Still Worth It? Who Is Satisfied After Degenerative Lumbar Spine Surgery Despite Not Achieving the Minimum Clinically Important Difference?

BACKGROUND AND OBJECTIVES: Although spine surgeons may intuitively presume that clinical improvement drives patient satisfaction, some patients remain satisfied despite limited clinical improvement. Therefore, in patients undergoing degenerative lumbar spine surgery who did not achieve minimum clinically important difference (MCID), we sought to identify predictors of long-term postoperative satisfaction. METHODS: A prospective, single-institution registry (2010-2023) was retrospectively queried to identify patients undergoing elective, degenerative lumbar spine surgery who did not achieve MCID at 12 months, defined as <30% improvement in the Oswestry Disability Index or Visual Analog Scale pain scores from baseline. Primary outcome was 12-month postoperative satisfaction, assessed using the North American Spine Society questionnaire. Bivariate and multivariable logistic regression identified predictors of satisfaction in the absence of MCID, both overall and stratified by procedure type. RESULTS: Among 3547 patients, 611 (17.2%) did not achieve MCID for disability or pain, of whom 334 (54.7%) remained satisfied. Older age (odds ratio [OR]: 1.02, 95% CI: 1.00-1.04, P = .035) and private insurance (OR: 1.63, 95% CI: 1.03-2.57, P = .035) independently increased the odds of satisfaction. Specifically, each additional decade of age conferred a 22% higher odds of 12-month satisfaction. Fusion: Among 2133 fusion patients, 390 (18.3%) did not achieve MCID, of whom 219 (56.2%) still reported satisfaction. Older age again increased odds of satisfaction (OR: 1.04, 95% CI: 1.00-1.09, P = .036), whereas baseline independent ambulation decreased odds (OR: 0.22, 95% CI: 0.08-0.58, P = .002). Decompression: Among 1386 decompression patients, those with a diagnosis of stenosis were three-times more likely to report satisfaction than those with other primary diagnoses (OR: 3.04, 95% CI: 1.06-8.72, P = .039). CONCLUSION: More than half of patients who did not achieve MCID still felt surgery was worthwhile, suggesting that long-term satisfaction is shaped by broader patient expectations and sociodemographic context. To optimize patients' perceived benefit of surgery, surgeons should engage in individualized counseling to understand patients' priorities and expectations, rather than selecting interventions based solely on their potential to maximize symptom relief.