A Conceptual Model for Spine Surgery Recovery

A Qualitative Study of Patients' Expectations, Experiences, and Satisfaction

Carrie E. Brintz, PhD; Rogelio A. Coronado, PT, PhD; David G. Schlundt, PhD; Christine Haug Jenkins, MPH; Mackenzie L. Bird, MD, MS; Jordan A. Bley, PhD; Jacquelyn S. Pennings, PhD; Stephen T. Wegener, PhD; Kristin R. Archer, PhD, DPT

Disclosures

Spine. 2023;48(14):E235-E244.

Abstract and Introduction

Abstract

Study Design: Qualitative interview study.

Objective: The aim was to develop a conceptual model for Spine Surgery Recovery in order to better understand why patients undergo lumbar spine surgery and what factors influence patient satisfaction.

Summary of Background Data: Quantitative studies have assessed patients' expectations for lumbar spine surgery outcomes, with greater expectation fulfillment leading to higher satisfaction. However, there is limited literature using qualitative methods to understand the patient perspective from the decision to undergo lumbar spine surgery through long-term recovery.

Materials and Methods: Semistructured phone interviews were conducted with 20 participants (nine females, mean age ±SD = 61.2 ± 11.1 yr) and three focus groups with 12 participants (nine females, mean age ±SD = 62.0 ± 10.9 yr). Sessions were audio recorded and transcribed. Two independent researchers coded the transcripts using a hierarchical coding system. Major themes were identified and a conceptual model was developed.

Results: A total of 1355 coded quotes were analyzed. The decision to have lumbar spine surgery was influenced by chronic pain impact on daily function, pain coping, and patient expectations. Results demonstrated that fulfilled expectations and setting realistic expectations are key factors for patient satisfaction after surgery, while less known constructs of accepting limitations, adjusting expectations, and optimism were found by many patients to be essential for a successful recovery. Emotional factors of fear, anxiety, and depression were important aspects of presurgical and postsurgical experiences.

Conclusion: Our Spine Surgery Recovery conceptual model provides guidance for future research and clinical practice to optimize treatment and improve overall patient satisfaction. Recommendations based on this model include the assessment of patient expectations and mental well-being throughout postoperative recovery as well as preoperatively to help set realistic expectations and improve satisfaction. Educational, acceptance-based or positive psychological interventions may be potentially beneficial for addressing key factors identified in this model.

Introduction

Chronic low back and radicular leg pain and associated functional limitations are common symptoms of degenerative lumbar spine conditions.^[1,2] Patients who do not experience meaningful symptom relief through conservative measures are often left with no option but to consider surgery.^[3,4,5] Many patients achieve immediate and lasting pain relief after spine surgery;^[6,7] however, a substantial number continue to experience persistent symptoms that impair functioning.^[6,8,9,10] How patients cope with postsurgical pain and physical limitations may influence postoperative outcomes.

Understanding patient experiences of lumbar spine surgery from the decision to have surgery through postoperative recovery is essential for optimizing treatment and improving outcomes. Several survey studies have described the patient's decision-making process for lumbar spine surgery.^{[11,12,13,14]} Bono et al^[11] concluded that pain intensity is the most influential factor in a patient's decision to undergo lumbar fusion, while other studies found that walking tolerance/capacity and pain severity and duration were of greatest importance to patients.^[12,14] In contrast, Roszell et al^[13] reported that general health and quality of life were more important than pain severity or physical disability in predicting who elected to undergo spine surgery.

Patients develop preoperative expectations of treatment success and the influence of patient expectations on postoperative satisfaction has been demonstrated in a number of orthopedic populations.^[15,16,17] Patients with realistic preoperative expectations (i.e. less discrepancy between expectations and actual reported outcomes) have a greater chance for satisfaction with surgical results.^{[14,15,17,18,19]}

There is limited literature using qualitative methods for an in-depth perspective of patients' experiences from the decision to undergo lumbar spine surgery through long-term recovery. Prior qualitative studies have focused on the immediate and short-term postoperative period. Therefore, the primary purpose of this qualitative study was to develop a conceptual model for Spine Surgery Recovery in order to better understand why patients undergo spine surgery and what factors influence patient satisfaction. A better understanding of patient expectations and postsurgical experiences has the potential to improve shared decision making and to identify new areas of research leading to improved patient satisfaction after lumbar spine surgery.

