (TLIF) for radiographically confirmed lumbar spondylolisthesis. All patients had chronic low back pain and radiculopathy. Patients who had undergone previous spine surgery, had concurrent spine pathologies (eg, tumors, infection, or fractures), or had high-grade spondylolisthesis were excluded from the study.

Standardized Consent-Taking Process

An independent spine specialist interviewed patients using a script that required patients to decide between MIS or open surgery at various points during the consent-taking process. Pictures of the scars from MIS and open surgery as well as information on the potential advantages and disadvantages of both approaches were also provided.

Only 24% of the patients kept to the same decision throughout the process. More than half the patients (57%) changed their minds more than once during the interview process, and 28% ultimately left it up to the doctor to make the final decision. The proportion of patients who chose MIS decreased significantly after the interviewer explained the pros and cons of each approach (P=0.002). This proportion decreased further after information on conversion to open or revision surgery was given (P=0.017).

Patients Preferred Appearance of Open Surgery Scar

The amount of radiation required for each approach, and the associated cosmesis of surgical scars were cited as the most important factors responsible for the patients’ final decisions.

“Our findings indicated that the longer midline incision of the open approach seems cosmetically more appealing to most patients than the paramedian stab wounds of MIS,” Dr. Hey explained.

“This finding is enlightening,” Dr. Hey said. “It would mean that in order to achieve better cosmesis, surgeons should now consider a midline skin incision while performing a multifidus muscle-sparing paramedian approach of MIS in these patients.”

The vast majority of patients (94%) felt that the information provided was sufficient for their decision-making and did not require further information.

Robust Informed Consent Process is Essential to Care

“This is a refreshing and insightful study that illustrates how the informed consent process can profoundly affect patient decision-making.  It appears the patients tend to favor MIS initially,” commented Choll W. Kim, MD, PhD, Associate Clinical Professor, University of California San Diego. “After several rounds of interviews, the tide turns in favor of open surgery.  It begs the question, can another set of equally logical scenarios have an opposite effect?

“The importance a robust informed consent process cannot be over-emphasized.  This field remains under-studied,” Dr. Kim told SpineUniverse. “The work of Hey et al is a much needed contribution to this important effort. For the present, patients considering lumbar spine surgery should be encouraged to seek additional opinions and study independent information from patient-centered health organizations and societies. Finally, spine surgeons should remain facile in both open and MIS techniques so that treatment be customized to the unique needs of the individual patient.”

Tips for Patient Education on Minimally Invasive Versus Open Spine Surgery

“The best way to educate patients on the pros and cons of MIS versus open surgery for lumbar fusion, apart from ensuring that patients are fully informed, would be to show pictures illustrating open and MIS incisions, as well as to provide information on radiation dose required for both approaches. This should be both patient- and surgeon-specific,” Dr. Hey said.

“Since both approaches are comparable in terms of long-term outcomes, and not every patient is suitable, keen or has equal perception of MIS, it is crucial that contextual, tailored information be given to patients during the consent-taking. This will help to ensure good surgical outcomes that meet patients' expectations.” Dr. Hey concluded.

Updated on: 09/17/19
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