Background context:

Fulfillment of expectations is a patient-centered outcome that has not been assessed based on fusion status for lumbar degenerative spondylolisthesis (LDS).

Purpose:

To compare preoperatively cited expectations and 2-year postoperative fulfillment of expectations between patients undergoing decompression alone (no-fusion) versus decompression plus fusion (fusion) for LDS.

Design:

Longitudinal cohort PATIENT SAMPLE: 357 patients OUTCOME MEASURES: Postoperative version of Lumbar Spine Surgery Expectations Survey, Oswestry Disability Index (ODI), satisfaction with surgery.

Methods:

Preoperatively patients completed the 20-item Expectations Survey measuring amount of ‘improvement expected’ for symptoms, physical function, and psychosocial well-being (score range 0-100); two years postoperatively patients completed the follow-up Survey measuring ‘improvement received’. The proportion of expectations fulfilled was calculated as ‘improvement received’ divided by ‘improvement expected’ (<1 some expectations fulfilled, >1 expectations surpassed). Patients also completed the ODI, SF-12 mental health subscale, satisfaction with surgery, and measures of comorbidity and psychosocial status, including social support (i.e. help at home) and prior orthopedic surgery (i.e. hip/knee arthroplasty).

Results:

Patients’ mean age was 67 years, 61% were women, 82% had single-level LDS, 73% had fusion, and mean follow-up was 26.2 months. Compared to patients with no-fusion, patients with fusion had more pain, spinal instability, use of opioids, disability, and greater preoperative Expectations Survey scores (69 vs 74, p=.008). The proportion of expectations fulfilled postoperatively was high and similar for both groups (.82 versus .79, p=.40), but more variable for fusion (IQR .32 versus .40). In multivariable analysis with the proportion as the dependent variable, fulfilled expectations was associated with better mental well-being (coeff=1.1, 95% CI 0.6-1.7, p=.0001) and more social support (coeff=3.3, 95% CI 1.1-5.6, p=.004) and unfulfilled expectations was associated with prior arthroplasty (coeff=-8.6, 95% CI -15.4-(-1.9), p=.01) and subsequent lumbar surgery (coeff=-15.6, 95% CI -25.2-(-6.0), p=.002). Similar associations were found for change in ODI and satisfaction.

Conclusion:

Patients had high preoperative expectations of surgery with greater expectations for decompression-fusion compared to decompression-alone. Although more variable for the fusion group, both groups had high proportions of expectations fulfilled. This study highlights the spectrum of clinical and psychosocial variables that impacts fulfillment of expectations for both decompression-alone and decompression-fusion for LDS surgery.