Is Pain Relief Enough? Early Response Discordance After Lumbar Decompressive Surgery: A Prospective Cohort Study

Is Pain Relief Enough? 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Early Response Discordance After Lumbar Decompressive Surgery: A Prospective Cohort Study Tomasz Szczepański, Marta Koźba-Gosztyła, Anastasija Krzemińska, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9065140/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Different patient-reported outcome measures (PROMs) may classify the same patient differently as a treatment responder after lumbar decompressive surgery. We aimed to quantify inter-instrument agreement on minimal clinically important difference (MCID)-based responder status at one month postoperatively, characterize multi-dimensional response discordance, and identify residual health dimensions independently driving patient dissatisfaction. Methods In this prospective observational cohort study, 158 consecutive adults undergoing lumbar decompressive surgery for disc herniation (n = 77) or spinal stenosis (n = 81) at a single neurosurgical center were enrolled. Of these, 134 (84.8%) completed paired baseline and one-month assessments using the Visual Analogue Scale for leg pain (VAS), Oswestry Disability Index (ODI), and EQ-5D-5L utility index. MCID thresholds were derived from external sources (VAS ≥1.5 points, ODI ≥10 points, EQ-5D-5L ≥0.10). Inter-instrument agreement was quantified using Cohen's kappa (κ). Patient dissatisfaction was defined by the Spine Surgery Satisfaction Questionnaire (SSSQ > 12). Independent predictors of dissatisfaction were identified by multivariable linear regression with bootstrapped confidence intervals. Results All instruments showed significant improvement at one month (all p < 0.001). MCID-based responder rates differed markedly: VAS 82.1%, EQ-5D-5L 83.6%, and ODI 54.5%. Inter-instrument agreement was slight to fair (κ = 0.19–0.29); Only 47.0% of patients achieved MCID across all three instruments simultaneously, while 94.0% achieved it on at least one — producing a 47-percentage-point disagreement zone (Figure 2). Pain and/or quality-of-life improvement without corresponding functional improvement (Type A discordance) affected 39.6% of patients. Twenty-three percent of patients were dissatisfied at one month. In multivariable regression (R² = 0.34), residual mobility limitation (β = 0.77; p = 0.006) and depression/anxiety (β = 0.81; p = 0.005) were independent predictors of dissatisfaction; residual pain was not significant. Conclusions Instrument selection alone changes responder classification rates by nearly 30 percentage points at one month after lumbar decompressive surgery. Dissatisfaction is driven by residual functional limitation and psychological distress, not residual pain. Multi-dimensional PROM assessment with diagnosis-informed instrument selection should be standard practice at the early postoperative visit to identify patients requiring targeted rehabilitation and psychological support. Trial registration Not applicable lumbar decompression patient-reported outcome measures minimal clinically important difference response discordance Oswestry Disability Index EQ-5D-5L visual analogue scale spinal stenosis disc herniation outcome assessment Figures Figure 1 Figure 2 BACKGROUND Patient-reported outcome measures (PROMs) are the standard for evaluating surgical benefit in lumbar degenerative spine surgery. Instruments such as the Visual Analogue Scale (VAS) for pain, the Oswestry Disability Index (ODI) for function, and the EQ-5D-5L for health-related quality of life are used to determine whether a patient has achieved a clinically meaningful improvement, typically by applying a minimal clinically important difference (MCID) threshold. The implicit assumption underlying this practice is that different instruments classify the same patients as treatment responders — that a patient who improves in pain also improves in function and quality of life [ 1 ]. This assumption has been challenged. Wertli et al. [ 2 ] demonstrated in a cohort of 466 patients with lumbar spinal stenosis that the prevalence of patients fulfilling MCID criteria ranged from 40% to 70% depending on the instrument, with inter-instrument agreement of only κ = 0.24–0.50 (fair to moderate). Mannion et al. [ 3 ] reported 22% individual-level disagreement between ODI and COMI responder status (κ = 0.56) in 3 324 patients. These findings suggest that pain, function, and quality of life may represent distinct recovery trajectories rather than a single unitary outcome. However, no study has systematically characterised the pattern, directionality, and clinical predictors of this inter-instrument discordance, nor has any study compared discordance patterns between disc herniation and spinal stenosis. Recovery after lumbar decompressive surgery is a multi-dimensional process that unfolds over 12 to 24 months, but the rate of improvement differs substantially across outcome domains. The Spine Patient Outcomes Research Trial (SPORT) demonstrated that surgical patients with disc herniation achieved approximately 96% of their eventual 8-year pain improvement (SF-36 Bodily Pain) within the first 3 months, with little further gain thereafter [ 33 , 34 ]; for spinal stenosis, a significant surgical advantage emerged by 3 months and was maintained at 2 years [ 35 ]. The Spine Tango registry (n = 4 287) confirmed this temporal pattern at finer resolution: the dominant recovery phase occurred from preoperatively to 3 months (COMI change 3.6 ± 2.8 points), with only a small additional gain from 3 to 12 months (0.3 ± 2.4 points) and no further significant change from 12 to 60 months [ 36 ]. The Swedish Spine Register equivalence study (n ≈ 98 700) corroborated that the proportion of patients reaching minimal important change on VAS, ODI, and EQ-5D differed by less than 2% between 1- and 2-year follow-up, establishing that PROMs stabilise after 12 months [ 37 ]. Critically, however, these aggregate trajectories mask a fundamental domain-specific asymmetry. DeVine et al. [ 38 ] showed in a systematic review that pooled effect sizes after lumbar surgery were largest for pain (VAS: 1.4 ± 0.57), intermediate for function (ODI: 1.1 ± 0.39), and smallest for quality of life (EQ-5D: 0.78 ± 0.12), with no inter-domain correlation exceeding ρ = 0.70 — confirming that these instruments measure genuinely distinct constructs that recover at different rates. This differential responsiveness translates into measurable clinical discordance at early timepoints: Asher et al. [ 39 ] reported in the N2QOD registry (n = 3 073) that 23% of patients were discordant for MCID achievement on the ODI between 3 and 12 months, and that substantial clinical benefit rose from 51% at 3 months to 61% at 12 months — a 10-percentage-point increase representing continued functional improvement well after pain relief had plateaued. These converging lines of evidence indicate that the first postoperative clinical contact — typically at 4 to 6 weeks — occupies a unique position in the recovery continuum: the acute surgical effects have resolved, the majority of pain improvement has already occurred, but functional reconditioning and psychological adaptation are still unfolding. This creates the biological and psychometric conditions under which different PROMs may yield discordant classifications of the same patient, and the clinical conditions under which such discordance, if identified, remains modifiable through targeted rehabilitation and psychological support. Understanding whether and how this asymmetry manifests as measurable inter-instrument discordance at the first postoperative visit is therefore essential for directing early care — yet no study has systematically characterised these patterns at this timepoint. We therefore aimed to: (1) quantify the inter-instrument agreement between pain (VAS), function (ODI), and quality of life (EQ-5D-5L index) on MCID-based responder status at 1 month after lumbar degenerative spine surgery; (2) determine whether discordance patterns differ between disc herniation and spinal stenosis; and (3) identify residual health dimensions that independently drive patient dissatisfaction and should be prioritised in early postoperative rehabilitation. Materials Study design and setting This work represents a secondary analysis of data from the PROGRES study ( Evaluation of the natural course of lumbar degenerative spine disease and factors influencing its progression, with an analysis of the impact of surgical intervention as a modifying factor in the long-term course of the disease – prospective observational study ), an ongoing prospective observational cohort study conducted at the Neurosurgical Department of the 4th Military Clinical Hospital in Wrocław, Poland. The PROGRES study employs a cohort design to evaluate the natural history and clinical outcomes of lumbar degenerative disease before and after surgical treatment. The present analysis uses preoperative assessment data and 1-month postoperative follow-up data collected between May 2025 and December 2025. The study is purely observational, involving the analysis of clinical, imaging, and patient-reported outcome data without any intervention in the diagnostic or therapeutic process. The research protocol was developed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cohort studies (Supplementary checklist). Participants Consecutive adult patients hospitalised at the Neurosurgical Department with a confirmed diagnosis of lumbar degenerative disease were screened for eligibility. Lumbar degenerative disease encompassed two primary diagnoses: lumbar spinal stenosis and lumbar disc herniation. Inclusion criteria were as follows: age between 18 and 90 years, clinically relevant degenerative changes of the lumbar spine confirmed by magnetic resonance imaging (MRI), ability to participate in long-term follow-up assessments, provision of written informed consent, and cognitive status sufficient to understand the purpose and methods of the study and complete questionnaires. Exclusion criteria included the following: history of previous spinal surgery; spinal neoplasms; neurological or muscular diseases causing motor function impairment (e.g., amyotrophic lateral sclerosis, multiple sclerosis, or myopathies); and inability to participate in long-term observation due to severe chronic illness with limited life expectancy. Between May and December 2025, determination of eligibility was conducted by a trained team comprising spine surgeons and clinical research coordinators. Following clinical assessment, all eligible patients completed standardized questionnaires on the day of hospital admission, prior to the consultation during which the surgical treatment plan and operative approach were discussed. All patients were informed about the study process and methods and about their right to withdraw at any time. Ethics The study protocol was approved by the Bioethics Committee of the Lower Silesian Medical Chamber in Wrocław (approval number: 09/DOBD/2025, date: April 9, 2025). The study was conducted in accordance with the tenets of the Declaration of Helsinki and its subsequent amendments. All participants provided written informed consent prior to enrolment. Participants were informed of their right to withdraw from the study at any time without consequences for their medical care. Data were anonymised and stored securely in compliance with applicable data protection regulations. Outcome measures PROMs were collected at baseline (preoperative, on the day of hospital admission) and at 1 month postoperatively. Pain intensity was assessed using VAS for leg pain and back pain (0–10 scale). Functional disability was measured using the ODI (0–100 scale). Health-related quality of life was assessed with the EQ-5D-5L, converted to a utility index using the Polish value set (Golicki et al. [4]). Patient satisfaction was assessed at follow-up using the Spine Surgery Satisfaction Questionnaire (SSSQ) satisfaction subscale as an external criterion independent of the PROMs under study; dissatisfaction was defined as SSSQ > 12 [5]. MCID thresholds and responder definition MCID thresholds were derived from published external literature and were not estimated within this cohort, thereby avoiding circularity with the SSSQ-based satisfaction criterion. The primary analysis used moderate thresholds: VAS leg pain ≥1.5 points [6], ODI ≥10 points [7], and EQ-5D-5L index ≥0.10 [8]. These thresholds are consistent with pathology-specific estimates from the Canadian Spine Outcomes and Research Network (CSORN) registry, in which Power et al. [31] reported MCID values for ODI change ranging from −10.0 to −16.9 depending on lumbar pathology, supporting our use of the moderate ≥10-point threshold as a balanced estimate across diagnostic groups. Sensitivity analyses were conducted at liberal (VAS ≥1.0, ODI ≥6, EQ-5D-5L ≥0.05) and conservative (VAS ≥2.0, ODI ≥12, EQ-5D-5L ≥0.15) thresholds. Statistical analysis Baseline characteristics were compared between diagnostic groups using Mann–Whitney U tests and chi-square tests. Within-group change was assessed by Wilcoxon signed-rank test; effect sizes are reported as Cohen’s d. Inter-instrument agreement on MCID-based responder status was quantified using Cohen’s kappa (κ), supplemented by overall percent agreement, specific positive agreement (Ppos), and specific negative agreement (Pneg) to address the known prevalence paradox of κ [9]. Kappa was interpreted according to Landis and Koch (1977): <0.20 slight, 0.21–0.40 fair, 0.41–0.60 moderate [10]. Multi-dimensional response discordance was defined as achieving MCID in pain and/or quality of life but not in function (Type A) or in function but not in pain/quality of life (Type B). Criterion validity of each PROM against SSSQ satisfaction was assessed via Spearman correlations and ROC analysis with 2 000-iteration bootstrap 95% confidence intervals. Independent predictors of dissatisfaction were identified by multivariable linear regression with SSSQ as the dependent variable; model stability was assessed via bootstrapped confidence intervals. With 31 events (dissatisfied patients) and a maximum of 5 predictors evaluated, the events-per-variable ratio (6.2) was sufficient for exploratory modelling but limits generalisability. Analyses were performed in Python 3.11 (SciPy, scikit-learn). Statistical significance was set at p < 0.05. Results Patient flow and baseline characteristics Of 161 patients screened, 3 were excluded (did not undergo surgery). Of 158 operated patients (disc herniation n = 77; spinal stenosis n = 81), 134 (84.8%) completed the 1-month