Department of Orthopaedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
Spine (Phila Pa 1976). 2013 Jan 15;38(2):140-7. doi: 10.1097/BRS.0b013e318279b648.
Cross-sectional study with prospective recruitment.
To determine the relationship of pain intensity (back and leg) on patients' acceptance of surgical complication risks when deciding whether or not to undergo lumbar spinal fusion.
To formulate informed decisions regarding lumbar fusion surgery, preoperative discussions should include a review of the risk of complications balanced with the likelihood of symptom relief. Pain intensity has the potential to influence a patient's decision to consent to lumbar fusion. We hypothesized that pain intensity is associated with a patient's acceptance of surgical complication risks.
Patients being seen for the first time by a spine surgeon for treatment of a nontraumatic or non-neoplastic spinal disorder completed a structured questionnaire. It posed 24 scenarios, each presenting a combination of risks of 3 complications (nerve damage, wound infection, and nonunion) and probabilities of symptom relief. For each scenario, the patient indicated whether he or she would or would not consent to a fusion for low back pain (LBP). The sum of the scenarios in which the patient responded that he or she would elect surgery was calculated to represent acceptance of surgical complication risks. A variety of other data were also recorded, including age, sex, education level, race, history of nonspinal surgery, duration of pain, and history of spinal injections. Data were analyzed using bivariate and multivariate regression analyses.
The mean number of scenarios accepted by 118 enrolled subjects was 10.2 (median, 8; SD, 8.5; range, 0-24, or 42.5% of scenarios). In general, subjects were more likely to accept scenarios with lower risks and higher efficacy. Spearman rank correlation estimates demonstrated a moderate association between the LBP intensity and acceptance of surgical complication risks (r = 0.37, P = 0.0001) whereas leg pain intensity had a weak but positive correlation (r = 0.19, P = 0.04). In bivariate analyses, a history of spinal injections was strongly associated with patients' acceptance of surgical complication risks and willingness to proceed with surgery (54.5% of scenarios accepted for those who had a history of spinal injections vs. 27.6% for those with no history of spinal injections, P = 0.0001). White patients were more willing to accept surgery (45.9% of scenarios) than non-white patients (28.4%, P = 0.03). With the available numbers, age, sex, history of nonspinal surgery, education, and the duration of pain demonstrated no clear association with acceptance of surgical complication risks. Although education overall was not an influential factor, more educated males had greater risk tolerance than less educated males whereas more educated females had less risk tolerance than less educated females (P = 0.023). In multivariate analysis, LBP intensity remained a highly statistically significant correlate (P = 0.001) of the proportion of scenarios accepted, as did a history of spinal injections (P = 0.001) and being white (0.03).
The current investigation indicates that the intensity of LBP is the most influential factor affecting a patient's decision to accept risk of complication and symptom persistence when considering lumbar fusion. This relationship has not been previously shown for any surgical procedure. These data could potentially change the manner in which patients are counseled to make informed choices about spinal surgery. With growing interest in adverse events and complications, these data could be important in establishing guidelines for patient-directed surgical decision making.
前瞻性招募的横断面研究。
确定疼痛强度（背部和腿部）与患者在决定是否进行腰椎融合时接受手术并发症风险的关系。
为了制定关于腰椎融合手术的知情决策，术前讨论应包括权衡并发症风险与症状缓解可能性的回顾。疼痛强度有可能影响患者同意腰椎融合的决定。我们假设疼痛强度与患者接受手术并发症风险的意愿相关。
首次由脊柱外科医生治疗非创伤性或非肿瘤性脊柱疾病的患者完成了一份结构化问卷。它提出了 24 种情况，每种情况都结合了 3 种并发症（神经损伤、伤口感染和不愈合）的风险和症状缓解的可能性。对于每种情况，患者表示他或她是否会同意进行融合手术以治疗下腰痛（LBP）。患者表示他或她会选择手术的情况的总和被计算为接受手术并发症风险的代表。还记录了其他各种数据，包括年龄、性别、教育水平、种族、非脊柱手术史、疼痛持续时间和脊柱注射史。使用双变量和多变量回归分析对数据进行分析。
118 名入组受试者平均接受了 10.2 个（中位数为 8；标准差为 8.5；范围为 0-24，或 42.5%的情况）。一般来说，患者更有可能接受风险较低、疗效较高的方案。Spearman 秩相关估计表明，LBP 强度与接受手术并发症风险之间存在中度关联（r = 0.37，P = 0.0001），而腿部疼痛强度则呈弱正相关（r = 0.19，P = 0.04）。在双变量分析中，脊柱注射史与患者接受手术并发症风险的意愿和进行手术的意愿密切相关（对于有脊柱注射史的患者，有 54.5%的情况被接受，而对于没有脊柱注射史的患者，有 27.6%的情况被接受，P = 0.0001）。白人患者比非白人患者更愿意接受手术（45.9%的情况下）（P = 0.03）。根据可用数据，年龄、性别、非脊柱手术史、教育程度和疼痛持续时间与接受手术并发症风险无明显关联。尽管整体教育程度不是一个有影响力的因素，但受过高等教育的男性比受过较低等教育的男性具有更高的风险承受能力，而受过高等教育的女性比受过较低等教育的女性具有较低的风险承受能力（P = 0.023）。在多变量分析中，LBP 强度仍然是影响患者接受风险和症状持续的比例的高度统计学相关因素（P = 0.001），脊柱注射史（P = 0.001）和白种人（0.03）也是如此。
目前的研究表明，LBP 的强度是影响患者在考虑腰椎融合时接受并发症风险和症状持续的决策的最具影响力的因素。这一关系以前没有在任何手术程序中显示过。这些数据可能会改变患者接受脊柱手术的知情选择的方式。随着对不良事件和并发症的兴趣日益增加，这些数据可能对制定患者导向的手术决策指南很重要。
