What Patients Want? A Pilot Single-Center Study Prioritizing Patient Expectations

Abstract

Study Design

Prospective study.

Objectives

To understand the patient’s priority in terms of various variables and asses the difference in priority of these variables pre and post-operatively.

Methods

In this single-surgeon prospective study, patients that had undergone spine surgery from January 2022 to September 2024 (excluding those with deformity correction, spinal infections, trauma, or tumors) completed a 12-variable questionnaire designed by us. The variables included scar size, preferred surgery type (open, minimally invasive, or no preference), limb pain relief, back pain relief, numbness relief, heaviness relief, disability relief, neurological improvement, operative site pain, discharge timing (same day, next day, or no preference), surgery duration (<1 h, >1 h, or no preference), and cost. Patients prioritized each variable by numbering tick boxes.

Results

A total of 228 forms (pre and post-operative each) were completed and ready for review. Order of priority varied pre and post-operatively. Priorities shifted post-operatively, with leg pain relief dropping from the top pre-operative priority to 11th, and back pain relief rising to third. Cost ranked fifth post-operatively, while incision size remained a low priority in both lists.

Conclusion

Based on the findings of our study, we can conclude that the patient’s priority shifts after surgery. Effective pre-operative counseling is crucial for bridging this gap. Therefore, it is crucial to assess the patient’s expectations and needs pre-operatively to ensure satisfaction post-surgery.

Introduction

Spine surgery often elicits significant anticipation and anxiety from patients, who seek relief, yet grapple with the possibility of incomplete recovery and persistent symptoms or the onset of new complications despite treatment. Patient expectations are often multifaceted, diverse, and unpredictable. Expectations tend to be high and frequently unmet often exceeding clinical outcome. ¹ Mere increase in walking distance or subsidence of back pain following surgery may not be enough. Patients desire complete relief from all symptoms, and this often relates to quality of life improvement resulting in patient satisfaction. Patients’ expectations are often overwhelming, regardless of factors such as the duration of symptoms, neurological deficits, etc. There is a notable disparity between the expectations of patients and surgeons, ² as well as between patients’ expectations and the actual outcomes. ¹ Advancements in spine surgery, particularly in realm of minimally invasive techniques, have heightened patient expectations of achieving outstanding outcomes. These techniques are appealing due to their numerous advantages, including minimal scarring, quicker return to work, reduced postoperative pain, greater precision, lower risks, decreased infection rates, and overall faster recovery. However, radiological changes or scores like SF-36, ODI, ³ and VAS do not always align with patient satisfaction, as they fail to fully account for subjective improvements. To address this discrepancy, it is essential to consider patients’ pre-operative expectations, as their fulfillment leads to improved functional outcomes and greater satisfaction. As evident, no consensus exists regarding the best instrument to measure patient satisfaction in the field of spine surgery. ⁴ With this as a background, we thought why not to survey and ask patient themselves what they want? Building on our extensive experience and case volume, we developed a questionnaire with 12 key variables to directly assess patient preferences and priorities regarding spine surgery.

Methods

This prospective, single-center study was conducted at Bombay Hospital and Medical Research Center, Mumbai, after approval of the ethical committee on 3rd December 2021, from January 2022 to September 2024, with a 1-year follow-up period. The study included all patients with degenerative cervical, thoracic, and lumbar pathologies who underwent surgery using either conventional or minimally invasive spine surgery (MIS) techniques. Patients with deformity, spinal tumors, infections, and trauma were excluded from the study. Drawing from our extensive experience and case volume, a questionnaire comprising 12 key variables was developed, PRIORITY LIST (Figure 1). Each patient meeting the inclusion criteria was asked to complete this questionnaire preoperatively and again at the 1-year follow-up postoperatively. When patients encountered difficulty completing the questionnaire, assistance was provided by the on-call medical officer, who was not a member of the surgical team, to eliminate investigator bias.

Figure 1.

Priority List - the Questionnaire Form

If a patient did not experience a specific symptom listed in the form, such as neurological weakness, it was assigned the lowest priority. Similarly, tick boxes labeled “does not matter” were provided for cases where the choice between open or MIS technique was irrelevant to the patient; they were asked to mark the priority for the variable and select “does not matter” as appropriate.