follow-up with full paired data; 24 (15.2%) had incomplete follow-up. Lost patients did not differ in age (56.8 ± 16.0 vs. 60.2 ± 14.5; p = 0.259) or baseline VAS leg (6.8 vs. 6.7; p = 0.692), though baseline ODI was marginally higher (32.7 vs. 29.7; p = 0.035). The analysed cohort (n = 134) had a mean age of 60.2 ± 14.5 years (range 24–86), 58.2% were female. Stenosis patients were significantly older than disc herniation patients (66.8 ± 9.7 vs. 52.1 ± 15.4; p 0.18) (Table 1 ). Table 1 Baseline characteristics of the study cohort stratified by primary diagnosis. Variable Disc herniation (n = 59) Spinal stenosis (n = 75) Total (n = 134) p-value Demographics Age, years; mean ± SD (range) 51.9 ± 15.5 (27–75) 66.7 ± 9.6 (36–81) 60.2 ± 14.5 (27–81) < 0.001 a Sex, female; n (%) 33 (55.9%) 47 (62.7%) 80 (59.7%) 0.541 b Education level; n (%) None 5 (8.5%) 0 (0.0%) 5 (3.7%) Primary 2 (3.4%) 3 (4.0%) 5 (3.7%) Vocational 12 (20.3%) 17 (22.7%) 29 (21.6%) Secondary 24 (40.7%) 36 (48.0%) 60 (44.8%) Higher 16 (27.1%) 19 (25.3%) 35 (26.1%) 0.141 b Baseline patient-reported outcome measures; mean ± SD VAS Leg Pain (0–10) 6.8 ± 2.4 6.7 ± 2.9 6.7 ± 2.7 0.831 a VAS Back Pain (0–10) 5.7 ± 2.9 5.8 ± 3.0 5.8 ± 2.9 0.780 a ODI total (0–100) 30.5 ± 7.9 29.1 ± 6.6 29.7 ± 7.2 0.355 a EQ-5D-5L index (− 0.59–1.00) c 0.42 ± 0.28 0.42 ± 0.27 0.42 ± 0.28 0.886 a EQ-5D-5L sum score (5–25) 14.7 ± 3.6 14.5 ± 3.4 14.6 ± 3.5 0.886 a SD = standard deviation; VAS = Visual Analogue Scale; ODI = Oswestry Disability Index; EQ-5D-5L = EuroQol five-dimension five-level instrument. a Mann–Whitney U test. b Chi-square test. c EQ-5D-5L utility index computed using the Polish population-based value set (Golicki et al., PharmacoEconomics 2019). Significance threshold: p < 0.05. Values in bold indicate statistically significant differences. Table 1 . Baseline characteristics of the study cohort stratified by primary diagnosis. Data are presented as mean ± standard deviation for continuous variables and as number (percentage) for categorical variables. p-values refer to between-diagnosis comparisons (Mann–Whitney U test for continuous variables; chi-square test for categorical variables). The EQ-5D-5L utility index was computed using the Polish population-based value set (Golicki et al., PharmacoEconomics 2019). SD = standard deviation; VAS = Visual Analogue Scale; ODI = Oswestry Disability Index. Early postoperative improvement All instruments showed significant improvement at 1 month (all p < 0.001). VAS leg pain decreased from 6.7 ± 2.7 to 2.0 ± 2.6 (mean change 4.7 ± 3.5; Cohen’s d = 1.36; 70% relative improvement), EQ-5D-5L index increased from 0.42 ± 0.28 to 0.80 ± 0.16 (Δ = 0.38 ± 0.29; d = 1.30), and ODI decreased from 29.7 ± 7.2 to 19.9 ± 6.5 (Δ = 9.8 ± 9.6; d = 1.02; 33% relative improvement). The asymmetry in recovery rates was evident: pain improved twice as fast (70%) as function (33%). MCID-based responder rates at moderate thresholds were: VAS leg 82.1%, EQ-5D-5L 83.6%, and ODI 54.5%. Responder rates for pain and quality of life were thus approximately 30 percentage points higher than for function. Inter-instrument agreement Cohen’s κ for pairwise agreement on responder status ranged from 0.19 to 0.29, indicating slight to fair agreement (Table 2 ). Overall percent agreement ranged from 61.9% (VAS vs. ODI) to 77.6% (VAS vs. EQ-5D-5L), but the high agreement for VAS–EQ-5D-5L largely reflected both instruments classifying patients as responders (Ppos = 0.87), with poor agreement on non-responders (Pneg = 0.35). Only 47.0% of patients achieved MCID across all three instruments simultaneously, while 94.0% achieved it on at least one — producing a 47-percentage-point disagreement zone (Fig. 1 ). This pattern was stable across all MCID threshold levels (κ range 0.15–0.31; disagreement zone 33.6–53.0%). Table 2 Inter-instrument agreement on MCID-based responder status (moderate thresholds). Statistic VAS Leg Pain vs ODI VAS Leg Pain vs EQ-5D-5L ODI vs EQ-5D-5L Responder rates (MCID achieved); n (%) Instrument A responders 110 (82.1%) 110 (82.1%) 73 (54.5%) Instrument B responders 73 (54.5%) 112 (83.6%) 112 (83.6%) 2 × 2 responder classification matrix; n Both responders (R / R) 66 96 70 Instrument A responder only (R / NR) 44 14 3 Instrument B responder only (NR / R) 7 16 42 Neither responder (NR / NR) 17 8 19 Agreement statistics Overall percent agreement (%) 61.9% 77.6% 66.4% Cohen's κ [95% CI] a 0.19 [0.06–0.32] 0.21 [0.08–0.34] 0.29 [0.15–0.42] Interpretation b Slight Slight Fair Specific agreement indices (addressing prevalence paradox) c Specific positive agreement (Ppos) 0.72 0.87 0.76 Specific negative agreement (Pneg) 0.40 0.35 0.46 Prevalence index (PI) 0.24 0.55 0.33 Multi-dimensional concordance across all three instruments Concordant responders (MCID on all three); n (%) 63 (47.0%) — — Disagreement zone (MCID on ≥ 1 but not all); n (%) 63 (47.0%) — — No MCID on any instrument; n (%) 8 (6.0%) — — Inter-instrument disagreement range (pp) d 28.3 pp — — MCID = minimal clinically important difference; VAS = Visual Analogue Scale (leg pain); ODI = Oswestry Disability Index; EQ-5D-5L = EuroQol five-dimension five-level utility index; pp = percentage points; R = responder; NR = non-responder; PI = prevalence index; Ppos = specific positive agreement; Pneg = specific negative agreement. a 95% confidence intervals estimated by bootstrap (2 000 iterations). b Interpreted according to Landis & Koch (1977): κ < 0.20 = slight; 0.21–0.40 = fair. c Ppos = 2a / (2a + b + c); Pneg = 2d / (2d + b + c); PI = (a + d − b − c) / n. Reported to address the known prevalence paradox of κ (Feinstein & Cicchetti, 1990). d Difference between the highest (EQ-5D-5L, 83.6%) and lowest (ODI, 54.5%) responder rates. Pairwise columns for the multi-dimensional concordance rows apply to the overall three-instrument analysis and are therefore not disaggregated by pair (—). MCID thresholds (moderate): VAS Leg Pain ≥ 1.5 points; ODI ≥ 10 points; EQ-5D-5L index ≥ 0.10. n = 134. Table 2 . Inter-instrument agreement on MCID-based responder status at 1-month follow-up (moderate thresholds; n = 134). Cohen's κ interpreted per Landis & Koch (1977). Ppos, Pneg, and PI reported to address the prevalence paradox of κ. MCID thresholds: VAS Leg Pain ≥ 1.5 pts; ODI ≥ 10 pts; EQ-5D-5L index ≥ 0.10. CI = confidence interval; NR = non-responder; ODI = Oswestry Disability Index; R = responder; VAS = Visual Analogue Scale.) — see Tables file. Multi-dimensional response discordance Pain/quality-of-life versus function discordance occurred in 39.6% of patients, exclusively as Type A: pain and/or QoL improved while function did not. The reverse pattern (Type B) did not occur in any patient. Type A discordance was numerically more prevalent in spinal stenosis (45.3%) than disc herniation (32.2%), though this did not reach statistical significance (OR = 1.75; p = 0.155). Dissatisfied patient profile Thirty-one patients (23.1%) were dissatisfied. They were significantly older (66.7 ± 12.0 vs. 58.2 ± 14.6 years; p = 0.002), but baseline PROM scores were identical to those of satisfied patients across all instruments (all p > 0.19; Table 3 ). Dissatisfaction arose from insufficient improvement rather than worse initial status: VAS leg improved by 49% in dissatisfied vs. 76% in satisfied patients, EQ-5D-5L index Δ = 0.34 vs. 0.40, and ODI by only 17% vs. 38%. The asymmetry was most pronounced for function. Table 3 Baseline and postoperative characteristics of satisfied and dissatisfied patients. Variable Satisfied (n = 103) Dissatisfied (n = 31) p-value Demographics Age, years; mean ± SD 58.2 ± 14.6 66.7 ± 12.0 0.002 a Sex, female; n (%) 64 (62.1%) 16 (51.6%) 0.494 b Spinal stenosis; n (%) 56 (54.4%) 19 (61.3%) 0.880 b SSSQ score; mean ± SD 8.8 ± 2.2 14.2 ± 1.7 < 0.001 a Baseline patient-reported outcome measures; mean ± SD VAS Leg Pain (0–10) 6.9 ± 2.4 6.1 ± 3.3 0.309 a VAS Back Pain (0–10) 5.8 ± 2.9 5.6 ± 3.0 0.826 a ODI total (0–100) 29.9 ± 7.2 29.4 ± 7.3 0.796 a EQ-5D-5L sum score (5–25) 14.4 ± 3.3 15.0 ± 4.1 0.486 a 1-month follow-up patient-reported outcome measures; mean ± SD VAS Leg Pain (0–10) 1.7 ± 2.4 3.1 ± 3.2 0.015 a VAS Back Pain (0–10) 2.0 ± 2.3 3.3 ± 3.1 0.060 a ODI total (0–100) 18.6 ± 6.0 24.4 ± 5.8 < 0.001 a EQ-5D-5L sum score (5–25) 7.3 ± 2.2 10.5 ± 3.3 < 0.001 a Change scores (baseline → 1 month); mean ± SD ΔVAS Leg Pain 5.3 ± 3.3 3.0 ± 3.7 0.002 a ΔVAS Back Pain 3.7 ± 3.5 2.4 ± 3.6 0.059 a ΔODI (decrease = improvement) 11.3 ± 9.3 5.0 ± 9.0 0.001 a ΔEQ-5D-5L sum score (decrease = improvement) −7.1 ± 3.9 −4.5 ± 4.8 0.001 a Relative improvement — VAS Leg Pain (%) 75.6% 35.0% — c Relative improvement — ODI (%) 33.7% 12.0% — c MCID-based responder rates at 1 month; n (%) d VAS Leg Pain responders (≥ 1.5 pts) 90 (87.4%) 20 (64.5%) 0.005 b ODI responders (≥ 10 pts) 63 (61.2%) 10 (32.3%) 0.006 b EQ-5D-5L responders (≥ 0.10 index) e 79 (76.7%) 22 (71.0%) 0.516 b Concordant responders (VAS + ODI); n (%) 57 (55.3%) 9 (29.0%) 0.009 b Residual symptom profile at 1 month in dissatisfied patients; n (%) No residual leg pain (VAS = 0) — 12 (38.7%) — Moderate functional disability (ODI 21–40) — 22 (71.0%) — EQ-5D-5L: mobility problems (score > 1) — 18 (58.1%) — EQ-5D-5L: depression / anxiety (score > 1) — 19 (61.3%) — Dissatisfaction defined as SSSQ satisfaction subscale score > 12. Significant p-values (p < 0.05) are shown in red. MCID = minimal clinically important difference; ODI = Oswestry Disability Index; SD = standard deviation; SSSQ = Spine Surgery Satisfaction Questionnaire; VAS = Visual Analogue Scale. a Mann–Whitney U test. b Chi-square test. c Relative improvement not tested statistically due to zero baseline values in a subset of patients. d MCID thresholds (moderate): VAS Leg Pain ≥ 1.5 pts; ODI ≥ 10 pts; EQ-5D-5L utility index ≥ 0.10. e EQ-5D-5L responder rate estimated from utility index change; computed using the Polish value set (Golicki et al., 2019). — Not applicable (statistic reported for dissatisfied group only or not calculated). Table 3 . Baseline and postoperative characteristics of satisfied and dissatisfied patients at 1-month follow-up. Dissatisfaction defined as SSSQ satisfaction subscale score > 12. Data are presented as mean ± SD for continuous variables and as n (%) for categorical variables. Significant p-values (p < 0.05) are highlighted. MCID thresholds (moderate): VAS Leg Pain ≥ 1.5 pts; ODI ≥ 10 pts; EQ-5D-5L index ≥ 0.10. MCID = minimal clinically important difference; ODI = Oswestry Disability Index; SD = standard deviation; SSSQ = Spine Surgery Satisfaction Questionnaire; VAS = Visual Analogue Scale. MCID-based responder rates in dissatisfied patients were: VAS leg 64.5%, EQ-5D-5L 71.0%, but ODI only 32.3%. Concordant response across all three instruments was achieved by 29.0% of dissatisfied vs. 52.4% of satisfied patients. The residual symptom profile of dissatisfied patients was notable: 38.7% reported no leg pain (VAS = 0) at follow-up, yet 71.0% maintained moderate functional disability (ODI 21–40). At the EQ-5D-5L dimension level, 77.4% still reported pain/discomfort, 61.3% depression/anxiety, and 58.1% mobility problems. Independent predictors of dissatisfaction In multivariable linear regression (R² = 0.34), only two EQ-5D-5L dimensions at follow-up were independent predictors of satisfaction level: residual mobility limitation (β = 0.77; p = 0.006) and depression/anxiety (β = 0.81; p = 0.005). Residual VAS leg pain, VAS back pain, and ODI subscale scores were not significant after controlling for mobility and depression. Bootstrapped 95% confidence intervals confirmed the stability of both predictors; the full coefficient plot with 95% CIs for all candidate variables is presented in Fig. 2 . Diagnosis-specific patterns Criterion validity differed by diagnosis: in disc herniation, ODI (AUC = 0.741) and VAS leg (0.721) best identified dissatisfied patients. In spinal stenosis, EQ-5D-5L index showed the strongest correlation with satisfaction (rho = − 0.440, p < 0.001), though ODI remained the best discriminator overall (AUC = 0.643). Discussion Principal findings This study demonstrates that after lumbar degenerative spine surgery, pain, functional disability, and health-related quality of life recover at fundamentally different rates within the first postoperative month. This temporal asynchrony produces a multi-dimensional response discordance in which each PROM identifies a different subset of patients as treatment responders at the same timepoint. Inter-instrument agreement on MCID-based responder status was only slight to fair (κ = 0.19–0.29), nearly half of patients fell into an inter-instrument disagreement zone, and four in ten patients showed the characteristic Type A discordance pattern: pain and quality of life improved while function lagged behind. The reverse pattern did not occur, implying a hierarchical recovery progression in which sensory pain relief precedes meaningful gains in physical mobility [ 14 , 15 ]. Most importantly, dissatisfaction at 1 month was independently driven by residual mobility limitation and depression/anxiety — not by residual pain — suggesting that early postoperative care should shift from a pain-centric paradigm toward targeted functional rehabilitation and psychological screening. Comparison with prior literature Our findings extend and refine the observations of Wertli et al. [ 2 ], who reported κ = 0.24–0.50 for inter-instrument MID agreement in 466 stenosis patients at 6 months. We confirm their conclusion that instrument choice substantially affects outcome classification and add three new dimensions: a systematic discordance taxonomy (Type A/B), the finding that discordance is exclusively unidirectional at 1 month, and the identification of mobility and depression as the specific residual dimensions driving dissatisfaction. The higher disagreement in our study (κ = 0.19–0.29 vs. 0.24–0.50) is expected at an earlier timepoint when recovery trajectories across domains are most divergent. Mannion et al. [ 3 ] reported κ = 0.56 for ODI–COMI agreement at 12 months, again suggesting that inter-instrument agreement improves as recovery progresses and outcome domains converge. This temporal gradient of concordance — from slight at 1 month to moderate at 6 months to good at 12 months — is consistent with our interpretation that the observed discordance represents differential recovery kinetics rather than a permanent measurement artefact. Several trajectory-modelling studies corroborate this interpretation, reporting that different domains may reach MCID at different timepoints across the first postoperative year [ 15 – 18 ]. In particular pain measures frequently show early improvement after decompression, whereas functional