For patients with low back pain caused by a herniated disk, expectations of good results without surgery are the main factor affecting the preference for nonsurgical treatment, reports a study in the November 15 issue of Spine.
The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health, a leading provider of information and business intelligence for students, professionals, and institutions in medicine, nursing, allied health, pharmacy and the pharmaceutical industry.
However, once patients overcome their reluctance to undergo surgery, they strongly prefer surgical treatment - generally for reasons that are "clinically sensible," according to the new study, led by Dr. Jon D. Lurie of Dartmouth Medical School, Lebanon, N.H.
As part of a larger trial comparing the results of surgical versus nonsurgical treatment, the researchers studied preferences and expectations for treatment in 740 patients with pain and other symptoms caused by herniated disks in the lower back (lumbar spine). The current study included only those patients who had declined to be randomly assigned to surgery or nonsurgical treatment.
Before discussing treatment alternatives with a spine specialist, the patients completed a questionnaire asking whether they preferred surgical or nonsurgical treatment, and about the results they expected. Factors affecting patient preferences were analyzed, along with the relationship between treatment preferences and expectations.
Expectations Are Strongest Reason for Treatment Preferences
Overall, 67 percent of the patients preferred surgical treatment for their herniated disk problem. Twenty-eight percent said they preferred nonsurgical treatment; the remaining six percent were unsure.
Patients preferring surgery were more certain of their choice: 53 percent stated a "definite preference," compared to 18 percent of those preferring nonsurgical treatment. Patients who preferred surgery were younger, less educated, and had higher rates of unemployment or disability.
A preference for surgery was related to other patient characteristics as well, including higher levels of pain, more problems with functioning, and more back pain-related disability. They had had back pain for a longer time and were more likely to be using strong pain-relieving drugs (opiates).
However, the factor most strongly related to treatment choice was the expectation that nonsurgical treatment would be effective. In other words, patients who thought that treatment without surgery would improve their symptoms tended to prefer nonsurgical treatment, regardless of their other characteristics.
Patients Must Cross 'Threshold' before Preferring Surgery
Patient expectations have an important but complex relationship with treatment results. For example, if expectations are unrealistically high, patients may be disappointed with the results. On the other hand, patients who expect good results may be more motivated to improve or follow their recommended treatment more closely—or may improve because of a "placebo effect." Patients' preferences for a certain type of treatment have an important effect on their expectations of the results.