Postoperative Experience of Older Adult Patients Who Underwent Lumbar Spine Surgery: A Qualitative Study
Article information
Abstract
Purpose
Older adult patients undergoing lumbar spine surgery often experience restricted daily activities due to sarcopenia and physical weakness, leading to a diminished quality of life. This study aimed to explore the postoperative experiences of older adult patients who underwent lumbar spine surgery.
Methods
This qualitative content analysis study collected data through individual interviews with 10 participants aged 60 years or older who underwent spinal surgery between 2016 and 2022.
Results
A total of 107 codes were identified and classified into 9 categories, 20 subcategories, and 4 main themes: "the boundary between acceptance and resistance," "distrust of hospitals and uncertainty about life due to unmet needs," "leading a different life compared to before surgery," and "living an adapted lifestyle."
Conclusion
Older adult patients desire healthcare providers to recognize their unmet needs and deliver individualized postoperative care tailored to their unique conditions and experiences.
INTRODUCTION
The number of people with degenerative lumbar spine disease and low back pain is increasing worldwide, with approximately 266 million people undergoing this surgery per year [1]. Notably, the growing older adult patients and advancements in medical technology are re-portedly leading to a significant increase in the rate of spinal surgery in the older adult patients [2,3]. In Korea, the proportion of older patients undergoing lumbar spinal fusion for degenerative spinal diseases increased by 13.4% between 2010 and 2018. In contrast, the proportion of younger patients decreased by 13.7% between 2010 and 2018. [4]. Guided by epidemiology, comprehending the postoperative experiences of older adult patients’ spine surgery is essential for enhancing recovery and providing holistic care, extending beyond mere disease treatment.
Older adult patients undergoing lumbar spine surgery have experienced chronic back pain, limited activity in daily life [5,6], sarcopenia [7], and frailty [8]. This suggests that postoperative recovery in older adult patients is not a short-term event, but rather a long-term process [9]. Furthermore, for those undergoing lumbar spine surgery, the critical focus should be on postsurgical functional recovery and pain relief, and not on mortality like cancer in removal surgery [10]. However, it is difficult for older adult patients to adopt healthy lifestyles who have formed harmful behavior patterns immediately after lumbar spine surgery, such as not exercising or prolonged bad posture. Hence, the 10 years of long-term reoperation rate following surgery for lumbar stenosis ranges from 18.6% to 20.6%, depending on the surgical type [11]. Furthermore, within an 8-year cohort from 2010 to 2018, the reoperation rate peaked in patients aged 60∼69 years, reaching 17.6 per 1,000 person-years. This rate represented a hazard ratio of 2.20 (Confidence Interval: 1.76∼2.75) compared to those under 40 years [4].
However, hospitals that provide lumbar spine surgery lack long-term care management that can help older adult patients maintain a healthy lifestyle [12]. Most intervention and recovery programs for older adult patients who underwent spinal surgery focused on preoperative education or intraoperative intervention (e.g., modification of anesthetic technic and surgery procedure) [13]. Moreover, postoperative recovery programs primarily concentrate on postoperative pain control and early mobilization before discharge, while a strong emphasis on the acute care setting [13]. While rehabilitation programs exist to improve post-discharge recovery, most developed postoperative programs require expert assistance [14]; therefore, services may not be accessible depending on prox-imity and available funds.
Although the roles of navigator, case manager, or coor-dinator can be utilized to fill the medical gap and ensure continuity of patient care [15], these roles, which can help older adult patients recover after lumbar surgery and increase treatment satisfaction [16], are absent, especially in Korea. Thus, understanding their experiences is essential to provide concrete evidence for long-term postoperative management. Furthermore, it is difficult to find a program where nurses lead the management of older adult patients’ physical, mental, psychological, and social support in an integrated way for older adult patient's healthy transition [14]. Understanding patients’ postsurgical challenges is essential for the development and clinical implementation of a postoperative patient-centered self-care program. Few studies have investigated the post-hospital experiences of older adults following lumbar spine surgery [12,17]. One study explored the experience of applying for a rehabilitation program prior to surgery [17], whereas another was conducted 20 years ago [18]. A more recent study focused on how to process older adult patients’ knowledge [19]. Therefore, this current qualitative study aimed to understand the experience of older adult patients who underwent lumbar spine surgery based on inductive content analysis.
METHODS
1. Design
This was a qualitative content analysis study to deter-mine and explore the experiences of older adult patients who underwent lumbar spine surgery.