indices lag behind, contributing to the asymmetric discordance pattern we observed [ 15 , 19 ]. Kowalski et al. [ 18 ] have highlighted that physical functioning is multidimensional and necessitates evaluation with measures beyond PROMs alone, further supporting the view that function and pain represent distinct constructs with independent recovery timelines. The finding that residual pain does not independently predict dissatisfaction once mobility and depression are accounted for aligns with the growing recognition that psychological distress and functional limitation are central to patient experience after spine surgery [ 11 , 12 ]. Preoperative and postoperative mental health states have been shown to influence satisfaction and recovery trajectories independently of pain intensity [ 20 – 24 ], and depressive symptoms may mediate dissatisfaction even when pain has substantially improved [ 23 – 26 ]. Yamamoto et al. [ 30 ] demonstrated that preoperative anxiety (HADS score ≥ median) was a significant predictor of dissatisfaction after lumbar decompression for spinal stenosis (OR = 3.95), while pain catastrophising and fear-avoidance beliefs were not, emphasising the primacy of mood-related factors over pain processing in determining satisfaction. Our results provide a mechanistic rationale for this observation through the lens of the Type A discordance pattern: pain-sensitive instruments detect early improvement from neural decompression, while function-sensitive instruments capture the slower process of musculoskeletal reconditioning. Across decompression cohorts, MCID attainment and patient satisfaction can diverge substantially, reflecting these multi-domain recovery patterns and unmet patient expectations [ 17 , 27 ]. Strengths and limitations Strengths of this study include its prospective design within the context of an ongoing structured cohort study (PROGRES), the simultaneous assessment of four PROM families covering complementary outcome domains, the use of the Polish EQ-5D-5L value set (Golicki et al. [ 4 ]) appropriate for the study population, externally-derived MCID thresholds — corroborated by the large CSORN registry data [ 31 ] — avoiding anchor circularity, and the inclusion of both major lumbar degenerative pathologies enabling direct comparison. Reporting of supplementary agreement statistics (Ppos, Pneg, prevalence index) alongside κ addresses the known prevalence paradox of the kappa statistic [ 9 ]. Several limitations must be acknowledged. First, the 1-month follow-up captures an early recovery snapshot rather than the definitive surgical outcome. The observed discordance likely reflects — at least in part — the natural temporal asymmetry between immediate pain relief from decompression and slower functional reconditioning; whether it persists at 3 or 12 months remains a critical question for future research. Multiple trajectory studies confirm that pain, function, and quality of life follow asynchronous courses in the early postoperative period [ 15 – 18 ], supporting the view that a single PROM at 1 month is insufficient to capture the full recovery landscape. Second, the sample size (n = 134; 31 dissatisfied) limits the regression analysis to exploratory status (EPV = 6.2); external validation in a larger cohort is warranted. Third, lost-to-follow-up patients (15.2%) had marginally higher baseline ODI, potentially introducing attrition bias toward less disabled patients. Fourth, complications were not systematically captured with a standardised adverse-event protocol, and we cannot exclude the possibility that unreported minor events contributed to dissatisfaction. Fifth, the inter-instrument kappa values should be interpreted with the awareness that VAS, ODI, and EQ-5D-5L measure different constructs by design; low agreement between conceptually distinct instruments is expected from a measurement theory perspective (Campbell and Fiske multitrait–multimethod framework [ 13 ]). The clinical relevance of our findings lies not in the kappa values per se but in the practical consequences for patient classification and care decisions. Finally, the deliberate movement restriction commonly observed during the initial six to eight weeks post-surgery may partly reflect patient compliance with postoperative precautions rather than a genuine spine-related mobility deficit [ 28 ], which should be considered when interpreting early ODI scores. Implications for clinical practice These findings carry three direct implications for early postoperative care. First, relying on a single PROM at the 1-month visit provides an incomplete and potentially misleading picture of recovery: a patient who is a “responder” on VAS may not be a responder on ODI, and vice versa. Multi-dimensional assessment — covering at minimum pain, function, and quality of life — is necessary to identify the 47% of patients who fall into the inter-instrument disagreement zone. Instrument selection should be diagnosis-informed: ODI and VAS leg for disc herniation, EQ-5D-5L for spinal stenosis. Second, since baseline PROM scores do not distinguish patients who will become dissatisfied, prospective identification of at-risk patients requires assessment at the 1-month visit rather than reliance on preoperative profiles. Screening for mobility limitation and depression/anxiety at this timepoint should be considered, given their independent predictive value. Implementing multi-domain modelling is critical because singular instruments such as the ODI may fail to explain up to 50% of the variability observed in broader health domains during the recovery period [ 29 ]. Third, for the 39.6% of patients who show Type A discordance (pain improved, function not), additional analgesia is unlikely to improve satisfaction. Hambrecht et al. [ 32 ] recently demonstrated that disaggregated ODI subsections for walking (AUC = 0.83) and personal care (AUC = 0.82) were the strongest predictors of patient satisfaction after lumbar surgery, corroborating our finding that mobility — not pain intensity — is the primary driver of patient satisfaction at the individual domain level. Early rehabilitation should therefore emphasise rapid, targeted improvements in mobility and functional activities of daily living — gait training, transfers, core stability, and graduated activity programmes — consistent with the Type A discordance pattern in which functional rehabilitation should be foregrounded in early care [ 15 – 18 ]. The association between depression/anxiety and dissatisfaction further supports embedding short, scalable mood screening (e.g., PHQ-9, GAD-7, or HADS) with timely mental health referral into the early postoperative pathway [ 20 , 22 , 23 , 25 , 26 , 30 ]. Such integrated behavioural health strategies can mitigate mood-related dissatisfaction and support engagement in functional rehabilitation. Conclusions At 1 month after lumbar degenerative spine surgery, pain and quality of life recover substantially faster than function, creating a multi-dimensional response discordance that affects four in ten patients. Different PROMs agree on responder status in fewer than half of patients (κ = 0.19–0.29). Dissatisfaction is driven by residual mobility limitation and depression, not by residual pain. The 1-month visit provides a critical window for identifying patients who require targeted functional rehabilitation and psychological support. Multi-dimensional PROM assessment at this timepoint, with diagnosis-specific instrument selection, should become standard in postoperative care pathways for lumbar degenerative spine disease. Abbreviations AUC Area under the receiver operating characteristic curve BMI Body mass index COMI Core Outcome Measures Index CONSORT Consolidated Standards of Reporting Trials CSORN Canadian Spine Outcomes and Research Network EPV Events per variable EQ-5D-5L EuroQol five-dimension five-level questionnaire GAD-7 Generalised Anxiety Disorder 7-item scale HADS Hospital Anxiety and Depression Scale MCID Minimal clinically important difference MCS Mental Component Summary MID Minimal important difference MRI Magnetic resonance imaging N2QOD National Neurosurgery Quality and Outcomes Database ODI Oswestry Disability Index OR Odds ratio PHQ-9 Patient Health Questionnaire 9-item scale Pneg Specific negative agreement Ppos Specific positive agreement PROGRES Prospective observational study of lumbar degenerative spine disease ( Evaluation of the natural course of lumbar degenerative spine disease and factors influencing its progression, with an analysis of the impact of surgical intervention as a modifying factor in the long-term course of the disease ) PROM Patient-reported outcome measure ROC Receiver operating characteristic SD Standard deviation SPORT Spine Patient Outcomes Research Trial SSSQ Spine Surgery Satisfaction Questionnaire STROBE Strengthening the Reporting of Observational Studies in Epidemiology TLIF Transforaminal lumbar interbody fusion VAS Visual Analogue Scale κ Cohen's kappa coefficient Declarations Ethics approval and consent to participate This study was approved by the Bioethics Committee of the Lower Silesian Medical Chamber in Wrocław, Poland (approval number: 09/DOBD/2025, date: 9 April 2025). The study was conducted in accordance with the principles of the Declaration of Helsinki and its subsequent amendments. All participants were informed of the study objectives and methods, and provided written informed consent prior to enrolment. Participants were informed of their right to withdraw from the study at any time without consequences for their medical care. Consent for publication Not applicable. This manuscript does not contain any individual person's data in any form that would allow identification of study participants. All data were fully anonymised prior to analysis. Competing interests The authors declare that they have no competing interests. Funding This research received no external funding. The study was conducted as part of the statutory research activity of the Neurosurgical Department of the 4th Military Clinical Hospital in Wrocław, Poland. No funding body had any role in the design of the study, collection, analysis, or interpretation of data, or in writing the manuscript. Authors' contributions Conceptualization: T.S., B.C. Data curation: A.K., M.K.G. Formal analysis: T.S. Investigation: T.S., M.K.G., A.K. Methodology: T.S., G.M. Project administration: T.S., M.K.G. Supervision: B.C., G.M. Validation: G.M. Writing – original draft: T.S. Writing – review & editing: M.K.G., G.M., B.C. All authors read and approved the final manuscript. Acknowledgements The authors wish to thank the staff of the Neurosurgical Department of the 4th Military Clinical Hospital in Wrocław for their support in patient recruitment and data collection. The authors also thank all patients who participated in the PROGRES study. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to patient privacy considerations and institutional data governance requirements. Anonymised data supporting the conclusions of this article are available from the corresponding author on reasonable request, subject to approval by the Bioethics Committee of the Lower Silesian Medical Chamber. References Ostelo RWJG, Deyo RA, Stratford P, et al. Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine 2008;33:90–94. Wertli MM, Buletti FC, Held U, et al. A comparison between different outcome measures based on “meaningful important differences” in patients with lumbar spinal stenosis. Eur Spine J 2016;26:450–461. Mannion AF, Elfering A, Fekete TF, et al. Development of a mapping function (“crosswalk”) for the conversion of scores between the ODI and the COMI. Eur Spine J 2022;31:3337–3346. Golicki D, Jakubczyk M, Graczyk K, Niewada M. Valuation of EQ-5D-5L health states in Poland: the first EQ-VT-based study in Central and Eastern Europe. PharmacoEconomics 2019;37:1165–1176. Mannion AF, Porchet F, Kleinstuck FS, et al. The quality of spine surgery from the patient’s perspective: Part 2. Eur Spine J 2009;18 Suppl 3:374–379. Copay AG, Glassman SD, Subach BR, et al. Minimum clinically important difference in lumbar spine surgery patients. Spine J 2008;8:968–974. Ostelo RWJG, de Vet HCW. Clinically important outcomes in low back pain. Best Pract Res Clin Rheumatol 2005;19:593–607. Solberg TK, Olsen J-A, Ingebrigtsen T, et al. Health-related quality of life assessment by the EuroQol-5D can provide cost-utility data in the field of low-back surgery. Eur Spine J 2005;14:1000–1007. Feinstein AR, Cicchetti DV. High agreement but low kappa: I. The problems of two paradoxes. J Clin Epidemiol 1990;43:543–549. