Shared Decision-making in the Treatment of Lumbar Spinal Stenosis

Introduction: Shared decision-making (SDM) involves incorporating patient preferences and values into treatment planning and has been associated with greater patient satisfaction, compliance, and outcomes. Lumbar spinal stenosis (LSS) can be surgically treated with decompression with or without fusion, and patient preferences may influence the choice of surgery. We investigate the use of SDM in the treatment of LSS as part of the Stenosis Outcomes in Lumbar Instrumentation and Decompression (SOLID) Trial. This study aimed to assess how often SDM was utilized, whether SDM affects surgical decision-making, and if patient outcomes differ when patients are involved in surgical treatment decisions for LSS.

Methods: We established the Lumbar Spinal Stenosis Learning Program (LSS-LP), a registry for patients undergoing treatment of spinal stenosis in Veterans Affairs hospitals (43 centers). Neurosurgeons and orthopedic surgeons were surveyed regarding factors involved in surgical decision-making for the treatment of LSS, including patient preference. Patient-reported outcomes were collected at 3, 6, 12, and 24 months post-operatively. Outcome measures included the Zurich Claudication Questionnaire (ZCQ), Oswestry Disability Index (ODI), and pain scores.

Results: Overall, in 58 /540 (10.7%) of cases, patient preference was reported by surgeons as an “important element that factored into the decision to fuse or not”. Patient preference was considered in a larger, but still minor, proportion (18.7%) in cases of clinical equipoise. Fusion rates were lower (21.1% vs 36.7%) when patient preference was considered. The improvement in symptom severity in cases of decompression with fusion was 84% higher (ZCQ score decreased by 29.1 vs 16.1) when patient preference was considered compared to when it was not.

Conclusion : SDM was associated with a decreased rate of fusion and improved clinical outcomes in the treatment of lumbar spinal stenosis. Despite these benefits, SDM use was infrequently reported, suggesting underutilization.