2. Participants and Setting
Using the snowball sampling method, 10 older adult patients (five men and five women) who underwent lumbar spine surgery at one tertiary hospital from 2016 to 2022. Because recovery after lumbar spinal surgery is a long-term process rather than a short-term event for older adult patients [9], those who underwent surgery longer ago often recalled its impact on their lives more vividly. These recollections provide valuable insights into the nature of long-term recovery. Moreover, including participants with varying postoperative timelines enabled a comprehensive understanding of both short-term changes and long-term adaptation processes. With prior approval from the one tertiary hospital where the researcher worked, a recruitment notice was posted outlining the study's pur-pose and methodology. Older adult patients aged ≥60 years who underwent lumbar spine surgery (e.g., lam-inectomy, fusion surgery) between 1 and 7 or more years ago were included in this study. Those who had cervical surgery, total hip replacement arthroplasty, sensory loss, cognitive impairment and were diagnosed with mental ill-ness, such as depression, anxiety disorder, bipolar disorder was excluded.
3. Data Collection and Procedure
The researcher posted a recruitment notice, and participants who voluntarily agreed to participate were sub-sequently recruited. The recruitment period was from January 2 to January 13, 2023, and the interviews were conducted from January 23 to February 21, 2023. Data were collected through in-depth, face-to-face interviews, all conducted by a single researcher who visited participants in their homes. To ensure the participants’ comfort and facilitate open communication, interviews were conducted at their residences by prior arrangement. Open-ended questions were used to encourage participants to share their postsurgical experiences. The main interview questions included: "How are you doing now after lumbar spine surgery?", "How is your life different before and after surgery?", and "What are the pros and cons of the surgery?". Each interview lasted approximately 45 to 60 minutes and was audio-recorded and transcribed verbatim to minimize data loss.
4. Data Analysis
The collected data were analyzed using an inductive content analysis approach [20] to explore the characteristics of older adult patients’ experiences with lumbar spine surgery. In the preparatory phase, interview tran-scripts were read repeatedly to grasp the overall context and identify key phrases and meanings related to the research questions. During the organizing phase, open coding was performed to generate meaningful codes. In the reporting phase, subcategories were abstracted and organized into higher-level categories, from which overarching themes were derived. To ensure the trustworthiness and validity of the analysis, multiple strategies were em-ployed. Up to the organizing phase, the first and second researchers independently analyzed the data. When dis-crepancies occurred, a third researcher participated in reviewing and resolving them, and the final theme development was conducted collaboratively by all researchers. In addition, member checking was performed by providing participants with a summary of the preliminary findings and interpretations, and their feedback was incorporated to verify that the results accurately reflected their actual experiences. This process enhanced the credibility of the data analysis and ensured that the findings remained faithful to participants' lived experiences.
5. Researcher Preparation
The researchers have strengthened their expertise in qualitative research through ongoing participation in training and academic conferences and have published several phenomenological studies in peer-reviewed journals. One researcher is a geriatric nurse practitioner specializing in geriatric nursing education. Another is a university professor and advanced practice nurse with over 12 years of experience in postoperative pain management in the Department of Anesthesia and Pain Medicine. The third has 4 years of experience in a spinal surgery ward and 15 years as a dedicated nurse for spinal surgery patients. These diverse clinical backgrounds contributed signifi-cantly to the interpretation of interview data and the deri-vation of research findings.
6. Rigor
To ensure the validity of this study, Guba and Lincoln's four criteria for trustworthiness— credibility, transferabil-ity, dependability, and confirmability— were applied [21]. Credibility was established by selecting participants capa-ble of articulating their experiences and by conducting interviews using open-ended questions in a natural and supportive environment. All interviews were transcribed verbatim in the participants’ native language to minimize distortion. Additionally, one participant (Participant 8) reviewed the derived themes and quotations to verify their accuracy. Transferability was ensured by continuing data collection until saturation was reached, when no new information emerged from the in-depth interviews.
Dependability was enhanced through regular consultation with a nursing professor experienced in qualitative research, who reviewed the research process and findings. Confirmability was ensured by employing diverse strategies to reduce subjective bias and strengthen the objectivity of the data analysis. First, the researcher maintained a reflexive journal immediately after each interview, doc-umenting emotions, preconceptions, and interpretive processes. This practice facilitated the recognition and management of potential subjective influence. Second, peer debriefing was conducted to confirm that the themes and categories derived from data analysis were not distorted by personal assumptions. Third, member checking was im-plemented by asking participants to review and validate the researcher's interpretations, thereby ensuring that the findings accurately reflected their lived experiences. Fourth, an audit trail was established to provide transparent doc-umentation of the entire process of data collection, analysis, and interpretation, enabling external reviewers to examine the research procedures. Through these procedures, the researcher ensured that personal values and preconceptions did not compromise the interpretation of the data, thereby strengthening both the objectivity and the validity of the study findings [21].
