Qualitative analysis of the patient journey following lumbar spinal fusion surgery in real-time as lived: Insights to inform rehabilitation

Purpose: Approximately 4500 NHS lumbar spinal fusion surgery (LSFS) procedures are performed annually, at an estimated annual cost of £26 million. Low-level evidence suggests inconclusive/variable outcomes for LSFS. However, meta-analyses of data from observational studies have demonstrated clinically relevant improvement in leg pain, back pain and disability long-term. UK surveys investigating physiotherapy/surgeon practice have identified that decisions regarding surgery and rehabilitation should be patient-specific owing to considerable clinical heterogeneity. An understanding of patients' lived experiences is therefore important. The purpose of this study was to understand patients' experiences of LSFS from the onset of their problems, through the decision for surgery and recovery/rehabilitation to 12 months following surgery. Methods A qualitative study using Interpretive Phenomenological Analysis, purposively recruited adult patients (n = 43) undergoing LSFS across 4 UK spinal surgery centres. In-depth semi-structured interviews at 2 weeks and 12 months were audio-recorded and transcribed verbatim. Weekly patient diaries (various formats to enable completion/quality) enabled insights over 12 months in real-time as lived. Participants received weekly/monthly prompts for diary completion. Initial interview topic guide (exploring pre-operative and post-operative experiences, expectations, facilitators and barriers to recovery, adherence to advice, rehabilitation, return-to-activities) and diary (exploring progress, recovery, motivation, symptoms, medications, healthcare appointments, rehabilitation, positive/negative thoughts, significant moments, comparison to the previous week) were developed from the literature and piloted. The interview topic guide at 12 months was informed by earlier analyses. Emergent themes were interpreted and clustered into subordinate themes for each transcript/diary individually, before comparing across participants. Trustworthiness was addressed e.g. through reflexivity and code/recode audits. Results: Data from interviews (n = 31, n = 13) and diaries (n = 28) contributed to the developed analytic framework. Participants provided diverse and vivid descriptions of their experiences. Three distinct recovery trajectories were identified early in participants' journeys: meaningful (engagement in physical and functional activities to return to functionality/mobility); progressive (small but meaningful improvement in physical ability with increasing confidence); and disruptive (limited purpose for meaningful recovery). Important interacting constructs shaped their trajectory and recovery e.g. self-efficacy where belief in self-efficacy and their recovery enabled participants to take control of their recovery, to adapt and manage their recovery journey. Alternatively, low self-efficacy appeared to interfere with recovery. A key theme remaining at 12 months was management of ongoing symptoms through medication and activity, which influenced participants' abilities to follow recommendations for recovery and rehabilitation. Conclusion(s): A rich density of data afforded understanding of the patient journey before, during and after LSFS. This is the first account of recovery trajectories from patients' perspectives. The findings illustrate that LSFS has an impact on all aspects of a person's life, and that recovery is a complex and dynamic process comprising of the complex inter-relationship between physical, functional, emotional and social factors. Impact: Recognition of a patient's recovery trajectory at the time of surgery may inform improved management of patient-centred recovery and follow-up. In particular, evidence-based rehabilitation that considers the complex inter-relationship of factors is important for optimised patient outcomes. Funding acknowledgements: The Chartered Society of Physiotherapy Charitable Trust Physiotherapy Research Foundation.