Patient and Spine Surgeon Perceptions on Shared Decision-Making in the Treatment of Older Adults Undergoing Corrective Surgery for Adult Spinal Deformity

Palvasha Deme, BA; Anjali Perera, BSN, RN; Sai Chilakapati, MS; Sonja Stutzman, PhD; Ravinderjit Singh, BS; Cody M. Eldridge, BS; James Caruso, BA, MD; Shaleen Vira, MD; Salah G. Aoun, MD; Una E. Makris, MD, Msc; Carlos A. Bagley, MD, MBA; Owoicho Adogwa, MD, MPH


Spine. 2022;47(10):730-736. 

In This Article

Abstract and Introduction


Study Design: Retrospective.

Objective: To understand patients' and spine surgeons' perspectives about decision-making around surgery for adult spinal deformity.

Summary of Background Data: Surgery for correction of adult spinal deformity is often beneficial; however, in over 20% of older adults (≥ 65 yrs of age), outcomes from surgery are less desirable.

Materials and Methods: We conducted semistructured, in-depth interviews with six patients and five spine surgeons. Two investigators independently coded the transcripts using constant comparative method, as well as an integrative, team-based approach to identify themes.

Results: Patients themes: 1) patients felt surgery was their only choice because they were running out of time to undergo invasive procedures; 2) patients mentally committed to surgery prior to the initial encounter with their surgeon and contextualized the desired benefits while minimizing the potential risks; 3) patients felt that the current decision support tools were ineffective in preparing them for surgery; and 4) patients felt that pain management was the most difficult part of recovery from surgery. Surgeons themes: 1) surgeons varied substantially in their interpretations of shared decision-making; 2) surgeons did not consider patients' chronological age as a major contraindication to undergoing surgery; 3) there is a goal mismatch between patients and surgeons in the desired outcomes from surgery, where patients prioritize complete pain relief whereas surgeons prioritize concrete functional improvement; and 4) surgeons felt that patient expectations from surgery were often established prior to their initial surgery visit, and frequently required recalibration.

Conclusion: Older adult patients viewed the decision to have surgery as time-sensitive, whereas spine surgeons expressed the need for recalibrating patient expectations and balancing the risks and benefits when considering surgery. These findings highlight the need for improved understanding of both sides of shared decision-making which should involve the needs and priorities of older adults to help convey patient-specific risks and choice awareness.

Level of Evidence: 3


While surgery for correction of adult spinal deformity is often beneficial and results in functional improvement for some older adults, it also confers risk.[1,2] These risks increase with advancing age, as physiologic changes coupled with multimorbidity and frailty increase the risk of treatment-related complica-tions.[3–5] Deciding between treatment strategies presents a considerable decision-making challenge for older adults, and their families/caregivers because the choices are rarely binary (i.e., operative vs. nonoperative), given the coexistence of multiple chronic conditions.

Because surgery involves trade-offs between clear benefits and risks, the patient's perspective is essential in deciding whether or not to undergo surgery. Ideally, both patients and surgeons make important contributions to treatment decision around surgery. Shared decision-making (SDM)—defined as the process by which patients and clinicians make healthcare decisions together, providing care that is respectful of and responsive to individual patient preferences, needs, and values—has emerged as a central component of a more patient-centered health system.[6,7] SDM has the potential to significantly improve treatment of older adults with spinal deformities by aligning the treatment received with the individual's values and preferences. However, to date, patient's and surgeon's familiarity with and willingness to incorporate SDM in management of older adults with spinal deformities have not been thoroughly investigated.

We conducted a qualitative study to better understand patients' and spinal surgeons' perspectives on SDM in older adults with spinal deformities, with distinct objectives for each group. Our objectives during interviews with older adults were to explore how their experiences shaped deci-sional needs related to spine deformity surgery. During interviews with spine surgeons, our objectives were to explore their familiarity with SDM, their perception of its usefulness in treatment of older adults, and specific barriers to adoption in routine clinical practice.