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–174. Archer KR, Devin CJ, Vanston SW, et al. Cognitive-behavioral-based physical therapy for patients with chronic pain undergoing lumbar spine surgery: a randomized controlled trial. J Pain 2016;17:76–89. Abbott AD, Tyni-Lenne R, Hedlund R. Early rehabilitation targeting cognition, behavior, and motor function after lumbar fusion: a randomized controlled trial. Spine 2010;35:848–857. Campbell DT, Fiske DW. Convergent and discriminant validation by the multitrait-multimethod matrix. Psychol Bull 1959;56:81–105. Papuga MO, Mesfin A, Molinari RW, Rubery PT. Correlation of PROMIS Physical Function and Pain CAT instruments with Oswestry Disability Index and Neck Disability Index in spine patients. Spine 2016;41:1153–1159. doi: 10.1097/BRS.0000000000001518. Jacob KC, Patel MR, Pawlowski H, et al. Single-level TLIF versus LLIF at L4-5: a comparison of patient-reported outcomes and recovery ratios. J Am Acad Orthop Surg 2021;29:e1233–e1242. Hey HWD, Luo N, Chin CT, et al. The predictive value of preoperative health-related quality-of-life scores on postoperative patient-reported outcomes in lumbar spine surgery. Global Spine J 2017;7:617–624. Moorthy DP, Ong JY, Wee TC, et al. What preoperative factors are associated with achieving a clinically meaningful improvement and satisfaction after single-level transforaminal lumbar interbody fusion for degenerative spondylolisthesis? Global Spine J 2022;12:1574–1582. Kowalski KL, Mistry J, Beilin A, et al. Physical functioning in the lumbar spinal surgery population: a systematic review and narrative synthesis of outcome measures and measurement properties of the physical measures. PLoS One 2024;19:e0307004. doi: 10.1371/journal.pone.0307004. Mummaneni PV, Bisson EF, Kerezoudis P, et al. Minimally invasive versus open fusion for Grade I degenerative lumbar spondylolisthesis. Neurosurg Focus 2017;43:E11. Siccoli A, Staartjes VE, de Wispelaere MP, et al. Machine learning–based preoperative predictive analytics for lumbar spinal stenosis. Neurosurg Focus 2020;46:E5. Evans JC, Vetter TR, Engel S, et al. Patient expectations and satisfaction after lumbar spine surgery: the role of mental health. J Neurosurg Spine 2022;37:685–693. Ezeonu FC, Jimenez D, Carr DA, et al. The impact of preoperative mental health component summary (MCS) score on short-term outcomes after lumbar fusion. Spine 2024;49:E153–E161. doi: 10.1097/BRS.0000000000004938. Rahman R, Ibaseta A, Reidler JS, et al. Mental health associated with postoperative satisfaction in lumbar degenerative surgery patients. Clin Spine Surg 2020;33:E556–E563. Lee J, Kim HS, Shim KD, et al. The effect of anxiety and depression on outcomes of lumbar spinal stenosis surgery. J Neurosurg Spine 2017;27:42–47. Vilà-Canet G, Covaro A, Cano-Gómez C, et al. Predictive factors of patient satisfaction after spine surgery. Eur Spine J 2021;30:2813–2819. Doi T, Akai M, Fujino K, et al. Effect of depression and anxiety on health-related quality of life outcomes and patient satisfaction after surgery for cervical compressive myelopathy. J Neurosurg Spine 2019;31:816–823. Joelson A, Sigmundsson FG, Karlsson J, et al. Satisfaction after lumbar decompression for spinal stenosis: which outcome measures tell the story? Eur Spine J 2023;32:1927–1935. Stienen MN, Ho AL, Staartjes VE, et al. Objective activity tracking in spine surgery: a prospective feasibility study with a low-cost consumer grade wearable accelerometer. Sci Rep 2020;10:4939. doi: 10.1038/s41598-020-61893-4. Halvorson RT, Torres-Espin A, Callahan M, et al. Multi-domain biopsychosocial postoperative recovery trajectories associate with patient outcomes following lumbar fusion. Eur Spine J 2023;32:1429–1436. doi: 10.1007/s00586-023-07572-0. Yamamoto Y, Kawakami M, Minetama M, et al. Psychological predictors of satisfaction after lumbar surgery for lumbar spinal stenosis. Asian Spine J 2022;16:270–278. doi: 10.31616/asj.2020.0402. Power JD, Perruccio AV, Canizares M, et al. Determining minimal clinically important difference estimates following surgery for degenerative conditions of the lumbar spine: analysis of the Canadian Spine Outcomes and Research Network (CSORN) registry. Spine J 2023;23:1323–1333. doi: 10.1016/j.spinee.2023.05.001. Hambrecht J, Köhli P, Duculan R, et al. The disaggregated Oswestry Disability Index: what is the most predictive subsection for patient satisfaction after lumbar surgery? Spine 2024;50:E308–E313. doi: 10.1097/BRS.0000000000005154. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451–2459. Lurie JD, Tosteson TD, Tosteson AN, et al. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine 2014;39:3–16. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008;358:794–810. Fekete TF, Loibl M, Jeszenszky D, et al. How does patient-rated outcome change over time following the surgical treatment of degenerative disorders of the thoracolumbar spine? Eur Spine J 2018;27:700–708. Parai C, Hägg O, Lind B, Brisby H. Follow-up of degenerative lumbar spine surgery — PROMs stabilize after 1 year: an equivalence study based on Swespine data. Eur Spine J 2019;28:2187–2197. DeVine J, Norvell DC, Ecker E, et al. Evaluating the correlation and responsiveness of patient-reported pain with function and quality-of-life outcomes after spine surgery. Spine 2011;36(21 Suppl):S69–74. Asher AL, Chotai S, Devin CJ, et al. Inadequacy of 3-month Oswestry Disability Index outcome for assessing individual longer-term patient experience after lumbar spine surgery. J Neurosurg Spine 2016;25:170–180. Additional Declarations No competing interests reported. Supplementary Files STROBEChecklist.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 Apr, 2026 Reviewers agreed at journal 17 Apr, 2026 Reviewers agreed at journal 15 Apr, 2026 Reviews received at journal 12 Apr, 2026 Reviewers agreed at journal 09 Apr, 2026 Reviewers invited by journal 07 Apr, 2026 Editor invited by journal 11 Mar, 2026 Editor assigned by journal 09 Mar, 2026 Submission checks completed at journal 09 Mar, 2026 First submitted to journal 08 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9065140","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":621723523,"identity":"a19815fb-3a92-4773-aad5-d7126c9c560a","order_by":0,"name":"Tomasz Szczepański","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAqUlEQVRIiWNgGAWjYJACxgYg7gczC4hQzgPTMrMBxDUgRcuGA8RqsWfvTnw4g2Gb7OYbuQeYC4iyhefsZsMNDLeNt93IS2CeQZQWidxtkg//3U7cdjvHgJmHSC3bfz5guJ24eTYJWrYxAh2WuEGaaC1nzm6WnAH0y4z77xIOE+UX9vbejR97GG7L9vecPfi4oIIILcgWMhwmTQNICzOpWkbBKBgFo2BkAADbZTdPeuqAdwAAAABJRU5ErkJggg==","orcid":"","institution":"4th Military Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tomasz","middleName":"","lastName":"Szczepański","suffix":""},{"id":621723524,"identity":"bb408eec-de2b-4b94-ba68-f291c1e7a5ab","order_by":1,"name":"Marta Koźba-Gosztyła","email":"","orcid":"","institution":"4th Military Hospital","correspondingAuthor":false,"prefix":"","firstName":"Marta","middleName":"","lastName":"Koźba-Gosztyła","suffix":""},{"id":621723525,"identity":"2adddbe0-6cc0-4cb3-88d3-03b076c33d55","order_by":2,"name":"Anastasija Krzemińska","email":"","orcid":"","institution":"4th Military Hospital","correspondingAuthor":false,"prefix":"","firstName":"Anastasija","middleName":"","lastName":"Krzemińska","suffix":""},{"id":621723526,"identity":"9f7042f9-e830-44cc-accd-973b8a969dcd","order_by":3,"name":"Grzegorz Miekisiak","email":"","orcid":"","institution":"Vratislavia Medica Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Grzegorz","middleName":"","lastName":"Miekisiak","suffix":""},{"id":621723528,"identity":"bfa535fc-986c-4ad8-8e11-8db52a48ea21","order_by":4,"name":"Bogdan Czapiga","email":"","orcid":"","institution":"4th Military Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bogdan","middleName":"","lastName":"Czapiga","suffix":""}],"badges":[],"createdAt":"2026-03-08 15:08:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9065140/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9065140/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106875881,"identity":"7c8c5ba3-24d9-4a8e-b276-434c8d934681","added_by":"auto","created_at":"2026-04-14 10:26:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":446448,"visible":true,"origin":"","legend":"\u003cp\u003eVenn diagram of MCID-based responder classification at 1-month follow-up (moderate thresholds; n = 134). Circles represent patients achieving MCID on VAS Leg Pain (≥1.5 pts; 82.1%), ODI (≥10 pts; 54.5%), and EQ-5D-5L index (≥0.10; 83.6%). The central overlap denotes concordant responders across all three instruments (n = 63; 47.0%); an equal proportion fell into the disagreement zone (n = 63; 47.0%). Eight patients (6.0%) achieved MCID on no instrument. Inter-instrument agreement: Cohen's κ = 0.19–0.29.\u003c/p\u003e","description":"","filename":"Fig1VennMCID.png","url":"https://assets-eu.researchsquare.com/files/rs-9065140/v1/adf73352fc7ab44fa72f207a.png"},{"id":106875891,"identity":"1a094559-cf59-44b9-9650-e7afc1cf1b73","added_by":"auto","created_at":"2026-04-14 10:26:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":196250,"visible":true,"origin":"","legend":"\u003cp\u003eCoefficient plot from multivariable linear regression (dependent variable: SSSQ satisfaction score; n = 134). Filled squares represent unstandardized regression coefficients (β); horizontal lines indicate 95% bootstrapped confidence intervals. Only two EQ-5D-5L dimensions at 1-month follow-up were independent predictors of dissatisfaction: residual mobility limitation (β = 0.77; 95% CI 0.22–1.32; p = 0.006) and depression/anxiety (β = 0.81; 95% CI 0.25–1.37; p = 0.005). Residual leg pain (VAS), back pain (VAS), and all ODI subscale scores were non-significant after controlling for these two dimensions. The dashed horizontal line separates significant from non-significant predictors. Model R² = 0.34.\u003c/p\u003e","description":"","filename":"Fig2Dissatisfactionpredictors.png","url":"https://assets-eu.researchsquare.com/files/rs-9065140/v1/de841c21ecd17a10d192ee61.png"},{"id":106875951,"identity":"281abafa-105a-4d24-81af-7cf3188b2f41","added_by":"auto","created_at":"2026-04-14 10:27:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1699686,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9065140/v1/37ede050-f465-497e-b958-59a5213a24a3.pdf"},{"id":106875923,"identity":"fab5a468-a013-40af-a218-1c75eee43c8f","added_by":"auto","created_at":"2026-04-14 10:27:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21917,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEChecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-9065140/v1/5f4e3e67b076921b1458b005.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eIs Pain Relief Enough? Early Response Discordance After Lumbar Decompressive Surgery: A Prospective Cohort Study\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003ePatient-reported outcome measures (PROMs) are the standard for evaluating surgical benefit in lumbar degenerative spine surgery. Instruments such as the Visual Analogue Scale (VAS) for pain, the Oswestry Disability Index (ODI) for function, and the EQ-5D-5L for health-related quality of life are used to determine whether a patient has achieved a clinically meaningful improvement, typically by applying a minimal clinically important difference (MCID) threshold. The implicit assumption underlying this practice is that different instruments classify the same patients as treatment responders — that a patient who improves in pain also improves in function and quality of life [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis assumption has been challenged. Wertli et al. [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e] demonstrated in a cohort of 466 patients with lumbar spinal stenosis that the prevalence of patients fulfilling MCID criteria ranged from 40% to 70% depending on the instrument, with inter-instrument agreement of only κ = 0.24–0.50 (fair to moderate). Mannion et al. [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e] reported 22% individual-level disagreement between ODI and COMI responder status (κ = 0.56) in 3 324 patients. These findings suggest that pain, function, and quality of life may represent distinct recovery trajectories rather than a single unitary outcome. However, no study has systematically characterised the pattern, directionality, and clinical predictors of this inter-instrument discordance, nor has any study compared discordance patterns between disc herniation and spinal stenosis.\u003c/p\u003e \u003cp\u003eRecovery after lumbar decompressive surgery is a multi-dimensional process that unfolds over 12 to 24 months, but the rate of improvement differs substantially across outcome domains. The Spine Patient Outcomes Research Trial (SPORT) demonstrated that surgical patients with disc herniation achieved approximately 96% of their eventual 8-year pain improvement (SF-36 Bodily Pain) within the first 3 months, with little further gain thereafter [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]; for spinal stenosis, a significant surgical advantage emerged by 3 months and was maintained at 2 years [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]. The Spine Tango registry (n = 4 287) confirmed this temporal pattern at finer resolution: the dominant recovery phase occurred from preoperatively to 3 months (COMI change 3.6 ± 2.8 points), with only a small additional gain from 3 to 12 months (0.3 ± 2.4 points) and no further significant change from 12 to 60 months [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. The Swedish Spine Register equivalence study (n ≈ 98 700) corroborated that the proportion of patients reaching minimal important change on VAS, ODI, and EQ-5D differed by less than 2% between 1- and 2-year follow-up, establishing that PROMs stabilise after 12 months [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. Critically, however, these aggregate trajectories mask a fundamental domain-specific asymmetry. DeVine et al. [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e] showed in a systematic review that pooled effect sizes after lumbar surgery were largest for pain (VAS: 1.4 ± 0.57), intermediate for function (ODI: 1.1 ± 0.39), and smallest for quality of life (EQ-5D: 0.78 ± 0.12), with no inter-domain correlation exceeding ρ = 0.70 — confirming that these instruments measure genuinely distinct constructs that recover at different rates. This differential responsiveness translates into measurable clinical discordance at early timepoints: Asher et al. [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e] reported in the N2QOD registry (n = 3 073) that 23% of patients were discordant for MCID achievement on the ODI between 3 and 12 months, and that substantial clinical benefit rose from 51% at 3 months to 61% at 12 months — a 10-percentage-point increase representing continued functional improvement well after pain relief had plateaued.\u003c/p\u003e \u003cp\u003eThese converging lines of evidence indicate that the first postoperative clinical contact — typically at 4 to 6 weeks — occupies a unique position in the recovery continuum: the acute surgical effects have resolved, the majority of pain improvement has already occurred, but functional reconditioning and psychological adaptation are still unfolding. This creates the biological and psychometric conditions under which different PROMs may yield discordant classifications of the same patient, and the clinical conditions under which such discordance, if identified, remains modifiable through targeted rehabilitation and psychological support. Understanding whether and how this asymmetry manifests as measurable inter-instrument discordance at the first postoperative visit is therefore essential for directing early care — yet no study has systematically characterised these patterns at this timepoint.\u003c/p\u003e \u003cp\u003eWe therefore aimed to: (1) quantify the inter-instrument agreement between pain (VAS), function (ODI), and quality of life (EQ-5D-5L index) on MCID-based responder status at 1 month after lumbar degenerative spine surgery; (2) determine whether discordance patterns differ between disc herniation and spinal stenosis; and (3) identify residual health dimensions that independently drive patient dissatisfaction and should be prioritised in early postoperative rehabilitation.