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Table 1. Demographic Characteristics of Interview and Focus Group Participants
Characteristics	Interview Group (N = 20), N (%)	Focus Group (N = 12), N (%)
Age in years, mean ± SD	61.2 ± 11.1	62.0 ± 10.9
Female	9 (45.0)	9 (75.0)
Self-report White race	18 (90.0)	11 (91.7)
More than high school education	13 (65.0)	11 (91.7)
Married	18 (90.0)	8 (66.7)
Obese BMI category	9 (45.0)	5 (41.7)
Preoperative opioids	9 (45.0)	7 (58.0)
Co-morbidities
None	15 (75.0)	6 (50.0)
1	3 (15.0)	4 (33.3)
2 or more	2 (10.0)	2 (16.7)
Fusion surgery	15 (75.0)	8 (66.7)

BMI indicates body mass index.

Table 2. Coding System With 16 Major Categories and Subcategories
Major Categories	Subcategories
Pain	Sources of pain before surgery
	Sources of pain after surgery
	Energy level before surgery
	Energy level after surgery
Condition before surgery	Location of presurgical pain
Condition before surgery	Degree of presurgical pain
Time since surgery	6 mo or less
	6–12 mo
	More than a year
Previous surgeries	Had previous surgery
Previous surgeries	No previous surgery
Decision to have surgery	Doctor told them it would be the best thing to do, they trusted them and did it
Decision to have surgery	Hoping to be done with the pain
Function	Movement before the Surgery
	Movement after the Surgery
	Daily activities before the Surgery
	Daily activities after the Surgery
	Vocation/education before surgery
	Vocation/education after surgery
	Social interactions and relationships before surgery
	Social interactions and relationships after surgery
	Emotional impact before surgery
	Emotional impact after surgery
	Pain treatment before surgery
	Pain treatment after surgery
Expectations for surgery	Pain level changes
	Physical movement
	Daily activities
	Social events
	Recovery expectations
Outcomes	Pain level changes
	Tingling/numbing sensation
	Recovery process
	Physical movement
	Daily activities
	Social events
	Degree of pain
Communication	Physician/surgeon
Satisfaction	Degree of satisfaction
Satisfaction	Area of satisfaction
Life after surgery	Back strengthening
	Expectation that possible treatment option may help regain a normal life
	Family interaction
	Adjusting expectations
	Goals
Advice for future patients	Find a reputable doctor
	Find a reputable hospital
	Do research on the doctors
	Have positive outlook
	Have support system for you after surgery
	Focus on therapy dedicated to recovery
	Have back surgery
Other	Not applicable
Successful and unsuccessful outcomes	Successful
	Unsuccessful
Other forms of treatment	Using other forms of treatment before surgery
Other forms of treatment	Using other forms of treatment after surgery
Complications from surgery	Leg pain that did not exist before
	Infection
	Re-hospitalization
	Neuropathy
	Other complications