Statistics

Null Hypothesis (H0)

There is no significant difference in patient priorities or outcomes.

Alternative Hypothesis (Ha)

There is a significant difference in patient priorities or outcomes.

Statistical Test Used: Chi Square Test

Since the data consists of categorical variables (ie, patient preferences across priority categories), a Chi-square test for independence was employed to compare the distribution of patient priorities before and after surgery.

Adjusted contigency table showing responses of patients pre and post operatively (Table 1).

Table 1.

Adjusted Contigency Table

Priority factor	Pre-operative (O)	Post-operative (O)	Total
Relief of leg pain	95	30	125
Relief of back pain	65	90	155
Relief of numbness	55	40	95
Relief of heaviness	105	150	255
Disability relief	70	60	130
Relief of neurological weakness	25	40	65
Post-operative pain	60	95	155
Cost	50	65	115
Surgery desirable	40	20	60
Size of scar	15	20	35
Day of discharge	10	5	15
Duration of surgery	3	3	6
Total	228	228	456

Significance level (α): 0.05.

Test static formula:

$\begin{array}{lll}{X}^2& =& \begin{array}{ll}\sum & {\left(\mathrm{O}-\mathrm{E}\right)}^2/\mathrm{E}\end{array}\end{array}$

where:

O = Observed frequency.

E = Expected frequency, calculated as:

$\frac{\begin{array}{lll}E& =& Row\hspace{0.17em}total\end{array}\begin{array}{ll}\times & Column\hspace{0.17em}Total\end{array}}{Grand\hspace{0.17em}total}$

Observed Frequencies (Table 2) – actual patient responses before and after surgery.

Table 2.

Observed Frequency

Priority factor	Pre-operative (O)	Post-operative (O)
Relief of leg pain	95	30
Relief of back pain	65	90
Relief of numbness	55	40
Relief of heaviness	105	150
Disability relief	70	60
Relief of neurological weakness	25	40
Post-operative pain	60	95
Cost	50	65
Surgery desirable	40	20
Size of scar	15	20
Day of discharge	10	5
Duration of surgery	3	3

Expected Frequencies (Table 3) – calculated values assuming no difference between pre-and post-operative responses.

Table 3.

Expected Frequency

Priority factor	Expected pre-op (E)	Expected post-op (E)
Relief of leg pain	62.50	62.50
Relief of back pain	77.50	77.50
Relief of numbness	47.50	47.50
Relief of heaviness	127.50	127.50
Disability relief	65.00	65.00
Relief of neurological weakness	32.50	32.50
Post-operative pain	77.50	77.50
Cost	57.50	57.50
Surgery desirable	30.00	30.00
Size of scar	17.50	17.50
Day of discharge	7.50	7.50
Duration of surgery	3.00	3.00

Chi-square Contributions (Tables 4 and 5) – individual contribution of each priority factor to the total chi-square value.

Table 4.

Onserved Values and Chi-Square Contribution

Priority factor	χ2 pre-op	χ2 post-op	Total χ2 contribution
Relief of leg pain	217.02	1.78	218.79
Relief of back pain	43.96	126.75	170.71
Relief of numbness	77.01	27.34	104.35
Relief of heaviness	67.65	216.66	284.31
Disability relief	84.67	51.56	136.24
Relief of neurological weakness	17.31	1.73	19.04
Post-operative pain	5.91	5.91	11.82
Cost	0.98	0.98	1.96
Surgery desirable	3.33	3.33	6.66
Size of scar	0.36	0.36	0.72
Day of discharge	0.83	0.83	1.66
Duration of surgery	0.00	0.00	0.00
Total	—	—	1439.35

Table 5.