\u003c/p\u003e "},{"header":"Materials ","content":"\u003cp\u003eStudy design and setting\u003c/p\u003e\n\u003cp\u003eThis work represents a secondary analysis of data from the PROGRES study (\u003cem\u003eEvaluation of the natural course of lumbar degenerative spine disease and factors influencing its progression, with an analysis of the impact of surgical intervention as a modifying factor in the long-term course of the disease \u0026ndash; prospective observational study\u003c/em\u003e), an ongoing prospective observational cohort study conducted at the Neurosurgical Department of the 4th Military Clinical Hospital in Wrocław, Poland. The PROGRES study employs a cohort design to evaluate the natural history and clinical outcomes of lumbar degenerative disease before and after surgical treatment. The present analysis uses preoperative assessment data and 1-month postoperative follow-up data collected between May 2025 and December 2025.\u003c/p\u003e\n\u003cp\u003eThe study is purely observational, involving the analysis of clinical, imaging, and patient-reported outcome data without any intervention in the diagnostic or therapeutic process. The research protocol was developed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cohort studies (Supplementary checklist).\u003c/p\u003e\n\u003cp\u003eParticipants\u003c/p\u003e\n\u003cp\u003eConsecutive adult patients hospitalised at the Neurosurgical Department with a confirmed diagnosis of lumbar degenerative disease were screened for eligibility. Lumbar degenerative disease encompassed two primary diagnoses: lumbar spinal stenosis and lumbar disc herniation.\u003c/p\u003e\n\u003cp\u003eInclusion criteria were as follows: age between 18 and 90 years, clinically relevant degenerative changes of the lumbar spine confirmed by magnetic resonance imaging (MRI), ability to participate in long-term follow-up assessments, provision of written informed consent, and cognitive status sufficient to understand the purpose and methods of the study and complete questionnaires.\u003c/p\u003e\n\u003cp\u003eExclusion criteria included the following: history of previous spinal surgery; spinal neoplasms; neurological or muscular diseases causing motor function impairment (e.g., amyotrophic lateral sclerosis, multiple sclerosis, or myopathies); and inability to participate in long-term observation due to severe chronic illness with limited life expectancy.\u003c/p\u003e\n\u003cp\u003eBetween May and December 2025, determination of eligibility was conducted by a trained team comprising spine surgeons and clinical research coordinators. Following clinical assessment, all eligible patients completed standardized questionnaires on the day of hospital admission, prior to the consultation during which the surgical treatment plan and operative approach were discussed. All patients were informed about the study process and methods and about their right to withdraw at any time.\u003c/p\u003e\n\u003cp\u003eEthics\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Bioethics Committee of the Lower Silesian Medical Chamber in Wrocław (approval number: 09/DOBD/2025, date: April 9, 2025). The study was conducted in accordance with the tenets of the Declaration of Helsinki and its subsequent amendments. All participants provided written informed consent prior to enrolment. Participants were informed of their right to withdraw from the study at any time without consequences for their medical care. Data were anonymised and stored securely in compliance with applicable data protection regulations.\u003c/p\u003e\n\u003cp\u003eOutcome measures\u003c/p\u003e\n\u003cp\u003ePROMs were collected at baseline (preoperative, on the day of hospital admission) and at 1 month postoperatively. Pain intensity was assessed using VAS for leg pain and back pain (0\u0026ndash;10 scale). Functional disability was measured using the ODI (0\u0026ndash;100 scale). Health-related quality of life was assessed with the EQ-5D-5L, converted to a utility index using the Polish value set (Golicki et al. [4]). Patient satisfaction was assessed at follow-up using the Spine Surgery Satisfaction Questionnaire (SSSQ) satisfaction subscale as an external criterion independent of the PROMs under study; dissatisfaction was defined as SSSQ \u0026gt; 12 [5].\u003c/p\u003e\n\u003cp\u003eMCID thresholds and responder definition\u003c/p\u003e\n\u003cp\u003eMCID thresholds were derived from published external literature and were not estimated within this cohort, thereby avoiding circularity with the SSSQ-based satisfaction criterion. The primary analysis used moderate thresholds: VAS leg pain \u0026ge;1.5 points [6], ODI \u0026ge;10 points [7], and EQ-5D-5L index \u0026ge;0.10 [8]. These thresholds are consistent with pathology-specific estimates from the Canadian Spine Outcomes and Research Network (CSORN) registry, in which Power et al. [31] reported MCID values for ODI change ranging from \u0026minus;10.0 to \u0026minus;16.9 depending on lumbar pathology, supporting our use of the moderate \u0026ge;10-point threshold as a balanced estimate across diagnostic groups. Sensitivity analyses were conducted at liberal (VAS \u0026ge;1.0, ODI \u0026ge;6, EQ-5D-5L \u0026ge;0.05) and conservative (VAS \u0026ge;2.0, ODI \u0026ge;12, EQ-5D-5L \u0026ge;0.15) thresholds.\u003c/p\u003e\n\u003cp\u003eStatistical analysis\u003c/p\u003e\n\u003cp\u003eBaseline characteristics were compared between diagnostic groups using Mann\u0026ndash;Whitney U tests and chi-square tests. Within-group change was assessed by Wilcoxon signed-rank test; effect sizes are reported as Cohen\u0026rsquo;s d.\u003c/p\u003e\n\u003cp\u003eInter-instrument agreement on MCID-based responder status was quantified using Cohen\u0026rsquo;s kappa (\u0026kappa;), supplemented by overall percent agreement, specific positive agreement (Ppos), and specific negative agreement (Pneg) to address the known prevalence paradox of \u0026kappa; [9]. Kappa was interpreted according to Landis and Koch (1977): \u0026lt;0.20 slight, 0.21\u0026ndash;0.40 fair, 0.41\u0026ndash;0.60 moderate [10]. Multi-dimensional response discordance was defined as achieving MCID in pain and/or quality of life but not in function (Type A) or in function but not in pain/quality of life (Type B).\u003c/p\u003e\n\u003cp\u003eCriterion validity of each PROM against SSSQ satisfaction was assessed via Spearman correlations and ROC analysis with 2\u0026thinsp;000-iteration bootstrap 95% confidence intervals. Independent predictors of dissatisfaction were identified by multivariable linear regression with SSSQ as the dependent variable; model stability was assessed via bootstrapped confidence intervals. With 31 events (dissatisfied patients) and a maximum of 5 predictors evaluated, the events-per-variable ratio (6.2) was sufficient for exploratory modelling but limits generalisability. Analyses were performed in Python 3.11 (SciPy, scikit-learn). Statistical significance was set at p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePatient flow and baseline characteristics\u003c/p\u003e \u003cp\u003eOf 161 patients screened, 3 were excluded (did not undergo surgery). Of 158 operated patients (disc herniation n\u0026thinsp;=\u0026thinsp;77; spinal stenosis n\u0026thinsp;=\u0026thinsp;81), 134 (84.8%) completed the 1-month follow-up with full paired data; 24 (15.2%) had incomplete follow-up. Lost patients did not differ in age (56.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.0 vs. 60.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5; p\u0026thinsp;=\u0026thinsp;0.259) or baseline VAS leg (6.8 vs. 6.7; p\u0026thinsp;=\u0026thinsp;0.692), though baseline ODI was marginally higher (32.7 vs. 29.7; p\u0026thinsp;=\u0026thinsp;0.035).\u003c/p\u003e \u003cp\u003eThe analysed cohort (n\u0026thinsp;=\u0026thinsp;134) had a mean age of 60.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5 years (range 24\u0026ndash;86), 58.2% were female. Stenosis patients were significantly older than disc herniation patients (66.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7 vs. 52.1\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); sex, education, and all baseline PROMs did not differ between diagnoses (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.18) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the study cohort stratified by primary diagnosis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e Variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eDisc herniation (n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eSpinal stenosis (n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;134)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years; mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e51.9\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5 (27\u0026ndash;75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e66.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6 (36\u0026ndash;81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e60.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5 (27\u0026ndash;81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001 a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, female; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e33 (55.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e47 (62.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e80 (59.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.541 b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level; n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (8.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e5 (3.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3 (4.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e5 (3.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVocational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (20.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e17 (22.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e29 (21.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (40.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e36 (48.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e60 (44.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (27.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e19 (25.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e35 (26.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e0.141 b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBaseline patient-reported outcome measures; mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS Leg Pain (0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e6.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.831 a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS Back Pain (0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.780 a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eODI total (0\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e30.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e29.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.355 a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L index (\u0026minus;\u0026thinsp;0.59\u0026ndash;1.00) c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.886 a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L sum score (5\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e14.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.886 a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c10\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eSD\u0026thinsp;=\u0026thinsp;standard deviation; VAS\u0026thinsp;=\u0026thinsp;Visual Analogue Scale; ODI\u0026thinsp;=\u0026thinsp;Oswestry Disability Index; EQ-5D-5L\u0026thinsp;=\u0026thinsp;EuroQol five-dimension five-level instrument.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003ea Mann\u0026ndash;Whitney U test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eb Chi-square test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003ec EQ-5D-5L utility index computed using the Polish population-based value set (Golicki et al., PharmacoEconomics 2019).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eSignificance threshold: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Values in bold indicate statistically significant differences.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Baseline characteristics of the study cohort stratified by primary diagnosis. Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for continuous variables and as number (percentage) for categorical variables. p-values refer to between-diagnosis comparisons (Mann\u0026ndash;Whitney U test for continuous variables; chi-square test for categorical variables). The EQ-5D-5L utility index was computed using the Polish population-based value set (Golicki et al., PharmacoEconomics 2019). SD\u0026thinsp;=\u0026thinsp;standard deviation; VAS\u0026thinsp;=\u0026thinsp;Visual Analogue Scale; ODI\u0026thinsp;=\u0026thinsp;Oswestry Disability Index.\u003c/p\u003e \u003cp\u003eEarly postoperative improvement\u003c/p\u003e \u003cp\u003eAll instruments showed significant improvement at 1 month (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). VAS leg pain decreased from 6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 to 2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 (mean change 4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5; Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;1.36; 70% relative improvement), EQ-5D-5L index increased from 0.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28 to 0.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16 (Δ\u0026thinsp;=\u0026thinsp;0.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29; d\u0026thinsp;=\u0026thinsp;1.30), and ODI decreased from 29.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2 to 19.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5 (Δ\u0026thinsp;=\u0026thinsp;9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6; d\u0026thinsp;=\u0026thinsp;1.02; 33% relative improvement). The asymmetry in recovery rates was evident: pain improved twice as fast (70%) as function (33%).\u003c/p\u003e \u003cp\u003eMCID-based responder rates at moderate thresholds were: VAS leg 82.1%, EQ-5D-5L 83.6%, and ODI 54.5%. Responder rates for pain and quality of life were thus approximately 30 percentage points higher than for function.\u003c/p\u003e \u003cp\u003eInter-instrument agreement\u003c/p\u003e \u003cp\u003eCohen\u0026rsquo;s κ for pairwise agreement on responder status ranged from 0.19 to 0.29, indicating slight to fair agreement (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Overall percent agreement ranged from 61.9% (VAS vs. ODI) to 77.6% (VAS vs. EQ-5D-5L), but the high agreement for VAS\u0026ndash;EQ-5D-5L largely reflected both instruments classifying patients as responders (Ppos\u0026thinsp;=\u0026thinsp;0.87), with poor agreement on non-responders (Pneg\u0026thinsp;=\u0026thinsp;0.35). Only 47.0% of patients achieved MCID across all three instruments simultaneously, while 94.0% achieved it on at least one \u0026mdash; producing a 47-percentage-point disagreement zone (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This pattern was stable across all MCID threshold levels (κ range 0.15\u0026ndash;0.31; disagreement zone 33.6\u0026ndash;53.0%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInter-instrument agreement on MCID-based responder status (moderate thresholds).