Table 3. Factors Impacting the Decision to Have Surgery: Selected Participant Quotes
Pain
Chronic back pain	"For almost four years now I have not known what it is to be pain free or even a lot of pain free"
Chronic leg pain	"It was giving me shooting pain down my legs to my knees and actually would buckle my knees"
Impact of pain on daily function
Movement	"Even lying in bed and trying to roll over at night. You're trying to roll over. The movement is just like somebody stabbing me with a knife"
Movement	"I had gotten to the point where I couldn't walk, I couldn't sit, I couldn't stand long enough to brush my teeth"
Daily activities	"I just wasn't really able to go with my daily routine without some pain medicine, and my weekends and my time off were basically … I could get some relief if I laid down, so I was pretty much always finding myself coming home after work and laying down to try to get out of pain…"
Daily activities	"I would cook supper and I'd be leaning on the cabinet cooking. Basically, laundry and cooking were about all I did. Sometimes it's so bad; I can't even go to church"
Social activities	"Well, I don't really have a social life and I get to go to church every once in a while"
Social activities	"I guess the other personal thing that has changed in my life would be the relationship between me and my wife as far as our love life. A big part of that kind of went away, because, there again, it's hard to be romantic when you're just in pain constantly"
Employment	"That's what finished me off. I just couldn't work. I couldn't work, and I couldn't do anything at home either. I was just that bad hurting"
Employment	"I was substitute teaching about twice a week. I had to give that up altogether. I really stayed home. I couldn't do anything. It was awful"
Emotions	"I had gotten recluse quite a bit and I'm not that way. I also knew with the pain I was more irritable to other people"
Emotions	"I got quite depressed. I got to the point actually that I told my husband, I said, "I don't believe in this but I can totally understand why somebody would want to end it if they had pain that they could not get to go away"
Fear and anxiety	"I was afraid that my wife might leave me or something like that because I can't take care of myself"
Coping with pain
Therapies	"Well, I weighed my options. I tried the physical therapy. They pretty much said that injections wouldn't do no good for the severity of my injury"
Medications	"In my lower back, I just … night and day, pain there and never could get it to relieve, and I was taking a lot of pain medicine and stuff like that just to get through my regular day"
Medications	"My pain just doubled, and I was eating Tylenol, the 600 milligrams, and 1200, and I was doubling it just trying to work"
Limiting activity	"I did my Christmas shopping two years in a row on the Internet before they started talking about doing it on the Internet, because I couldn't go shopping"
Seeking help	"It got where I couldn't live with it. I said, they're going to have to do something. I couldn't stand it"
Communication with healthcare team	"…a lot of it to me was they actually listened and let me tell them where I'm hurting, how I'm hurt and not be ready to just give me a pill or give me a therapy and say, "Hey this will make it feel all better," because it didn't"
Expectations
Pain relief	"I thought that once this healed up, I would be better. In the long run, I would feel better. I wouldn't hurt"
Pain relief	"He told me that I would probably have more back pain and my leg pain would be gone the next morning"
Physical movement	"I expected to be able to get out and walk"
Daily activities	"I thought once they got me through surgery and dismissed from the hospital and to come home and follow their directions, I thought I would improve day by day. Then finally get back to where I could do a lot of my own things that I need to be done"
Daily activities	"I just hoped I could get back to life and not be in pain all the time and start back with my hobbies and social life, etc. That's all I was hoping for"
Employment	"To really be built up you know, and get back to my regular routine, and doing the same kind of work. No different kind of work…"
Social activities	"Well, I guess just, most of it was just return to a normal life as much as possible, or as … you know, with the family, with my grandchildren"
Time to recover	"He told me that it would literally probably take me 6 mo to a year to get back to fully being able to lift and bend and squat"