Expected Values and Chi-Square Contribution

Priority factor	Expected (pre)	Expected (post)	χ2 (pre)	χ2 (post)	Total χ2
Relief of leg pain	62.5	62.5	16.84	16.84	33.68
Relief of back pain	77.5	77.5	2.02	2.02	4.04
Relief of numbness	47.5	47.5	1.18	1.18	2.36
Relief of heaviness	127.5	127.5	0.61	0.61	1.22
Disability relief	65.0	65.0	0.38	0.38	0.76
Relief of neurological weakness	32.5	32.5	1.73	1.73	3.46
Post-operative pain	77.5	77.5	5.91	5.91	11.82
Cost	57.5	57.5	0.11	0.11	0.22
Surgery desirable	30.0	30.0	3.33	3.33	6.66
Size of scar	17.5	17.5	0.36	0.36	0.72
Day of discharge	7.5	7.5	0.83	0.83	1.66
Duration of surgery	3.0	3.0	0.00	0.00	0.00
Total					66.60

Degrees of Freedom (df):

$\text{df}=(\mathrm{r}-1)\times (\mathrm{c}-1)=(12-1)\times (2-1)=11$

Final Result

Total Chi-square statistic (χ²): 66.60.

Degrees of freedom (df): 11

P-value: <0.0001 (highly significant).

For 11 degrees of freedom and a chi-square value of 66.60, the P-value will be extremely small, indicating a statistically significant difference between the pre-operative and post-operative priorities. This suggests that there is an association between the timing of the survey and patient priorities.

Results

The order of priority preoperatively was relief of leg pain, relief of heaviness, relief of numbness, disability relief, relief of back pain, post operative pain, cost, surgery desirable, size of scar, day of discharge, duration of surgery, relief of neurological weakness where the top priority was relief of leg pain while surgery desirable, Size of scar, day of discharge, duration of surgery where of less priority. While post-operatively, the order of priority was relief of heaviness, relief of numbness, relief of back pain, disability relief, cost, post-operative pain, surgery desirable, size of scar, day of discharge, duration of surgery, relief of leg pain, relief of neurological weakness. The values of the priority pre and post-operatively is depicted in Table 2.

Results also revealed shocking facts that patients were more concerned about their symptom relief than the cost and technique of surgery, and the duration of surgery and day of discharge are usually not patients concern and mentioned it as does not matter in their answers. It was quite surprising to note that patients don’t realize that their leg pain is relieved, and it does not become their priority post-operatively. That is how the priority which was at the top pre-operatively fell to sixth post-operatively. In patients having neurological deficit, it was their prime concern both pre and post-operatively. Patient’s undergoing MIS surgery usually placed surgery desirable above the cost and gave priority over open surgery, while patients undergoing open surgery placed cost above the surgical technique and mentioned does not matter in their list.

Discussion

Patient satisfaction stands as the ultimate benchmark of a surgeon’s performance and the true measure of cure for patients suffering. In an era where clinical and radiological outcomes often dominate our focus, the assessment of patient’s satisfaction remained inconsistently measured and inadequately reported. As highlighted in the systematic review conducted by Manendez JY et al, ⁴ the current approach to measuring patient satisfaction remains largely unstandardized. In most instances, there is little effort to identify the underlying factors that influence satisfaction or dissatisfaction. Moreover, there is no widely accepted, disease-specific tool that captures the various domains consistently and directly impacts patient satisfaction in spinal surgery. We firmly believe that without a clear understanding of a patient’s priorities from the outset, any attempt to assess postoperative satisfaction is incomplete, as patient satisfaction is independent of functional outcomes. ⁵

