Which spine surgery techniques are most appealing to the public? A survey examining public perception of spine surgery techniques and factors associated with procedure preference

Abstract

Background

Public awareness and understanding of spine surgery techniques can influence patient decision-making and outcomes. Healthcare organizations often market these techniques, but the public's comprehension and perceptions of these procedures remain unclear.

Methods

A cross-sectional survey study was conducted via an online platform. The target population was the general United States population, with filters set for English-speaking participants aged 18 and older, and a Prolific approval rating of 80-100%. The survey collected demographic data and responses on awareness of spine surgery techniques, understanding of these techniques, perceived effectiveness, personal preferences, concerns, and decision-making processes in surgeon selection. Multivariate linear regression was employed to analyze the influence of demographic variables on surgical preferences.

Results

High awareness was observed for spinal fusion (76.9%) and disc replacement (79.3%), while terms like laminectomy (19.7%) and AR-assisted spine surgery (10.9%) were less known. “Robotic spine surgery” and “disc replacement” were perceived as the most efficacious. ``Minimally invasive'' techniques and “laser spine surgery” were the preferred choices. Multivariate analysis revealed that sex, insurance type, income, and location significantly influenced surgical preferences. Concerns about surgical complications (87%) and recovery time (68.1%) were prevalent. Social media, particularly YouTube, Instagram, and Facebook, were primary information sources. Surgeon selection was mainly influenced by professional recommendations and hospital reputations.

Conclusions

The study identifies significant gaps in public knowledge of spine surgery techniques and underscores the need for targeted educational initiatives to improve patient understanding and decision-making.

Introduction/Background

Spine surgery has seen significant advancements over the last 2 decades, particularly with the integration of image-guidance, robotic systems, and augmented reality (AR), which are increasingly recognized as valuable adjuncts in spine surgery [[1], [2], [3]]. Endoscopic surgery and minimally invasive outpatient spine surgery are revolutionizing the field, offering patients less invasive options with favorable outcomes [[4], [5], [6]]. Patient-directed marketing tends to focus on these advances, as healthcare organizations and surgeons seek to increase the volume of spine procedures. Terms such as “robotic,” “endoscopic,” “minimally invasive,” and “disc replacement” are frequently employed in marketing materials, yet the general public's understanding of these terms remains unclear [7,8].

Prior investigations have demonstrated that patient preferences can be significantly influenced by the perceived benefits and risks of specific surgical techniques. For example, minimally invasive spine (MIS) surgery is often preferred over open surgery due to perceptions of reduced postoperative pain, fewer complications, shorter recovery times, and lower costs [7]. Understanding these preferences is crucial for guiding patient education and ensuring informed decision-making. A study analyzing public perceptions about robotic-assisted surgery (RS) found that while most respondents perceived benefits to RS, a significant portion still preferred conventional minimally invasive surgery due to various misconceptions, indicating a need for better patient education [7]. Additionally, an online crowdsourcing study investigating public perceptions surrounding joint arthroplasty revealed that many patients were unaware of the similar outcome profile associated with RS, when compared with traditional techniques [9]. Public perceptions are also shaped by the sources of information patients access. Social media platforms, particularly YouTube, Instagram, and Facebook, play a substantial role in disseminating information about surgical options. However, the quality and accuracy of information available on these platforms can vary, leading to potential misconceptions and misinformation which can affect patient decision-making.

Although previous studies have explored patient perceptions of traditional spine techniques, there is scarce literature assessing the public's awareness and preferences for newer technologies [8]. The aim of this study is to evaluate the public's knowledge and preferences regarding spine surgery techniques, including traditional open procedures (e.g., laminectomy and spinal fusion) and newer methods promoted through marketing. By assessing the public's knowledge and preferences, we aim to identify areas where educational efforts can be improved to enhance patient understanding and satisfaction.

Materials and methods

After obtaining institutional review board (IRB) exemption, a digital survey was developed through Qualtrics to query respondents on spine surgery technique preferences. The survey was distributed using the online research platform Prolific. This platform is a crowdsourcing website that connects researchers with reliable participants, who can select which surveys they wish to complete and are paid to complete them. This cross-sectional survey was limited to English-speaking respondents 18 and over located in the United States with a Prolific approval rating of 80%−100%.

This method of collecting data has been previously established with similar crowdsourcing websites and allows for high-quality and efficient data collection [[10], [11], [12], [13], [14]]. Prolific was specifically selected as the crowdsourcing platform for its overall quality, ethical survey distribution, and its ability to quickly gather reliable data from a vetted and diverse participant pool. Furthermore, with concerns over the presence of inattentive survey participants and nonhuman respondents (bots) in online survey platforms, Prolific was selected for its superior vetting criteria [15,16].