Table 4. Factors Impacting Satisfaction With Surgical Outcomes: Selected Participant Quotes
Postsurgical experiences
Pain	"I still have a lot of pain now. So, now, after 3 surgeries, I still experience a lot of pain … especially in the car. Driving is horrendous, even with the steroid shots"
Function	"Well, in the beginning I couldn't do too much. After I had the rehab I got stronger, could take care of myself, and start to cook, do some housekeeping and things like that, cleaning and whatever"
Function	"It just started out with being able to take care of myself so I didn't have to rely on anyone else and then, I was able to go back to work"
Social support	"I was happier about things when I got home. I had a lot of people come by and see me and things"
Emotions	"So, emotionally, I was a basket case for the first couple of weeks especially"
	"I was a little depressed then"
	"Just such relief. It just felt freer and felt, yeah, I'm going to be able to plan next week to have this outing or to do something and to feel confident that I'll feel OK to do it"
Fear and anxiety	"Well, I have concerns that the pains that I'm having are going to end up being permanent nerve damage"
Fear and anxiety	"I am very careful of having more pain than I have already and not being able to drive. I find that's scary to me, losing all my independence if I can't drive. I also have a fear that if the pain gets worse, I'll end up having a fusion again"
Fulfilled expectations	"I was hoping at about three months that I'd be back to normal, and it took longer than that. I'm going to say about eight months"
	"I was hoping I would get out of pain, and it has helped. I am out of that constant pain, but I have experienced some side effects from the surgery that I didn't even know were possible"
	"But, as soon as I got home, which I thought it [the pain] would just continue to get better from there, it didn't. It went downhill"
Postsurgical actions
Accepting limitations	"My main thing is to constantly be conscious of what my limitations are and don't overdo it"
Accepting limitations	"Again, I just can't say it enough, I am satisfied, I'd do it again. I have no regrets. Whatever limitations I have, I can live with it, I can accept it, it's no problem"
Adjusting expectations	"Well, I had to realize that I'm still not able to do the things that I need to do. I just work towards getting it taken care of again"
Adjusting expectations	"Yeah, because they said that this deal in my leg should go away, but it hasn't, so I've had to adjust"
Active participation	"…be willing to participate in your own recovery. Your own healing and your own recovery"
Active participation	"At first twelve weeks was stabilization. Then the next twelve weeks was strengthening because one of my goals was to take care of X, who, as I said, was getting heavier and more active"
Pain management	"I was taking pain medicine until about six months, I think it was. That was a struggle to get off pain medicine"
Optimism	"You almost pretty much have a bad day every day while you're healing because you're still in pain, but you could look at it as a glass half empty or a glass half full, and I just decided to always look at it as a glass half full"
Optimism	"I had a lot of things to do so I don't have time to sit around and think I'm going to be bad or anything. I just rather think about that I'm going to get stronger"
Communication with healthcare team	"I remember at week six, I can remember that like it was yesterday. She could just tell a difference in my voice. I was having a little bit of depression, and she said the most wonderful thing. She says, "This happens to everybody on week six." That made me feel so much better…"

Authors and Disclosures

Carrie E. Brintz, PhD^a,b,c, Rogelio A. Coronado, PT, PhD^b,c,d,e, David G. Schlundt, PhD^f, Christine Haug Jenkins, MPH^g, Mackenzie L. Bird, MD, MS^h, Jordan A. Bley, PhD^d, Jacquelyn S. Pennings, PhD^b,d, Stephen T. Wegener, PhDⁱ and Kristin R. Archer, PhD, DPT^b,c,d,e

^aDepartment of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; ^bVanderbilt Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN; ^cOsher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN; ^dDepartment of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN; ^eDepartment of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN; ^fDepartment of Psychology, Vanderbilt University, Nashville, TN; ^gCVS Health, Charlotte, NC; ^hDepartment of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA; and ⁱDepartment of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD.

Address correspondence and reprint requests to
Kristin R. Archer, PT, PhD, Department of Orthopaedic Surgery, 1215 21st Avenue South, Medical Center East, South Tower, Suite 4200, Nashville, TN 37232; E-mail: kristin. archer@vumc.org

C.E.B. contributed to interpretation of the data and drafting and critically revising the manuscript. R.A.C. contributed to the design of the study, interpretation of the data, and critically revising the manuscript. D.G.S. contributed to the design of the study, acquisition and analysis of the data and critically revising the manuscript. C.M.H. contributed to the design of the study, acquisition and analysis of the data, and critically revising the manuscript. M.L.B. and J.A.B. contributed to the interpretation of the data and drafting and critically revising the manuscript. J.S.P. contributed to the interpretation of the data and critically revising the manuscript. S.T.W. contributed to the design of the study, interpretation of the data, and critically revising the manuscript. K.R.A. was the principal investigator of the study and contributed to the conception and design of the study, oversight of study conduct, interpretation of the data, and drafting and critically revising the manuscript.

J.S.P. receives consulting fees from 3 Spine and Steamboat Orthopaedic Spine Institute. K.R.A. receives consulting fees from NeuroSpinal Innovation Inc. and financial support as a deputy editor for Spine. The remaining authors report no conflicts of interest.