Given the limited literature addressing patients’ preoperative expectations in spine surgery, conclusions regarding the relationship between expectations, outcomes, and satisfaction remain inconsistent. Several studies have suggested that patients with positive expectations tend to report higher satisfaction postoperatively,^2,6-9 whereas those with negative or unrealistic expectations are more likely to experience dissatisfaction. ⁹ Contrarily, Rampersaud et al. ¹⁰ reported that patients with higher preoperative expectations were less likely to have those expectations met, regardless of actual improvements in functional outcomes, while a study by McGregor AH et al ¹¹ states “The impact of unrealistic expectations on outcome remains unclear”. Additionally, it has been observed that patients presenting with more severe disability and pain preoperatively—who often harbor higher expectations—may experience greater postoperative improvement. Thus, baseline functional status may be a more reliable predictor of satisfaction than expectations alone. ¹¹ Moreover, while many surgeons perceive patient expectations as overly optimistic or unrealistic, studies have also shown that surgeons themselves may hold overly optimistic expectations about outcomes. ⁶ A multicenter study by Soroceanu et al. ⁵ emphasized that simply identifying patient expectations is not adequate; rather, the fulfillment of those expectations is a critical determinant of postoperative satisfaction. This finding is further supported by the study conducted by Rampersaud et al., ¹⁰ which reported that patient expectations regarding spine surgery varied widely and often surpassed the actual outcomes. Nonetheless, it was the fulfillment of expectations—even those not considered most important —that emerged as the strongest predictor of overall satisfaction. Given the growing role of minimally invasive spine surgery (MISS), we also believe the type of surgical approach (MISS vs open) significantly influences preoperative decision-making. This is supported by the findings of White et al., ¹² who concluded that patients generally view MISS favorably and would prefer it in the future. A growing trend in spine surgery is the increasing preference for minimally invasive spine surgery (MISS) among patients. One of the key factors influencing this shift is the surgical scar, which often becomes a pivotal consideration in decision-making. A smaller scar is commonly perceived as indicative of reduced tissue disruption, better preservation of spinal curvature, and improved cosmetic outcomes. These aesthetic and functional advantages are emphasized by MISS surgeons, who often use the minimal scar as a visual hallmark to illustrate the benefits of the technique. In this context, the scar becomes not only a clinical outcome but also a symbolic representation—arguably the signature—of MISS, which contributes to its appeal over conventional open surgery. Therefore, instead of merely asking patients postoperatively whether the intervention met their expectations, it is imperative to assess their specific expectations beforehand to optimize surgical planning and improve patient satisfaction.

While shared decision-making—especially in setting realistic expectations regarding surgical outcomes—is a common practice among spine surgeons, a significant number of patients continue to express postoperative dissatisfaction, as highlighted in previous studies.^6,7,13 This persistent discrepancy indicates a critical aspect that may be overlooked in current clinical practice. Our study is the first to systematically explore this dimension, offering novel insights by examining multiple influencing factors, as reflected in the results.

We evaluated multiple factors that potentially influence patient expectations, and the results were unexpectedly revealing. Analysis of the priority list questionnaires completed by patients preoperatively and at final postoperative follow-up demonstrated a significant mismatch, indicating that patient priorities often shift following surgery. Interestingly, issues that remained unresolved after surgery—despite not being primary concerns during initial shared decision-making—became more prominent in the postoperative period.

The findings also revealed that patients prioritized symptom relief over both the cost and the surgical technique. Factors such as the duration of surgery and the timing of hospital discharge were generally regarded as unimportant, with many patients indicating they “did not matter.” Among those presenting with neurological deficits, restoration of neurological function remained the top concern both before and after surgery.

Patients undergoing minimally invasive surgery (MIS) typically ranked the surgical technique as more important than cost, often expressing a clear preference for MIS over open procedures. In contrast, patients who underwent open surgery tended to prioritize cost over the type of surgical approach and frequently indicated that the surgical technique “did not matter.”

These findings highlight the dynamic nature of patient priorities and underscore the importance of incorporating a standardized priority list questionnaire into routine preoperative assessment. Such a tool should be considered as essential as the informed consent process in spine surgery. Documenting these priorities not only facilitates alignment between patient expectations and surgical goals but also serves as a valuable reference in the event of postoperative dissatisfaction, potentially offering medicolegal protection for the treating surgeon.

The authors accept that one of the major limiting factors of this study is the absence of multi-centricity which would have extracted a better representation of priorities and expectations based on countries and cultures. However, the authors are positive that this project should be considered a pilot study and take the role of a catalyst to churn a global, multi-centric study in the future.

Conclusion

Patient expectations should be considered paramount when planning surgical interventions, as they are a strong predictor of perceived surgical success. While the choice of surgical technique—whether minimally invasive or open—may influence short-term outcomes, it often plays a lesser role in determining overall patient satisfaction. Notably, patient priorities can shift significantly between the preoperative and postoperative periods, a finding that is statistically validated in our study. This underscores that patient perceptions and expectations evolve following surgery. Therefore, the systematic incorporation of a priority-based assessment (ie, a patient priority list) into routine clinical practice is essential to align surgical goals with patient expectations and to optimize outcomes.