The current review is of a study by Singh et al published in The Spine Journal that examines the association between postoperative changes in patient-reported outcome measures (PROMs) and multidimensional expectation fulfillment following elective lumbar spine surgery. This study arrives at a time of growing recognition that the success of spine surgery cannot be defined solely by radiographic alignment, fusion rates, or complication avoidance.

Over the past several decades, the spine field has increasingly embraced PROMs as measures of patient outcomes. The current study takes this evolution a step further by asking the relatively simple but important question: do the improvements we measure with PROMs actually correspond to what patients feel they got out of surgery? At its core, this question gets at what arguably matters most: is the patient satisfied?

The study draws on the Canadian Spine Outcomes Research Network (CSORN) registry, a well-established national database that prospectively enrolls patients undergoing elective spine surgery from 72 spine surgeons across 23 sites in Canada. All lumbar surgery cases were included, and 6260 met their eligibility criteria for inclusion.

The mean patient age was 59.6 years, 50% were female, 19% were current or recent smokers, and 28% used daily opioids. Primary diagnoses included lumbar spinal stenosis (37%), degenerative spondylolisthesis (33.2%), lumbar disc herniation (22.4%), and degenerative disc disease (7.4%). One-fifth of patients had prior spine surgery, and 7.3% underwent reoperation at the index level within one year.

Postoperative expectation fulfillment, the primary outcome, was assessed using the North American Spine Society (NASS) Lumbar Spine Questionnaire, in which patients rated whether their preoperative expectations were completely met, somewhat met, or unmet across seven dimensions.

The primary exposure variables were pre- to postoperative changes in 5 PROMs: the Numeric Rating Scale (NRS) for leg and back pain, the Oswestry Disability Index (ODI), the EuroQol 5-Dimension (EQ-5D), and the Short Form-12 Physical Component Summary (SF-12 PCS). Ordinal logistic regression modeled the association between PROM changes and ordinal levels of expectation fulfillment, adjusting for confounders.

The results demonstrated a clear, graded association between the magnitude of PROM improvement and the level of expectation fulfillment. Patients whose expectations were completely met had substantially larger improvements across all PROMs compared to those whose expectations were somewhat met or unmet.

A particularly noteworthy finding was the domain-specific alignment between PROM instruments and expectation dimensions. Pain NRS scores were most strongly associated with pain-related expectation fulfillment, while ODI, EQ-5D, and SF-12 PCS were most strongly associated with expectations for improvement in general physical capacity.

​​The authors also assessed the graded relationships between PROMs and satisfaction relative to minimally clinically important difference (MCID) achievement. The −28-​point​ ODI improvement in the completely met group clearly exceeded established MCID thresholds, which generally range from approximately −10 to −22 points, depending on pathology and calculation method. In contrast, the −4-point change in the unmet group fell well below any published MCID threshold, suggesting that patients whose expectations were unmet were, on average, not achieving clinically meaningful functional improvement.​

The correlation between MCID achievement and expectation fulfillment provides convergent validity for both approaches of assessing improvement: patients who achieve clinically meaningful improvement on standardized instruments also tend to report that their expectations had been met. However, the relationship was not perfectly linear. The authors appropriately note that, while PROM improvements closely mirror patient-perceived success, they do not fully capture expectation fulfillment in all cases. Satisfaction is likely shaped by broader factors beyond measurable clinical improvement, such as psychosocial context, coping strategies, and the absolute level of improvement a patient anticipated preoperatively.

The authors include all elective lumbar procedures in their analysis, which they argue broadens generalizability. The large sample size of 6260 patients provides robust statistical power. However, it would have been interesting to see whether the association between PROM changes and expectation fulfillment was consistent across different procedure types. For example, patients undergoing lumbar discectomy may show different domain-specific PROM alignment than those undergoing fusion for spondylolisthesis. Procedure-stratified subanalysis may be an interesting direction for further study.

Several additional limitations warrant consideration. The degree to which psychosocial factors, such as depression, anxiety, and coping strategies were accounted for in the regression models is important, as these have been shown to independently influence both PROM scores and expectation fulfillment. Additionally, while the measures were done out to a year, it would be interesting if these change over longer periods.

In summary, this well-powered registry study by Singh et al adds meaningfully to the literature by supporting the central role of patient-reported outcomes in defining surgical success. By demonstrating that PROM changes are strongly associated with expectation fulfillment across multiple domains, the study provides evidence that the instruments clinicians routinely collect do reflect what patients care about.