7. Ethical Considerations
This study was approved by the ethical committee of Gyeongsang national university (IRB approval GIRB-G22- Y-0074) and was conducted in accordance with the Decla-ration of Helsinki. Written informed consent was obtained from all participants.
RESULTS
A total of 10 participants (five men and five women) who had undergone lumbar spine surgery were included in this study, with a mean age of 69.4 years. After surgery, seven participants were discharged to their homes, while three remained hospitalized for further care (Table 1). Nine were cared for by their spouses, and one lived alone.
Characteristics of Participants (N=10)
A total of 107 codes were identified and organized into 20 subcategories, 9 categories, and 4 overarching themes: (1) the boundary between acceptance and resistance, (2) distrust of hospitals and uncertainty about life due to unmet needs, (3) leading a differnet life compared to before surgery, and (4) living an adapted lifestyle. These themes are described below and summarized in Table 2, along with illustrative quotes from the interviews.
Postoperative Experiences or Complications Divided into Subcategories, Categories, and Themes
1. The Boundary between Acceptance and Re-sistance
Participants described experiencing various postoperative complications, including delirium, surgical site infection, dysuria, constipation, falls, and sleep disturbances. These complications posed significant challenges to self-care. Additionally, long-term difficulties such as neurological pain (lower back, hip, legs, feet), numbness, swelling, leg weakness, and stiffness caused ongoing discomfort. Older adult patients perceived back pain, leg numbness and discomfort as expected complications, but inflammation, dysuria, constipation, falls, and sleep disturbances as unexpected, and formed opinions about which complications were acceptable and which were not.
The pain was so intense that even after the surgery, the pain was unbearable. (Participants 4)
I suffered a lot from delirium after surgery. Even after being discharged, my mental health did not come back to normal right away, and I said nonsense at least occasionally…. There was nothing wrong with it. At that time, I was really surprised that I fell after lumbar spine surgery. (Participants t 1)
After the operation, I could not move and eat well and had constipation. Eventually, it was not my back that hurt after the surgery, it was my abdomen. This was my first lumbar spine surgery, so I did not know what to do. (Participants 5)
My legs had frequent cramps, probably because of surgical complications… and sometimes it feels like it is going to explode completely and hurts so much, which I did not expect. (Participants 3)
2. Distrust of Hospitals and Uncertainty about Life due to Unmet Needs
Although participants received instructions regarding postoperative outpatient visits, they were discharged without clear guidance on how to manage their daily lives. This lack of information and professional support from healthcare providers led to negative feelings and uncertainty among participants. Consequently, they struggled with routine tasks and adjusting pre-existing lifestyle habits. Participant 8 highlighted the need for individualized education tailored to older adult patients’ characteristics, including job-related postures and habitual behaviors prior to surgery.
When I go to the hospital, the doctor always pre-scribes me a bunch of medicines, draws blood every time, but never tells me the results, or how to live life after surgery. (Participants 3)
My doctor told me to ride a bike to help my recovery, but I know it does not fit me. However, the doctors do not know me or my preference. (Participant 6)
Unfortunately, I repeated my previous activities after surgery because nobody specifically told me I shouldn't. I was only provided with general post-surgery information. (Participants 8)
I think recovery would have been quicker if the hospital had provided patients with support like physical therapy. (Participants 6)
Participants expressed that, because they were not clearly informed about postoperative care, the attitude of the hospital staff made them feel as though they were being treated like test subjects. As a result, they were hesitant to recommend the surgery to others and developed fear toward the procedure itself.
The doctor and nurses only focused on setting the surgery date, but they did not tell me anything about postoperative precautions. (Participants 6)
They only thought of me as a subject for surgery. (Participants 5)
Moreover, in an effort to understand the cause and find relief from symptoms, which appeared as sequelae of neurologic injuries of unknown origin following surgery, participants engaged in hospital shopping, seeking care from hospital other than where the surgery had been performed.
