An observational cohort study of factors associated with patients’ reports of being offered lumbar spine surgery during orthopaedic spine consultations for chronic low back pain

Background Guidelines do not recommend lumbar spine surgery for people with chronic low back pain (CLBP). It remains unknown how these guidelines are implemented, and which factors affect the decision to offer surgery. Objectives This study examined factors associated with patients reporting that lumbar spine surgery was recommended during specialist consultation for CLBP. Methods Clinical, demographic and psychosocial factors were measured pre-consultation in people referred with CLBP for their first consultation with orthopaedic spine clinicians in secondary care in eight hospitals. Patients reporting leg pain, previous spinal surgery, or other specific spinal pathology were excluded. Data were analysed using binomial logistic regression. In addition, three surgeons independently rated a subsample of the MRI reports as suitable or unsuitable for lumbar spine surgery, blinded to clinical background of patients and to the consultation outcome. Results A total of 424 patients were included in the analysis, of whom 96 reported being offered lumbar spine surgery. Patients were more likely to report being offered surgery if they were older, had a longer pain duration, had consulted more widely, and had stronger positive expectations of surgery. Pain intensity, disability, depression, and anxiety were not associated with the decision to offer surgery. The model correctly classified 80.6% of cases. In the subsample analysis based on MRI reports alone, the proportion judged as potentially suitable for lumbar spine surgery (20%) was similar to the actual consultations (22%), but concordance on who was offered surgery was poor (27%). Conclusion In this cohort of people with CLBP without leg pain, patient perception that surgery was offered during the consultation was associated with a longer history of pain and a greater number of prior consultations. Surgical offer was patient-reported and surgeons’ rationale was not captured. Subsample findings suggest that MRI findings alone should not drive surgical decision-making in CLBP.