Scoliosis Surgery Outcomes and Cognitive Dissonance

Are Patients Unable to View Scoliosis Surgery as Failed?

A Major Spinal Surgery  is impossible to reverse.

Why is there a relatively small number of patients who regret having scoliosis surgery, in spite of greater than 50% complication rates AND greater than 27% rate of reoperations after the first surgery has failed (and even sometimes the second one) ?!!

Below is a summary of two very interesting articles that discuss the high complication and re-surgical rates for scoliosis surgery.  The researchers explore the psychological factors surrounding the apparent “disconnect” between having complications (or a failed surgery) and being unable to admit regret about having the surgery.

A 2008 systematic review of the PubMed literature (Weiss et al.), discussed the possible influence of cognitive dissonance in scoliosis surgery outcomes. They address the varying but high rate of complications with scoliosis surgery and that the rate of complications may even be higher than reported.

“ Instead of achieving long-term evidence for surgical treatment on a higher level and addressing the problems after surgery to attempt to improve patient’s safety, the surgical community is presenting large numbers of papers describing HRQL after surgery and related research [223241]. The problem with such studies however, is that they lack validity as they do not investigate the actual signs of scoliosis or the symptoms of the patient post surgery [242].

The studies containing psychological questionnaires may be compromised by the dissonance effect [242246]. Unable to face an inconsistency, such as being dissatisfied with a surgical procedure, a person will often change their attitude or action. Surgery is impossible to reverse, but subjective beliefs and public attitude can be altered more easily. In terms of research, this is important because a patient not satisfied with scoliosis surgery may not admit it. [242]”

The authors of the study also give examples of possible dissonance effect as reflected in scoliosis research:

Figure 5

Figure 5 “Balanced appearance with marked rib-hump after surgery. Although a marked rib-hump is clearly visible after surgery the patient is satisfied with the operation. The rib-hump reappeared after 5 years, however compensation has been maintained. The best cosmetic result was achieved directly after surgery.” (Weiss et al., 2008)

“Radiographic and physical measures of deformity do not correlate well with patients’ and parents’ perceptions of appearance. Patients and parents do not strongly agree on the cosmetic outcome of AIS surgery”. (Figure 6​, 7, and 8)

Figure 6

Figure 6 “Excellent clinical result without patient satisfaction. Excellent clinical result 20 years after Harrington instrumentation. The patient is without pain, however suffers from lack of spinal function although the lumbar spine remained unfused. Additionally, the patient, operated on at the age of 13 years, complained that her parents made the decision. After operation the patient experienced significant functional problems she feels unable to cope with.”(Weiss et al., 2008)

Figure 7

Figure 7 “Excellent radiological result without patient satisfaction. An ‘excellent radiological result’ one year after ventral fusion. But the patient complained about the decompensation (clinical overcorrection) and the visual prominence of the shoulder blade.” (Weiss et al., 2008)

Figure 8

Figure 8 “Not the best clinical result with patient satisfaction. This patient was satisfied although two operations have been necessary and the rib-hump and decompensation are still visible. This satisfaction may be the result of the dissonance effect [242].” (Weiss et al., 2008)

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What is Cognitive Dissonance?

Leon Festinger’s cognitive dissonance theory (1957) suggests that we have an internal need to hold all our attitudes and beliefs in harmony to avoid disharmony or dissonance. Therefore cognitive dissonance refers to a situation involving conflicting attitudes, beliefs or behaviors. This produces a feeling of discomfort leading to an alteration of one’s attitudes, beliefs or behaviors to reduce the discomfort/anxiety and restore comfort/harmony.

Festinger’s theory focused on the principle of cognitive consistency, the idea that we seek consistency in our beliefs and attitudes in any situation where two cognitions are inconsistent. Irrational and sometimes maladaptive behavior can arise from the desire to maintain cognitive consistency.

Cognitive dissonance was first mentioned in Festinger’s study of a cult which believed that the earth was going to be destroyed by a flood. When the flood did not happen, the fringe members were more inclined to recognize that they had made fools of themselves and to “put it down to experience”. The really committed members who had given up their homes and jobs to work for the cult were more likely to re-interpret the evidence to show that they were right all along (the earth was not destroyed because of the faithfulness of the cult members).

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A classic illustration of cognitive dissonance is expressed in the fable “The Fox and the Grapes” by Aesop (ca. 620–564 BCE). In the story, a fox sees some high-hanging grapes and wishes to eat them. When the fox is unable to think of a way to reach them, he decides that the grapes are probably not worth eating, with the justification the grapes probably are not ripe or that they are sour (hence the common phrase “sour grapes”). This example follows a pattern: one desires something, finds it unattainable, and reduces one’s dissonance by criticizing it.

Cognitive dissonance can occur when people seek to:

  • Explain inexplicable feelings
  • Minimize regret of irrevocable choices: e.g. Bettors at a racetrack are more confident in their chosen horse just after placing the bet because they cannot change it (the bettors felt “post-decision dissonance”).
  • Justify behavior that is opposite of one’s views
  • Align one’s perceptions of a person with one’s actions toward that person
  • Reaffirm already held beliefs: Congeniality bias or Confirmation Bias refers to how people seek information that affirms their already established opinions, rather than information that contradicts them.

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“Today, from the patient’s perspective, health care professionals have more open questions than answers when approaching the subject of spinal surgery in patients with scoliosis. For example; What are the long-term effects in the elderly; how long does the cosmetic effect of an operation last; is there a prospective controlled study clearly showing that scoliosis surgery really prevents progression in the long term; does the untreated patient really feel more impaired when progressing 10 degrees more in 20 years?” (Weiss et al., 2008)

A more recent study by the same authors (Weiss et al., 2013) yet again addressed the lack of regard for cognitive dissonance in scoliosis literature. They suggest that spinal fusion for Adolescent Idiopathic Scoliosis should only be considered when it is the rare curve that has progressed to a very severe degree, or in patients with substantial psychological trauma due to the deformity presented by scoliosis, “However, this is rarely the case in a population treated conservatively according to the latest standards.”

Most importantly, they stress the need for informed consent to be obtained for patient’s awareness and a surgeon’s liability in patients requiring surgery. That the patients be aware of the high percentage of long-term complications of fusion surgery and the extent of long-term complications to expect [15,16,17], “Additionally, the stress the patient experiences due to the deformity must be documented.”

“It is highly recommended that patients complete the preoperative patient awareness documentation regarding possible complications, sometimes presenting more than 20 years post-operatively[15,16,17]. This documentation, in conjunction with the deformity-related stress level questionnaire, should be read carefully for full disclosure of long-term effects.”

The authors conclude:

“ A medical indication for AIS spinal fusion surgery does not exist, except in extreme cases. The rate of complications of spinal fusion surgery appears to increase with time. The risk/reward relationship of spinal fusion surgery is unfavourable for the AIS patient, except in rare cases. There is no evidence that spinal fusion surgery improves quality of life for AIS patients versus natural history. The risks and long-term costs, in terms of pain and suffering, after spinal fusion surgery exceeds what is reasonable for AIS patients, putting the common practice of surgery in question, except in extreme cases.”

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Posted in Scoliosis Research, Awareness & News, Scoliosis Surgery

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