Should I say I put glue on my legs?… In my search to understand and find solutions for the symptoms from neurologic injuries of unknown origin after my surgery, I've found myself going from hospital to hospital, looking for one where I hadn't undergone surgery. Even now, I'm receiving a kind of nerve in-jection once a week. After that, I can walk a bit. (Participants 7)
3. Leading a Different Life Compared to before Surgery
Participants were admitted to a long-term care facility, such as a nursing home for controlling postoperative complications and lived a dependent life for a while.
My legs get cramped a lot, probably because of the surgical complications… and sometimes it feels like it is going to explode completely and hurts so much that I did not expect it. (Participants t 5)
Post surgery, older adult patients felt anxious that the complications would last for a long time or that the entire spine would be destroyed. Therefore, their activities in daily life were limited.
Numbness itself was not a problem after surgery, but they said that the entire spine could become a problem due to surgery. I went to the mountain well before, but after the surgery, I could not go out. (Participants 3)
After the surgery, my whole body and muscle strength became weak. I was running a store and started working when I recovered, but I did not get any better after 5 months. When I was in the hospital, the doctor said that there was nothing else to do. (Participants 7)
After the surgery, the nerves in my leg did not seem to survive, and it got worse that I thought I could not do anything normal. (Participants 6)
4. Living an Adapted Lifestyle
Older adult patients acknowledge and accept that their pain and numbness in their legs will continue and that they must manage it for the rest of their lives over time.
I bent down here, but my legs were numb. Surgery was not that perfect. Even now, I think that I did not return to normal, and that I am handicapped or disabled. (Participants 7)
Participants could not obtain adequate information on postoperative management and were left to develop their own routines. They sought information on lifestyle mod-ifications, precautions, and exercises from peers with sim-ilar conditions, informal caregivers at outpatient clinics, friends, and the internet.
In the outpatient clinic, the doctor told me that my condition was not serious, but I still searched on the Internet and YouTube for complication. (Participants 2)
I searched about postsurgical care on YouTube myself and listened to people who were sick. (Participants 6)
After surgery, participants actively sought appropriate exercises and developed personalized self-management strategies. They became aware of the need to exercise caution in daily activities and to integrate prescribed routines into their lifestyle.
I think it is more important to take good care of yourself rather than with medication alone. (Participants 2)
I believe that if I wore a belly band and waist tight like this, my back would become stronger and softer. (Participants 4)
DISCUSSION
This study discovered the post lumbar spine surgery experience of older adult patients. The experience of older adult patients was structured based on inductive content analysis with four themes: the boundary between acceptance and resistance, distrust of hospitals and uncertainty about life due to unmet needs, leading a different life compared to before surgery, and living an adapted lifestyle.
Our participants experienced difficulties and frustration owing to complications that developed or continued until after lumbar spine surgery and it was difficult to cope with them. Previous studies have reported various postoperative complications such as nausea and vomiting, severe pain, and fall in lumbar spine surgery older adult patients [22-24]. Participants 1 and 3 experienced fear and pain due to postoperative delirium and constipation from hospitalization to discharge. Recently, the age of patients who underwent spinal surgery is increasing [4]. As a result, the incidence of postoperative complications, such as delirium, wound-related inflammation, and hip fracture surgery due to falls, increases with age [22-24]. Therefore, nurses and physicians should carefully evaluate complications that may occur in older adult patients, be aware that complications can continue even after discharge, and edu-cate older adult patients about these risks. Furthermore, implementing Enhanced Recovery After Surgery programs would be helpful for optimizing postoperative patient recovery by reducing complications, lowering opioid and antiemetic use, and enhancing functional recovery [25].
Our participants experienced discomfort, such as new pain onset and numbness, even after surgery. The neurological complications induced confusion, fear, and anxiety in older adult patients, consequently leading to an unac-ceptable resistance to their current circumstances. Postoperative neurological deficit is a complication experienced by older adult patients who receive lumbar spine surgery [26], and in most cases the cause is unknown, bar-ring any surgical defects [27]. Older adult patients decide to have lumbar spine surgery to relieve neurologic symptoms [28], but new symptoms may burden and frustrate older adult patients.
