Gadjradj Pravesh S, Smeele Nicholas V R, de Jong Mandy, Depauw Paul R A M, van Tulder Maurits W, de Bekker-Grob Esther W, Harhangi Biswadjiet S
1Department of Neurosurgery, Park MC, Rotterdam, The Netherlands.
2Department of Neurological Surgery, Weill Cornell Brain and Spine Center, NewYork-Presbyterian Hospital, New York, New York.
J Neurosurg Spine. 2021 Nov 26;36(5):704-712. doi: 10.3171/2021.8.SPINE21995. Print 2022 May 1.
Lumbar discectomy is a frequently performed procedure to treat sciatica caused by lumbar disc herniation. Multiple surgical techniques are available, and the popularity of minimally invasive surgical techniques is increasing worldwide. Clinical outcomes between these techniques may not show any substantial differences. As lumbar discectomy is an elective procedure, patients' own preferences play an important role in determining the procedure they will undergo. The aims of the current study were to determine the relative preference weights patients apply to various attributes of lumbar discectomy, determine if patient preferences change after surgery, identify preference heterogeneity for choosing surgery for sciatica, and calculate patient willingness to pay for other attributes.
A discrete choice experiment (DCE) was conducted among patients with sciatica caused by lumbar disc herniation. A questionnaire was administered to patients before they underwent surgery and to an independent sample of patients who had already undergone surgery. The DCE required patients to choose between two surgical techniques or to opt out from 12 choice sets with alternating characteristic levels: waiting time for surgery, out-of-pocket costs, size of the scar, need of general anesthesia, need for hospitalization, effect on leg pain, and duration of the recovery period.
A total of 287 patients were included in the DCE analysis. All attributes, except scar size, had a significant influence on the overall preferences of patients. The effect on leg pain was the most important characteristic in the decision for a surgical procedure (by 44.8%). The potential out-of-pocket costs for the procedure (28.8%), the wait time (12.8%), need for general anesthesia (7.5%), need for hospitalization (4.3%), and the recovery period (1.8%) followed. Preferences were independent of the scores on patient-reported outcome measures and baseline characteristics. Three latent classes could be identified with specific preference patterns. Willingness-to-pay was the highest for effectiveness on leg pain, with patients willing to pay €3133 for a treatment that has a 90% effectiveness instead of 70%.
Effect on leg pain is the most important factor for patients in deciding to undergo surgery for sciatica. Not all proposed advantages of minimally invasive spine surgery (e.g., size of the scar, no need of general anesthesia) are necessarily perceived as advantages by patients. Spine surgeons should propose surgical techniques for sciatica, not only based on own ability and proposed eligibility, but also based on patient preferences as is part of shared decision making.
腰椎间盘切除术是治疗腰椎间盘突出症所致坐骨神经痛的常用手术。有多种手术技术可供选择，且微创外科技术在全球范围内的普及程度日益提高。这些技术之间的临床疗效可能并无显著差异。由于腰椎间盘切除术是一种择期手术，患者自身的偏好对于决定他们将接受的手术方式起着重要作用。本研究的目的是确定患者对腰椎间盘切除术各种属性的相对偏好权重，确定患者偏好术后是否改变，识别因坐骨神经痛选择手术的偏好异质性，并计算患者对其他属性的支付意愿。
对腰椎间盘突出症所致坐骨神经痛患者进行了一项离散选择实验（DCE）。在患者手术前及已接受手术的独立患者样本中发放问卷。DCE要求患者在两种手术技术之间进行选择，或从12个具有交替特征水平的选择集中选择退出：手术等待时间、自付费用、疤痕大小、是否需要全身麻醉、是否需要住院、对腿痛的影响以及恢复期时长。
共有287例患者纳入DCE分析。除疤痕大小外，所有属性对患者的总体偏好均有显著影响。对腿痛的影响是手术决策中最重要的特征（占44.8%）。其次是手术的潜在自付费用（2占8.8%）、等待时间（占12.8%）、是否需要全身麻醉（占7.5%）、是否需要住院（占4.3%）以及恢复期（占1.8%）。偏好与患者报告的结局指标得分和基线特征无关。可识别出具有特定偏好模式的三个潜在类别。对腿痛疗效的支付意愿最高，患者愿意为有效率90%而非70%的治疗支付3133欧元。
对腿痛的影响是患者决定接受坐骨神经痛手术的最重要因素。并非微创脊柱手术所有预期的优势（如疤痕大小、无需全身麻醉）患者都必然视为优势。脊柱外科医生在为坐骨神经痛患者推荐手术技术时，不仅应基于自身能力和推荐的适应症，还应基于患者偏好，这是共同决策的一部分。