This structured survey included multiple-choice questions, ranking scales, and open-ended responses allowing for detailed feedback (Fig. 1). Recorded information included demographic information (age, sex, education, region, income, insurance type), awareness of spine surgery techniques, understanding of these techniques, perceived effectiveness, personal preferences, concerns about surgeries, sources of information, and decision-making processes in surgeon selection. A pilot survey was initially given to 100 participants to ensure the survey was well-comprehended, then delivered to the remainder of participants. Participants were paid 80 cents per survey. Participants were included in analysis with successful completion of the survey and submitting a unique completion code once finished.

Fig. 1.

Structured survey: questions and responses.

Statistical analysis

After responses were tabulated, multivariate linear regression was used to determine the independent association of patient demographic factors and preference for a specific surgical technique. In this analysis, positive β-coefficients indicated an increased likelihood of selecting a particular surgical technique associated with the demographic factor, whereas negative β-coefficients indicated a decreased likelihood. A P -value <0.05 was considered statistically significant. Data was analyzed using Stata/MP 18.0 (StataCorp LLC, College Station, TX).

Ethical approval and patient consent

This study was conducted after IRB exemption. Patient consent was obtained electronically, with participants providing informed consent prior to completing the survey. All participants had the option to withdraw at any point without penalty.

Results

A total of 520 surveys were sent, with 493 complete responses (94.8%) and a median response time of 5 min. Demographic data revealed a majority female participation (58.62%), with approximately 60% under the age of 40. An undergraduate degree was the most common level of education (39.96%) (Table 1).

Table 1.

Demographics of Participants.

		No	(%)
Total		493	100
Age group
	Under 30	148	30
	31– 40	145	29.41
	41–50	86	17.44
	51–60	73	14.81
	Over 60	41	8.32
Sex
	Male	194	39.35
	Female	289	58.62
	Nonbinary/other	10	2
Education
	High School	146	29.61
	Associate Degree	64	12.98
	College Degree	197	39.96
	Master's Degree	72	14.6
	Doctorate Degree	14	2.84
Region
	West	163	33.06
	Midwest	92	18.66
	South	155	31.44
	Northeast	83	16.84
Income
	Less than $30,000	107	21.7
	$30,000–$49,999	88	17.85
	$50,000–$99,999	162	32.86
	$100,000–$150,000	82	16.63
	Greater than $150,000	54	10.95
Insurance
	Private insurance plan	264	53.55
	Medicare	71	14.4
	Medicaid	88	17.85
	No health Insurance/ Self-pay	54	10.95
	Other	16	3.25

Awareness of surgical techniques such as “spinal fusion” (76.9%) and “disc replacement” (79.3%) were high while “laminectomy” (19.7%) and “augmented-reality” (10.9%) were low. “Robotic spine surgery” (76%) and “Disc replacement” surgery (76%) were felt to be the most effective techniques, and when asked which techniques they would choose for themselves, “minimally invasive” (72%) and “laser spine surgery” (61%) were the most popular choices (Fig. 2) (Table 2).

Fig. 2.

Heard of spine techniques before (%).

Table 2.

Spine Surgery Techniques.

	Heard	Understanding			Effectiveness	Choose
	(%)	None (%)	Some (%)	Clear (%)	Mean (SD)	Mean (SD)
Laser Spine Surgery	43.6	51.9	43.6	4.5	7.4 (1.8)	6.1 (2.8)
Robotic Spine Surgery	49.1	43.2	50.9	5.9	7.6 (1.8)	5.2 (3.1)
Disc Replacement	79.3	24.1	64.3	11.6	7.6 (1.8)	5.5 (2.7)
Spinal Fusion	76.9	34.5	49.1	16.4	7.2 (1.8)	4.7 (2.8)
Minimally Invasive	57.6	44.2	47.3	8.5	7.4 (1.8)	7.2 (2.7)
Endoscopic	39.4	65.5	28.6	5.9	7 (1.8)	5 (2.8)
Laminectomy	19.7	83.6	11.6	4.9	6.4 (2)	3.8 (2.8)
Outpatient	42.4	55.2	35.1	9.7	6.8 (2)	5.5 (3.1)
Augmented-Reality	10.9	80.3	16.6	3	6 (2.2)	3.9 (3.2)

"Heard" indicates if participants had heard of the technique (yes/no). “Understanding” reflects perceived knowledge as “None,” “Some,” or “Clear.” “Effectiveness” rates perceived efficacy (0-10, 10=most effective). “Choose” rates likelihood of choosing the technique for themselves or loved ones (0-10, 10=most likely).