Numerous studies, along with our study, have reported the unmet needs of surgical patients [16,18,29], highlighting their preference for receiving individually tailored information regarding their daily life management [12]. The lack of education given to patients and insufficient supportive care by the healthcare providers for older adult patients resulted in distrust of the hospital and uncertainty regarding their health recovery. Our study participants expressed that they would not recommend surgery to other patients experiencing degenerative spinal conditions due to unsolved unmet needs (e.g., persistent neurological symptoms). Because the participants were not clearly informed about postoperative care, they perceived them-selves as "subjects in a medical experiment" with unmet needs. They expressed discomfort with their surgical experience and reported fear regarding the possibility of undergoing further surgery. Our participants’ anxiety about the persistence and origin of their symptoms often led to "hospital shopping," where they sought care at a hospital where they had not undergone their initial operation. Hospital shopping decreases when an accurate diagnosis is made or when the counseling is satisfactory [30]. Due to the lack of satisfactory educational, counseling support, and treatment at the hospital where they underwent surgery, our participants continued hospital shopping long after their postoperative follow-up appointments. This un-derscores the critical impact of unmet needs on fostering distrust and uncertainty towards healthcare institutions, as patients navigate their recovery journey feeling un-supported and uninformed. Therefore, to ensure continuity of care even after surgery, we suggest building a program using tailored artificial intelligence or establishing a hotline to provide patients with information and support in a timely manner [31,32].
Orthopedic patients, such as fear moving due to pain and hesitancy in walking outside due to the risk of falling experienced changes in their lives after surgery [18,33]. Patients preferred continued professional supportive care, such as consultation and physical therapy [12]. However, unresolved postoperative barriers and fear made our participants shrink in facing their lives and changing their lifestyle. Therefore, it is important that the team of healthcare providers, including doctors, nurses, and physical therapists, focus on long-term care as well as acute postoperative care. It is needed to provide effectiveness of tailored post-lumbar spine surgery planning of moving from a hospital that can provide optimal help by considering the patient's condition and characteristics during admission [34]. Nurse navigators monitor symptom management, track medical procedures and outcomes, ensure fol-low-up on referrals, provide self-care guidance, and support patients in maintaining daily life and social activities, ensuring continuity of care and recovery [15]. Applying the navigator to older adult patients who underwent TKR surgery could improve patient satisfaction and experience [16]. As such, it may also be necessary to apply the navigator program for older adult patients who underwent lumbar spine surgery to provide professional counseling and improve recovery.
Persistent postoperative complications forced older adult patients to come to terms with and accept the reality of living with certain disabilities and discomforts. Over time, they recognized the critical importance of lifelong management to maintain their quality of life and mitigate these ongoing issues. This profound understanding em-powered them to take a more active role in their care, moving beyond passive reliance on medical professionals. They obtained information about postoperative management through other resources, such as other patients in the outpatient clinic, websites, and YouTube, and found their self-management method [12]. Health care providers should empower older adult patients by offering self-management strategies that leverage a variety of resources and correct information, enabling them to take an active role in their own care and recovery process. By doing so, older adult patients can better navigate the complexities of their postoperative journey and improve their overall well-being.
1. Limitations
This study has several limitations. First, our study is a qualitative study that analyzed the postoperative experience of 10 older adult patients recruited using the snowball sampling method, and included only those who had undergone lumbar spine surgery. Second, the time since participant's lumbar spine surgeries ranged from 1 year to over 7 years go. thus, it is suggested that the older adult patient's experience be revealed by subdividing it by the period in the future.
CONCLUSION
The findings highlight that unmet informational needs, persistent postoperative symptoms, and inadequate support can lead to psychological distress, distrust in healthcare providers, and maladaptive coping behaviors such as hospital shopping in older adult patients undergoing lumbar surgery. Additionally, older adult patients gradually adopt self-management and accept lifestyle changes as part of their long-term adaptation. These insights contrib-ute to a holistic understanding of postoperative care in older adult patients, underscoring the need for personalized and continuous support beyond the acute care phase. To provide customized intervention, continuous follow-up is required, such as overseeing long-term postoperative symptoms and outcomes, providing self-care guid-ance, and supporting older adult patients in their daily lives, rather than only focusing on the acute phase after lumbar spine surgery.
Notes
CONFLICTS OF INTEREST
The authors declared no conflict of interest.
AUTHORSHIP
Conceptualization or/and Methodology - Baek W, Suh Y and Lee H; Data curation or/and Analysis - Baek W, Suh Y and Lee H; Funding acquisition - Baek W; Investigation - Baek W; Project ad-ministration or/and Supervision - Baek W, Suh Y and Lee H; Resources or/and Software - Baek W, Suh Y and Lee H; Validation - Baek W, Suh Y and Lee H; Writing (original draft) - Baek W, Suh Y and Lee H; Writing (review & editing) - Baek W, Suh Y and Lee H.
DATA AVAILABILITY
Please contact the corresponding author for data availability.