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Spotlight on Research 2009

May 2009 (historical)

Back Pain—Expectations Drive Patient Decisions

When it comes to back pain caused by herniated disks, many patients have strong opinions about whether surgery is right for them. But what influences those opinions? Researchers funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) recently looked into some possible answers to that question.

Jon Lurie, M.D., M.S., and his colleagues at the Dartmouth Medical School and the University of California, San Francisco, examined data from the NIH-funded Spine Patient Outcomes Research Trial (SPORT). SPORT was a five-year, multicenter study supported by NIAMS. It is the largest study of surgical and non-operative treatment among participants with confirmed diagnoses of lumbar intervertebral disk herniation, spinal stenosis, or degenerative spondylolisthesis.

Dr. Lurie and his co-authors looked at patients’ knowledge and understanding of their herniated disk condition, as well as their understanding of the available treatment options, immediately after their first visit to a spine surgeon for their back pain diagnosis. The researchers published their findings in the journal Spine.

The authors of the study analyzed data from subjects who had at least 6 weeks of physical therapy or nonoperative treatment for herniated disk, and were judged to be surgical candidates. At enrollment in SPORT, 67 percent of these patients preferred surgery, 28 percent preferred nonoperative treatment, and 6 percent said they were unsure.

Patients preferring surgery were more definite about their preference than those preferring nonoperative treatment. They were younger than those who wished to avoid surgery or were unsure of their preferences, and they had lower levels of education. People who preferred surgery had longer periods away from work, either because of disability or because of unemployment. In terms of their medical condition, those with a preference for surgery reported higher levels of pain, worse physical and mental functioning, and more disability directly related to back pain. Their symptoms also lasted longer and they were more likely to be taking narcotic pain medications.

Those who preferred surgery expected more benefit from having surgery, and had a low anticipation of risk associated with such an operation—almost 20 percent lower than the group who had a preference for types of care that did not involve the operating room. The measurement of patients’ opinions and the correlation of these preferences with other factors are important because a patient’s expectations for a therapy are closely linked to his or her response to and ultimate satisfaction with care. This has important implications for tools to assist people in making informed choices about herniated disk surgery.

The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases, a part of the Department of Health and Human Services' National Institutes of Health, is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. For more information about NIAMS, call the information clearinghouse at 301-495-4484 or 877-22-NIAMS (free call) or visit the NIAMS Web site at http://www.niams.nih.gov.

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Reference: Lurie JD, Berven SH, Gibson-Chambers J, Tosteson T, Tosteson A, Hu SS, Weinstein JN. Patient preferences and expectations for care: determinants in patients with lumbar intervertebral disc herniation. Spine. 2008 Nov 15;33(24):2663-8. PMID: 18981962.