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVAS Leg Pain\u003c/p\u003e \u003cp\u003evs ODI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVAS Leg Pain\u003c/p\u003e \u003cp\u003evs EQ-5D-5L\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eODI\u003c/p\u003e \u003cp\u003evs EQ-5D-5L\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eResponder rates (MCID achieved); n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstrument A responders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110 (82.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110 (82.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73 (54.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstrument B responders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (54.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112 (83.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112 (83.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2 \u0026times; 2 responder classification matrix; n\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth responders (R / R)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e66\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e96\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e70\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstrument A responder only (R / NR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstrument B responder only (NR / R)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeither responder (NR / NR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e19\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAgreement statistics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall percent agreement (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCohen's κ [95% CI] a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.19 [0.06\u0026ndash;0.32]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.21 [0.08\u0026ndash;0.34]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.29 [0.15\u0026ndash;0.42]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterpretation b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSlight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSlight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eSpecific agreement indices (addressing prevalence paradox) c\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecific positive agreement (Ppos)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecific negative agreement (Pneg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevalence index (PI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMulti-dimensional concordance across all three instruments\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcordant responders (MCID on all three); n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e63 (47.0%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026mdash;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026mdash;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagreement zone (MCID on \u0026ge;\u0026thinsp;1 but not all); n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e63 (47.0%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026mdash;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026mdash;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo MCID on any instrument; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInter-instrument disagreement range (pp) d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.3 pp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eMCID\u0026thinsp;=\u0026thinsp;minimal clinically important difference; VAS\u0026thinsp;=\u0026thinsp;Visual Analogue Scale (leg pain); ODI\u0026thinsp;=\u0026thinsp;Oswestry Disability Index; EQ-5D-5L\u0026thinsp;=\u0026thinsp;EuroQol five-dimension five-level utility index; pp\u0026thinsp;=\u0026thinsp;percentage points; R\u0026thinsp;=\u0026thinsp;responder; NR\u0026thinsp;=\u0026thinsp;non-responder; PI\u0026thinsp;=\u0026thinsp;prevalence index; Ppos\u0026thinsp;=\u0026thinsp;specific positive agreement; Pneg\u0026thinsp;=\u0026thinsp;specific negative agreement.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ea 95% confidence intervals estimated by bootstrap (2 000 iterations).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eb Interpreted according to Landis \u0026amp; Koch (1977): κ\u0026thinsp;\u0026lt;\u0026thinsp;0.20\u0026thinsp;=\u0026thinsp;slight; 0.21\u0026ndash;0.40\u0026thinsp;=\u0026thinsp;fair.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ec Ppos\u0026thinsp;=\u0026thinsp;2a / (2a\u0026thinsp;+\u0026thinsp;b + c); Pneg\u0026thinsp;=\u0026thinsp;2d / (2d\u0026thinsp;+\u0026thinsp;b + c); PI = (a\u0026thinsp;+\u0026thinsp;d \u0026minus; b\u0026thinsp;\u0026minus;\u0026thinsp;c) / n. Reported to address the known prevalence paradox of κ (Feinstein \u0026amp; Cicchetti, 1990).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ed Difference between the highest (EQ-5D-5L, 83.6%) and lowest (ODI, 54.5%) responder rates. Pairwise columns for the multi-dimensional concordance rows apply to the overall three-instrument analysis and are therefore not disaggregated by pair (\u0026mdash;).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eMCID thresholds (moderate): VAS Leg Pain\u0026thinsp;\u0026ge;\u0026thinsp;1.5 points; ODI\u0026thinsp;\u0026ge;\u0026thinsp;10 points; EQ-5D-5L index\u0026thinsp;\u0026ge;\u0026thinsp;0.10. n\u0026thinsp;=\u0026thinsp;134.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Inter-instrument agreement on MCID-based responder status at 1-month follow-up (moderate thresholds; n\u0026thinsp;=\u0026thinsp;134). Cohen's κ interpreted per Landis \u0026amp; Koch (1977). Ppos, Pneg, and PI reported to address the prevalence paradox of κ. MCID thresholds: VAS Leg Pain\u0026thinsp;\u0026ge;\u0026thinsp;1.5 pts; ODI\u0026thinsp;\u0026ge;\u0026thinsp;10 pts; EQ-5D-5L index\u0026thinsp;\u0026ge;\u0026thinsp;0.10. CI\u0026thinsp;=\u0026thinsp;confidence interval; NR\u0026thinsp;=\u0026thinsp;non-responder; ODI\u0026thinsp;=\u0026thinsp;Oswestry Disability Index; R\u0026thinsp;=\u0026thinsp;responder; VAS\u0026thinsp;=\u0026thinsp;Visual Analogue Scale.) \u0026mdash; see Tables file.\u003c/p\u003e \u003cp\u003eMulti-dimensional response discordance\u003c/p\u003e \u003cp\u003ePain/quality-of-life versus function discordance occurred in 39.6% of patients, exclusively as Type A: pain and/or QoL improved while function did not. The reverse pattern (Type B) did not occur in any patient. Type A discordance was numerically more prevalent in spinal stenosis (45.3%) than disc herniation (32.2%), though this did not reach statistical significance (OR\u0026thinsp;=\u0026thinsp;1.75; p\u0026thinsp;=\u0026thinsp;0.155).\u003c/p\u003e \u003cp\u003eDissatisfied patient profile\u003c/p\u003e \u003cp\u003eThirty-one patients (23.1%) were dissatisfied. They were significantly older (66.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.0 vs. 58.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6 years; p\u0026thinsp;=\u0026thinsp;0.002), but baseline PROM scores were identical to those of satisfied patients across all instruments (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.19; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Dissatisfaction arose from insufficient improvement rather than worse initial status: VAS leg improved by 49% in dissatisfied vs. 76% in satisfied patients, EQ-5D-5L index Δ\u0026thinsp;=\u0026thinsp;0.34 vs. 0.40, and ODI by only 17% vs. 38%. The asymmetry was most pronounced for function.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline and postoperative characteristics of satisfied and dissatisfied patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSatisfied\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;103)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDissatisfied\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years; mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002 a\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, female; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (62.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (51.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.494 b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpinal stenosis; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (54.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (61.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.880 b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSSSQ score; mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 a\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBaseline patient-reported outcome measures; mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS Leg Pain (0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.309 a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS Back Pain (0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.826 a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eODI total (0\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.796 a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L sum score (5\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.486 a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1-month follow-up patient-reported outcome measures; mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS Leg Pain (0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.015 a\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS Back Pain (0\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.060 a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eODI total (0\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 a\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L sum score (5\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 a\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChange scores (baseline \u0026rarr; 1 month); mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eΔVAS Leg Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002 a\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eΔVAS Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.059 a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eΔODI (decrease\u0026thinsp;=\u0026thinsp;improvement)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001 a\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eΔEQ-5D-5L sum score (decrease\u0026thinsp;=\u0026thinsp;improvement)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;7.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001 a\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelative improvement \u0026mdash; VAS Leg Pain (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash; c\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelative improvement \u0026mdash; ODI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash; c\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMCID-based responder rates at 1 month; n (%) d\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS Leg Pain responders (\u0026ge;\u0026thinsp;1.5 pts)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (87.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (64.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.005 b\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eODI responders (\u0026ge;\u0026thinsp;10 pts)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (61.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (32.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.006 b\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L responders (\u0026ge;\u0026thinsp;0.10 index) e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79 (76.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (71.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.516 b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConcordant responders (VAS\u0026thinsp;+\u0026thinsp;ODI); n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e57 (55.3%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e9 (29.0%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.009 b\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidual symptom profile at 1 month in dissatisfied patients; n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo residual leg pain (VAS\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (38.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate functional disability (ODI 21\u0026ndash;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (71.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L: mobility problems (score\u0026thinsp;\u0026gt;\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (58.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEQ-5D-5L: depression / anxiety (score\u0026thinsp;\u0026gt;\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (61.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDissatisfaction defined as SSSQ satisfaction subscale score\u0026thinsp;\u0026gt;\u0026thinsp;12. Significant p-values (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) are shown in red. MCID\u0026thinsp;=\u0026thinsp;minimal clinically important difference; ODI\u0026thinsp;=\u0026thinsp;Oswestry Disability Index; SD\u0026thinsp;=\u0026thinsp;standard deviation; SSSQ\u0026thinsp;=\u0026thinsp;Spine Surgery Satisfaction Questionnaire; VAS\u0026thinsp;=\u0026thinsp;Visual Analogue Scale.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ea Mann\u0026ndash;Whitney U test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eb Chi-square test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ec Relative improvement not tested statistically due to zero baseline values in a subset of patients.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ed MCID thresholds (moderate): VAS Leg Pain\u0026thinsp;\u0026ge;\u0026thinsp;1.5 pts; ODI\u0026thinsp;\u0026ge;\u0026thinsp;10 pts; EQ-5D-5L utility index\u0026thinsp;\u0026ge;\u0026thinsp;0.10.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ee EQ-5D-5L responder rate estimated from utility index change; computed using the Polish value set (Golicki et al., 2019).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026mdash; Not applicable (statistic reported for dissatisfied group only or not calculated).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Baseline and postoperative characteristics of satisfied and dissatisfied patients at 1-month follow-up. Dissatisfaction defined as SSSQ satisfaction subscale score\u0026thinsp;\u0026gt;\u0026thinsp;12. Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD for continuous variables and as n (%) for categorical variables. Significant p-values (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) are highlighted. MCID thresholds (moderate): VAS Leg Pain\u0026thinsp;\u0026ge;\u0026thinsp;1.5 pts; ODI\u0026thinsp;\u0026ge;\u0026thinsp;10 pts; EQ-5D-5L index\u0026thinsp;\u0026ge;\u0026thinsp;0.10. MCID\u0026thinsp;=\u0026thinsp;minimal clinically important difference; ODI\u0026thinsp;=\u0026thinsp;Oswestry Disability Index; SD\u0026thinsp;=\u0026thinsp;standard deviation; SSSQ\u0026thinsp;=\u0026thinsp;Spine Surgery Satisfaction Questionnaire; VAS\u0026thinsp;=\u0026thinsp;Visual Analogue Scale.\u003c/p\u003e \u003cp\u003eMCID-based responder rates in dissatisfied patients were: VAS leg 64.5%, EQ-5D-5L 71.0%, but ODI only 32.3%. Concordant response across all three instruments was achieved by 29.0% of dissatisfied vs. 52.4% of satisfied patients.\u003c/p\u003e \u003cp\u003eThe residual symptom profile of dissatisfied patients was notable: 38.7% reported no leg pain (VAS\u0026thinsp;=\u0026thinsp;0) at follow-up, yet 71.0% maintained moderate functional disability (ODI 21\u0026ndash;40). At the EQ-5D-5L dimension level, 77.4% still reported pain/discomfort, 61.3% depression/anxiety, and 58.1% mobility problems.\u003c/p\u003e \u003cp\u003eIndependent predictors of dissatisfaction\u003c/p\u003e \u003cp\u003eIn multivariable linear regression (R\u0026sup2; = 0.34), only two EQ-5D-5L dimensions at follow-up were independent predictors of satisfaction level: residual mobility limitation (β\u0026thinsp;=\u0026thinsp;0.77; p\u0026thinsp;=\u0026thinsp;0.006) and depression/anxiety (β\u0026thinsp;=\u0026thinsp;0.81; p\u0026thinsp;=\u0026thinsp;0.005). Residual VAS leg pain, VAS back pain, and ODI subscale scores were not significant after controlling for mobility and depression. Bootstrapped 95% confidence intervals confirmed the stability of both predictors; the full coefficient plot with 95% CIs for all candidate variables is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDiagnosis-specific patterns\u003c/p\u003e \u003cp\u003eCriterion validity differed by diagnosis: in disc herniation, ODI (AUC\u0026thinsp;=\u0026thinsp;0.741) and VAS leg (0.721) best identified dissatisfied patients. In spinal stenosis, EQ-5D-5L index showed the strongest correlation with satisfaction (rho\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.440, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), though ODI remained the best discriminator overall (AUC\u0026thinsp;=\u0026thinsp;0.643).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrincipal findings\u003c/p\u003e \u003cp\u003eThis study demonstrates that after lumbar degenerative spine surgery, pain, functional disability, and health-related quality of life recover at fundamentally different rates within the first postoperative month. This temporal asynchrony produces a multi-dimensional response discordance in which each PROM identifies a different subset of patients as treatment responders at the same timepoint. Inter-instrument agreement on MCID-based responder status was only slight to fair (κ\u0026thinsp;=\u0026thinsp;0.19\u0026ndash;0.29), nearly half of patients fell into an inter-instrument disagreement zone, and four in ten patients showed the characteristic Type A discordance pattern: pain and quality of life improved while function lagged behind. The reverse pattern did not occur, implying a hierarchical recovery progression in which sensory pain relief precedes meaningful gains in physical mobility [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Most importantly, dissatisfaction at 1 month was independently driven by residual mobility limitation and depression/anxiety \u0026mdash; not by residual pain \u0026mdash; suggesting that early postoperative care should shift from a pain-centric paradigm toward targeted functional rehabilitation and psychological screening.\u003c/p\u003e \u003cp\u003eComparison with prior literature\u003c/p\u003e \u003cp\u003eOur findings extend and refine the observations of Wertli et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], who reported κ\u0026thinsp;=\u0026thinsp;0.24\u0026ndash;0.50 for inter-instrument MID agreement in 466 stenosis patients at 6 months. We confirm their conclusion that instrument choice substantially affects outcome classification and add three new dimensions: a systematic discordance taxonomy (Type A/B), the finding that discordance is exclusively unidirectional at 1 month, and the identification of mobility and depression as the specific residual dimensions driving dissatisfaction. The higher disagreement in our study (κ\u0026thinsp;=\u0026thinsp;0.19\u0026ndash;0.29 vs. 0.24\u0026ndash;0.50) is expected at an earlier timepoint when recovery trajectories across domains are most divergent.\u003c/p\u003e \u003cp\u003eMannion et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] reported κ\u0026thinsp;=\u0026thinsp;0.56 for ODI\u0026ndash;COMI agreement at 12 months, again suggesting that inter-instrument agreement improves as recovery progresses and outcome domains converge. This temporal gradient of concordance \u0026mdash; from slight at 1 month to moderate at 6 months to good at 12 months \u0026mdash; is consistent with our interpretation that the observed discordance represents differential recovery kinetics rather than a permanent measurement artefact. Several trajectory-modelling studies corroborate this interpretation, reporting that different domains may reach MCID at different timepoints across the first postoperative year [\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In particular pain measures frequently show early improvement after decompression, whereas functional indices lag behind, contributing to the asymmetric discordance pattern we observed [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Kowalski et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] have highlighted that physical functioning is multidimensional and necessitates evaluation with measures beyond PROMs alone, further supporting the view that function and pain represent distinct constructs with independent recovery timelines.\u003c/p\u003e \u003cp\u003eThe finding that residual pain does not independently predict dissatisfaction once mobility and depression are accounted for aligns with the growing recognition that psychological distress and functional limitation are central to patient experience after spine surgery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Preoperative and postoperative mental health states have been shown to influence satisfaction and recovery trajectories independently of pain intensity [\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and depressive symptoms may mediate dissatisfaction even when pain has substantially improved [\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Yamamoto et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] demonstrated that preoperative anxiety (HADS score\u0026thinsp;\u0026ge;\u0026thinsp;median) was a significant predictor of dissatisfaction after lumbar decompression for spinal stenosis (OR\u0026thinsp;=\u0026thinsp;3.95), while pain catastrophising and fear-avoidance beliefs were not, emphasising the primacy of mood-related factors over pain processing in determining satisfaction. Our results provide a mechanistic rationale for this observation through the lens of the Type A discordance pattern: pain-sensitive instruments detect early improvement from neural decompression, while function-sensitive instruments capture the slower process of musculoskeletal reconditioning. Across decompression cohorts, MCID attainment and patient satisfaction can diverge substantially, reflecting these multi-domain recovery patterns and unmet patient expectations [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eStrengths of this study include its prospective design within the context of an ongoing structured cohort study (PROGRES), the simultaneous assessment of four PROM families covering complementary outcome domains, the use of the Polish EQ-5D-5L value set (Golicki et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]) appropriate for the study population, externally-derived MCID thresholds \u0026mdash; corroborated by the large CSORN registry data [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] \u0026mdash; avoiding anchor circularity, and the inclusion of both major lumbar degenerative pathologies enabling direct comparison. Reporting of supplementary agreement statistics (Ppos, Pneg, prevalence index) alongside κ addresses the known prevalence paradox of the kappa statistic [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral limitations must be acknowledged. First, the 1-month follow-up captures an early recovery snapshot rather than the definitive surgical outcome. The observed discordance likely reflects \u0026mdash; at least in part \u0026mdash; the natural temporal asymmetry between immediate pain relief from decompression and slower functional reconditioning; whether it persists at 3 or 12 months remains a critical question for future research. Multiple trajectory studies confirm that pain, function, and quality of life follow asynchronous courses in the early postoperative period [\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], supporting the view that a single PROM at 1 month is insufficient to capture the full recovery landscape. Second, the sample size (n\u0026thinsp;=\u0026thinsp;134; 31 dissatisfied) limits the regression analysis to exploratory status (EPV\u0026thinsp;=\u0026thinsp;6.2); external validation in a larger cohort is warranted. Third, lost-to-follow-up patients (15.2%) had marginally higher baseline ODI, potentially introducing attrition bias toward less disabled patients. Fourth, complications were not systematically captured with a standardised adverse-event protocol, and we cannot exclude the possibility that unreported minor events contributed to dissatisfaction. Fifth, the inter-instrument kappa values should be interpreted with the awareness that VAS, ODI, and EQ-5D-5L measure different constructs by design; low agreement between conceptually distinct instruments is expected from a measurement theory perspective (Campbell and Fiske multitrait\u0026ndash;multimethod framework [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]). The clinical relevance of our findings lies not in the kappa values per se but in the practical consequences for patient classification and care decisions. Finally, the deliberate movement restriction commonly observed during the initial six to eight weeks post-surgery may partly reflect patient compliance with postoperative precautions rather than a genuine spine-related mobility deficit [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], which should be considered when interpreting early ODI scores.\u003c/p\u003e \u003cp\u003eImplications for clinical practice\u003c/p\u003e \u003cp\u003eThese findings carry three direct implications for early postoperative care. First, relying on a single PROM at the 1-month visit provides an incomplete and potentially misleading picture of recovery: a patient who is a \u0026ldquo;responder\u0026rdquo; on VAS may not be a responder on ODI, and vice versa. Multi-dimensional assessment \u0026mdash; covering at minimum pain, function, and quality of life \u0026mdash; is necessary to identify the 47% of patients who fall into the inter-instrument disagreement zone. Instrument selection should be diagnosis-informed: ODI and VAS leg for disc herniation, EQ-5D-5L for spinal stenosis.\u003c/p\u003e \u003cp\u003eSecond, since baseline PROM scores do not distinguish patients who will become dissatisfied, prospective identification of at-risk patients requires assessment at the 1-month visit rather than reliance on preoperative profiles. Screening for mobility limitation and depression/anxiety at this timepoint should be considered, given their independent predictive value. Implementing multi-domain modelling is critical because singular instruments such as the ODI may fail to explain up to 50% of the variability observed in broader health domains during the recovery period [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThird, for the 39.6% of patients who show Type A discordance (pain improved, function not), additional analgesia is unlikely to improve satisfaction. Hambrecht et al. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] recently demonstrated that disaggregated ODI subsections for walking (AUC\u0026thinsp;=\u0026thinsp;0.83) and personal care (AUC\u0026thinsp;=\u0026thinsp;0.82) were the strongest predictors of patient satisfaction after lumbar surgery, corroborating our finding that mobility \u0026mdash; not pain intensity \u0026mdash; is the primary driver of patient satisfaction at the individual domain level. Early rehabilitation should therefore emphasise rapid, targeted improvements in mobility and functional activities of daily living \u0026mdash; gait training, transfers, core stability, and graduated activity programmes \u0026mdash; consistent with the Type A discordance pattern in which functional rehabilitation should be foregrounded in early care [\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The association between depression/anxiety and dissatisfaction further supports embedding short, scalable mood screening (e.g., PHQ-9, GAD-7, or HADS) with timely mental health referral into the early postoperative pathway [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Such integrated behavioural health strategies can mitigate mood-related dissatisfaction and support engagement in functional rehabilitation.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAt 1 month after lumbar degenerative spine surgery, pain and quality of life recover substantially faster than function, creating a multi-dimensional response discordance that affects four in ten patients. Different PROMs agree on responder status in fewer than half of patients (κ\u0026thinsp;=\u0026thinsp;0.19\u0026ndash;0.29). Dissatisfaction is driven by residual mobility limitation and depression, not by residual pain. The 1-month visit provides a critical window for identifying patients who require targeted functional rehabilitation and psychological support. Multi-dimensional PROM assessment at this timepoint, with diagnosis-specific instrument selection, should become standard in postoperative care pathways for lumbar degenerative spine disease.