The most common concerns after spine surgery were fear of complications (87%), surgery not working (78.7%), and recovery time (68.1%) (Fig. 3) (Table 3). Social media use was primarily YouTube (70.6%), Instagram (56.6%), and Facebook (51.9%) (Fig. 4) (Table 4). The most important factors when deciding on a surgeon were the recommendation of former patients (8.6), hospital reputation (8.4), and recommendation of other physicians (8.4) (Fig. 5) (Table 5).

Fig. 3.

Concerns about spine surgery (%).

Table 3.

Spine Surgery Concerns.

	No	%
Fear of complication	429	87.0
Recovery time	336	68.1
Cost and Insurance Coverage	334	67.8
Fear of Pain	287	58.2
Surgery not working	388	78.7
Desire for alternative treatments	102	20.7
Not having enough information to decide	215	43.6
Need for another surgery	251	50.9

Participants could select multiple concerns about spine surgery.

Fig. 4.

Sources of information (%).

Table 4.

Social Media Usage.

	No	%
Facebook	256	51.9
Instagram	279	56.6
Reddit	251	50.9
TikTok	180	36.5
Snapchat	79	16
YouTube	348	70.6
I don't use social media often	11	2.2

Participants could select multiple platforms, with selection indicating ≥30 min of daily usage.

Fig. 5.

Surgeon selection importance (0-10).

Table 5.

Importance When Deciding Surgeon.

	Mean (SD)
Online reviews/comments	7.4 (2.2)
Time spent with patient	7.8 (1.8)
Recommendation of other physicians	8.4 (1.6)
Hospital reputation	8.4 (1.6)
Recommendation of former patients	8.6 (1.6)
Reputation of surgeon's training institution	7.4 (2)

Factors were rated 0-10, with 10 as most important and 0 as least important.

Logistic regression analysis

Factors influencing surgical choices were sex, region, income, and education (Table 6). For robotic spine surgery, female sex was negatively associated with preference (β=−0.9, p<.001). Spinal fusion preferences were negatively influenced by female sex (β = −0.7, p=.009) and positively influenced by Medicaid coverage (β=0.8, p=.049). Minimally invasive surgery was more preferred by females (β=0.7, p=.004) and individuals with only a high school education (β=0.8, p=.011). Endoscopic surgery preferences were negatively associated with living in the Midwest (β=−0.8, p=.037) and Northeast (β=−0.9, p=.019). Laminectomy preferences were also negatively associated with female sex (β=−0.7, p=.005). For AR-assisted spine surgery, female sex was strongly negatively associated (β=−1.1, p<.001), while an income greater than $100k (β=+1.04, p=.015) and high school education (β=−1.1, p=.003) showed significant associations. No significant factors were found for preferences related to laser spine surgery, disc replacement, or outpatient surgery.

Table 6.

Regression Analysis for Factors Associated with Procedure Preference.

Laser Spine Surgery	None
Robotic Spine Surgery	Female sex (−0.9, p < 0.001)
Disc Replacement	None
Spinal Fusion	Female sex (−0.7, p = 0.009), Medicaid (0.8, p = 0.049)
Minimally Invasive	Female sex (0.7, p = 0.004), Highschool education (0.8, p = 0.011)
Endoscopic	Midwest (−0.8, p = 0.037), Northeast (−0.9, p = 0.019)
Laminectomy	Female sex (−0.7, p = 0.005)
Outpatient	None
Augmented-Reality	Female sex (−1.1, p < 0.001), Income >100k (+1.04, p = 0.015), Highschool education (−1.1, p = 0.003)

Beta coefficient analysis was performed to identify factors associated with procedure preference, with significant results shown as beta values.

Discussion

Spine surgery has seen remarkable advancements in recent years [[1], [2], [3]]. However, despite these advances and increased marketing of these techniques, there is limited understanding of the general public's perception of the benefits and risks associated with them. The aim of this study was to assess public awareness and preferences regarding spine surgery techniques, including traditional and newer methods, to identify areas where educational efforts can be improved.

Our results show that while there is high awareness of common procedures like spinal fusion and disc replacements, patients are less familiar with laminectomies, which are also commonly used. Newer technologies such as AR in spine surgery may challenges without targeted education, with only 10.9% of respondents having heard of it, 80.3% lacking understanding, and a low perceived effectiveness and selection score. Notably, nearly 60% of the study's participants were under the age of 40, which suggests a more technology-savvy patient population [17]. This is important to note as older patients may be even more hesitant to adopt these technologies without a proper understanding of their associated risks and benefits. These technologies have grown significantly over recent years, and their uses and adoption in the field are likely to grow [18,19]. Overall, these results indicate that AR assisted spine surgery is a great target for patient education to improve awareness, understanding, and confidence in this emerging technology. Additionally, there was a larger proportion of younger patients represented in this survey. These patients typically present with single-level spinal disease, which is often treatable using minimally invasive techniques [20,21]. This is important to note as minimally invasive spine procedures had one of the highest awareness and selection rates, and this term could be used to help patients make the best decisions for their care.