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"636\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAUC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eArea under the receiver operating characteristic curve\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBody mass index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCOMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCore Outcome Measures Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCONSORT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eConsolidated Standards of Reporting Trials\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCSORN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCanadian Spine Outcomes and Research Network\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEvents per variable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEQ-5D-5L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEuroQol five-dimension five-level questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGAD-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGeneralised Anxiety Disorder 7-item scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHADS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHospital Anxiety and Depression Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMCID\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMinimal clinically important difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMental Component Summary\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMID\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMinimal important difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eN2QOD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNational Neurosurgery Quality and Outcomes Database\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eODI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOswestry Disability Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOdds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePHQ-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePatient Health Questionnaire 9-item scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePneg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSpecific negative agreement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePpos\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSpecific positive agreement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePROGRES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eProspective observational study of lumbar degenerative spine disease (\u003cem\u003eEvaluation of the natural course of lumbar degenerative spine disease and factors influencing its progression, with an analysis of the impact of surgical intervention as a modifying factor in the long-term course of the disease\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePROM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePatient-reported outcome measure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eROC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eReceiver operating characteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStandard deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSPORT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSpine Patient Outcomes Research Trial\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSSSQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSpine Surgery Satisfaction Questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSTROBE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eStrengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTLIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTransforaminal lumbar interbody fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eVisual Analogue Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026kappa;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCohen\u0026apos;s kappa coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Bioethics Committee of the Lower Silesian Medical Chamber in Wrocław, Poland (approval number: 09/DOBD/2025, date: 9 April 2025). The study was conducted in accordance with the principles of the Declaration of Helsinki and its subsequent amendments. All participants were informed of the study objectives and methods, and provided written informed consent prior to enrolment. Participants were informed of their right to withdraw from the study at any time without consequences for their medical care.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual person\u0026apos;s data in any form that would allow identification of study participants. All data were fully anonymised prior to analysis.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research received no external funding. The study was conducted as part of the statutory research activity of the Neurosurgical Department of the 4th Military Clinical Hospital in Wrocław, Poland. No funding body had any role in the design of the study, collection, analysis, or interpretation of data, or in writing the manuscript.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eConceptualization: T.S., B.C. Data curation: A.K., M.K.G. Formal analysis: T.S. Investigation: T.S., M.K.G., A.K. Methodology: T.S., G.M. Project administration: T.S., M.K.G. Supervision: B.C., G.M. Validation: G.M. Writing \u0026ndash; original draft: T.S. Writing \u0026ndash; review \u0026amp; editing: M.K.G., G.M., B.C. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors wish to thank the staff of the Neurosurgical Department of the 4th Military Clinical Hospital in Wrocław for their support in patient recruitment and data collection. The authors also thank all patients who participated in the PROGRES study.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to patient privacy considerations and institutional data governance requirements. Anonymised data supporting the conclusions of this article are available from the corresponding author on reasonable request, subject to approval by the Bioethics Committee of the Lower Silesian Medical Chamber.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eOstelo RWJG, Deyo RA, Stratford P, et al. 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The impact of preoperative mental health component summary (MCS) score on short-term outcomes after lumbar fusion. Spine 2024;49:E153\u0026ndash;E161. doi: 10.1097/BRS.0000000000004938.\u003c/li\u003e\n \u003cli\u003eRahman R, Ibaseta A, Reidler JS, et al. Mental health associated with postoperative satisfaction in lumbar degenerative surgery patients. Clin Spine Surg 2020;33:E556\u0026ndash;E563.\u003c/li\u003e\n \u003cli\u003eLee J, Kim HS, Shim KD, et al. The effect of anxiety and depression on outcomes of lumbar spinal stenosis surgery. J Neurosurg Spine 2017;27:42\u0026ndash;47.\u003c/li\u003e\n \u003cli\u003eVil\u0026agrave;-Canet G, Covaro A, Cano-G\u0026oacute;mez C, et al. Predictive factors of patient satisfaction after spine surgery. Eur Spine J 2021;30:2813\u0026ndash;2819.\u003c/li\u003e\n \u003cli\u003eDoi T, Akai M, Fujino K, et al. Effect of depression and anxiety on health-related quality of life outcomes and patient satisfaction after surgery for cervical compressive myelopathy. J Neurosurg Spine 2019;31:816\u0026ndash;823.\u003c/li\u003e\n \u003cli\u003eJoelson A, Sigmundsson FG, Karlsson J, et al. Satisfaction after lumbar decompression for spinal stenosis: which outcome measures tell the story? Eur Spine J 2023;32:1927\u0026ndash;1935.\u003c/li\u003e\n \u003cli\u003eStienen MN, Ho AL, Staartjes VE, et al. Objective activity tracking in spine surgery: a prospective feasibility study with a low-cost consumer grade wearable accelerometer. Sci Rep 2020;10:4939. doi: 10.1038/s41598-020-61893-4.\u003c/li\u003e\n \u003cli\u003eHalvorson RT, Torres-Espin A, Callahan M, et al. Multi-domain biopsychosocial postoperative recovery trajectories associate with patient outcomes following lumbar fusion. Eur Spine J 2023;32:1429\u0026ndash;1436. doi: 10.1007/s00586-023-07572-0.\u003c/li\u003e\n \u003cli\u003eYamamoto Y, Kawakami M, Minetama M, et al. Psychological predictors of satisfaction after lumbar surgery for lumbar spinal stenosis. Asian Spine J 2022;16:270\u0026ndash;278. doi: 10.31616/asj.2020.0402.\u003c/li\u003e\n \u003cli\u003ePower JD, Perruccio AV, Canizares M, et al. Determining minimal clinically important difference estimates following surgery for degenerative conditions of the lumbar spine: analysis of the Canadian Spine Outcomes and Research Network (CSORN) registry. Spine J 2023;23:1323\u0026ndash;1333. doi: 10.1016/j.spinee.2023.05.001.\u003c/li\u003e\n \u003cli\u003eHambrecht J, K\u0026ouml;hli P, Duculan R, et al. The disaggregated Oswestry Disability Index: what is the most predictive subsection for patient satisfaction after lumbar surgery? Spine 2024;50:E308\u0026ndash;E313. doi: 10.1097/BRS.0000000000005154.\u003c/li\u003e\n \u003cli\u003eWeinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451\u0026ndash;2459.\u003c/li\u003e\n \u003cli\u003eLurie JD, Tosteson TD, Tosteson AN, et al. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine 2014;39:3\u0026ndash;16.\u003c/li\u003e\n \u003cli\u003eWeinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008;358:794\u0026ndash;810.\u003c/li\u003e\n \u003cli\u003eFekete TF, Loibl M, Jeszenszky D, et al. How does patient-rated outcome change over time following the surgical treatment of degenerative disorders of the thoracolumbar spine? Eur Spine J 2018;27:700\u0026ndash;708.\u003c/li\u003e\n \u003cli\u003eParai C, H\u0026auml;gg O, Lind B, Brisby H. Follow-up of degenerative lumbar spine surgery \u0026mdash; PROMs stabilize after 1 year: an equivalence study based on Swespine data. Eur Spine J 2019;28:2187\u0026ndash;2197.\u003c/li\u003e\n \u003cli\u003eDeVine J, Norvell DC, Ecker E, et al. Evaluating the correlation and responsiveness of patient-reported pain with function and quality-of-life outcomes after spine surgery. Spine 2011;36(21 Suppl):S69\u0026ndash;74.\u003c/li\u003e\n \u003cli\u003eAsher AL, Chotai S, Devin CJ, et al. Inadequacy of 3-month Oswestry Disability Index outcome for assessing individual longer-term patient experience after lumbar spine surgery. J Neurosurg Spine 2016;25:170\u0026ndash;180.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"lumbar decompression, patient-reported outcome measures, minimal clinically important difference, response discordance, Oswestry Disability Index, EQ-5D-5L, visual analogue scale, spinal stenosis, disc herniation, outcome assessment","lastPublishedDoi":"10.21203/rs.3.rs-9065140/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9065140/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eDifferent patient-reported outcome measures (PROMs) may classify the same patient differently as a treatment responder after lumbar decompressive surgery. We aimed to quantify inter-instrument agreement on minimal clinically important difference (MCID)-based responder status at one month postoperatively, characterize multi-dimensional response discordance, and identify residual health dimensions independently driving patient dissatisfaction.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eIn this prospective observational cohort study, 158 consecutive adults undergoing lumbar decompressive surgery for disc herniation (n = 77) or spinal stenosis (n = 81) at a single neurosurgical center were enrolled. Of these, 134 (84.8%) completed paired baseline and one-month assessments using the Visual Analogue Scale for leg pain (VAS), Oswestry Disability Index (ODI), and EQ-5D-5L utility index. MCID thresholds were derived from external sources (VAS ≥1.5 points, ODI ≥10 points, EQ-5D-5L ≥0.10). Inter-instrument agreement was quantified using Cohen's kappa (κ). Patient dissatisfaction was defined by the Spine Surgery Satisfaction Questionnaire (SSSQ \u0026gt; 12). Independent predictors of dissatisfaction were identified by multivariable linear regression with bootstrapped confidence intervals.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eAll instruments showed significant improvement at one month (all p \u0026lt; 0.001). MCID-based responder rates differed markedly: VAS 82.1%, EQ-5D-5L 83.6%, and ODI 54.5%. Inter-instrument agreement was slight to fair (κ = 0.19–0.29); Only 47.0% of patients achieved MCID across all three instruments simultaneously, while 94.0% achieved it on at least one — producing a 47-percentage-point disagreement zone (Figure 2). Pain and/or quality-of-life improvement without corresponding functional improvement (Type A discordance) affected 39.6% of patients. Twenty-three percent of patients were dissatisfied at one month. In multivariable regression (R² = 0.34), residual mobility limitation (β = 0.77; p = 0.006) and depression/anxiety (β = 0.81; p = 0.005) were independent predictors of dissatisfaction; residual pain was not significant.\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eInstrument selection alone changes responder classification rates by nearly 30 percentage points at one month after lumbar decompressive surgery. Dissatisfaction is driven by residual functional limitation and psychological distress, not residual pain. Multi-dimensional PROM assessment with diagnosis-informed instrument selection should be standard practice at the early postoperative visit to identify patients requiring targeted rehabilitation and psychological support.\u003c/p\u003e\n\u003cp\u003eTrial registration\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"Is Pain Relief Enough? Early Response Discordance After Lumbar Decompressive Surgery: A Prospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-14 10:25:19","doi":"10.21203/rs.3.rs-9065140/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-18T18:15:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219033980406599359628591521013769691491","date":"2026-04-17T07:50:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"179185876143029493944186053058509590133","date":"2026-04-15T06:55:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-12T15:04:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83480402039246125398425835365076232036","date":"2026-04-09T16:28:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-07T15:22:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-11T09:05:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-10T03:25:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-10T03:25:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-03-08T14:59:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"93caf773-d2c2-409e-be4b-a4ae3a6bd3ac","owner":[],"postedDate":"April 14th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-14T10:25:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-14 10:25:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9065140","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9065140","identity":"rs-9065140","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}