Laser spine surgery, with the second highest selection rate, regardless of the participants' understanding, potentially suggests that patients are drawn to the perception that these techniques offer fewer complications and a less challenging recovery period. These perceptions are important to note as lasers in spine surgery has not demonstrated significant clinical benefit as compared to traditional procedures and even add distinct potential complications [22]. Furthermore, there is a paucity of randomized controlled trials looking at the efficacy of lasers in spine surgery [23]. These findings suggest that although patients would prefer what they perceive to be less invasive techniques, these preferences don't always align with the best decisions for their care. This highlights the need for improved patient education regarding the use of lasers in spine surgery, ensuring that treatment decisions are based on evidence-based information rather than perceptions of reduced invasiveness that may not align with the best clinical outcomes. The inclination for less invasive spine procedures presents a great opportunity for outpatient spine procedures, which, despite their potential benefits, are less recognized by patients and had a lower selection score [24]. With the right indication and patient population, outpatient spine procedures have been found to have comparable results to inpatient procedures, with a faster recovery and improved cost-effectiveness [25]. With current trends demonstrating increased use of outpatient spine procedures and the need for outpatient spine surgery projected to increase significantly in the coming years, targeted patient education on its use and benefits is important [26,27]. Understanding patients' preferences is crucial to guide them away from techniques that are less favorable in the literature and advocate for those that are both efficacious and align with their long-term goals of care.

Previous studies corroborate our findings regarding patient perceptions and preferences for minimally invasive spine surgery [[7], [8], [9]]. Narain et al. (2018) found that patients generally favor minimally invasive techniques due to perceptions of reduced postoperative pain, fewer complications, and shorter recovery times when compared with open techniques [28]. Lam et al. (2022) highlighted the importance of addressing patient needs and expectations, and found that patients often have specific treatment preferences based on their level of understanding and the information provided to them [29]. Overall, patient education, realistic discussions about treatment options, and clear communication are crucial for enhancing patient satisfaction and ensuring informed decision-making [30].

Another insight from this investigation is that the highest factors influencing patients' choice of surgeon were recommendations from former patients, hospital reputation, and the advice of other physicians. Online reviews and the reputation of a surgeon's training institution were less impactful. These findings align with current literature, which shows that patients often rely on word-of-mouth and physician referrals when choosing a surgeon [31]. Additionally, aligning with our results, many patients prioritize hospital characteristics, such as reputation, over individual surgeon attributes when selecting surgical care [31]. This highlights the importance of fostering strong relationships with patients and physicians, as well as ensuring that hospitals and surgeons maintain a positive reputation within their communities, as these factors play a critical role in patient decision-making. The fear of complications was the highest concern among participants, with 87% expressing worry about potential complications following spine surgery, closely followed by concern about the surgery's effectiveness (78.7%). Recognizing these fears is important, as many patients harbor misconceptions about treatments, which impacts their choices and satisfaction [32]. Furthermore, Mancuso et al. (2014) reported that patients have varied and often unrealistic expectations of cervical spine surgery, which can lead to dissatisfaction if not preemptively managed prior to surgery [33]. Understanding and addressing patient anxieties early is important, as concerns about risks and outcomes heavily influence decision-making [34].

The limitations of this study include potential bias from using a paid survey platform, which may have potentially skewed the results. Also, there was greater participation of younger individuals, who may not represent the typical spine surgery patient population for certain pathologies. Additionally, participants who do not use online platforms were likely underrepresented, limiting the generalizability of the findings. Lastly, surveying the general public is a limitation, as it may not reflect the targeted knowledge of patients actively seeking treatment for spine-related conditions. Future studies should consider alternative data collection methods to ensure a more diverse and representative sample.

Conclusion

This study reveals gaps in public awareness and understanding of spine surgery techniques among patients, though high rates of awareness of common procedures like spinal fusion and disc replacement was present. Overall, our findings emphasize the need for targeted educational initiatives to bridge the knowledge gap in spine surgery. With advancing technologies and newer techniques being introduced to the field of spine surgery, targeting misconceptions and providing clear, evidence-based guidance is of the essence for optimal care. Enhancing public understanding will help align patient expectations with outcomes, leading to better-informed decision-making and improved patient satisfaction following spine surgery.

Funding

None.

Declaration of competing interest

AP and JH have nothing to declare. AHD discloses the following: receives royalties from Spineart, Stryker, and Medicrea, consulting fees from Medtronic, research support from Alphatec, Medtronic, and Orthofix, grant from Medtronic, and fellowship support from Medtronic. BB reports the following: receives consulting fees from Medtronic, Globus, and Stryker.