Introduction: there is a general impression that surgeries performed in private non-teaching relative to public teaching hospitals have a higher therapeutic outcome.
Aim: We aimed to compare surgical outcome and satisfaction rate of microlumbar discectomy in the patients with refractory lumbar disc herniation in teaching versus non-teaching hospitals.
Patients and Methods: In this retrospective study, we assessed 176 patients who had been treated with simple microlumbar discectomy from April 2018 to December 2019 in a teaching university and a private non-teaching hospital (88 patients in each group) with a follow-up limitation of 6 to 24 months. The main operating surgeon and surgical technique were the same in both hospitals. Pain, disability, and the patient’s satisfaction were assessed by visual analogue scale (VAS), Oswestry Disability Index (ODI), and Macnab questionnaires, respectively. We used student’s t-test and Chi-Square for statistical analysis.
Results: The two groups were homogenous preoperatively in the terms of age, gender, body mass index (BMI), and pain, but preoperative disability was higher in teaching group (ODI: 45±10.3 versus 40.5±11.3). At the last follow-up visit, pain, disability, and satisfaction rate were all more pleasant in private group, significantly (VAS: 0.4±0.7 vs. 1.2±1.6, and ODI: 8.9±7.1 vs. 16.6±15.3).
Conclusion: Comparison of surgical outcome and satisfaction rate of microlumbar discectomy between non-teaching versus teaching hospital showed that postoperative pain and disability, and satisfaction rate were all more pleasant in non-teaching private hospital. It seems that surgical outcome and patient’s satisfaction rate of these patients may be at least partially affected by some non-surgical issues.
Surgical training requires practical work on the patient’s bedside. Since maintaining the patient’s safety and health is the main basic principle of medical practice, one of the concerns of the faculty members has always been to establish a suitable educational environment while maintaining safety for the patients. It is commonly thought that resident participation in the surgical procedure not only increases the density of the operating room staff and its consequent complications, but also her/his insufficient surgical skills may lead to increased surgical unpleasant adverse effects. However, scientific studies
have not been able to prove existence of a strong link between resident participation in the operating room and an increase in complications [1-4].
It seems that the difference in treatment results between teaching and non-teaching hospitals is not simply related to the presence of the resident, and various other factors including patient’s insurance status, cultural and educational level, job satisfaction, and etc. are also important and effective [5-8]. Apparently, a combination of these factors has led to a general impression that surgeries performed in private hospitals relative to public teaching hospitals have a higher therapeutic outcome. In
this study, we aimed to compare surgical outcome and satisfaction
rate of simple lumbar discectomy in the patients with refractory
lumbar disc herniation who were operated in teaching public
versus non-teaching private hospitals.
In this longitudinal retrospective study, after institutional
review board approval (record number: 970252, ethical code:
IR.MUMS.MEDICAL.REC.1397.613), we assessed our patients
who had been treated with microlumbar discectomy from April
2018 to December 2019 in a teaching university hospital (Imam
Reza Hospital; group A) and in a private non-teaching hospital
(Razavi Hospital; group B) in Mashhad, Iran. Criteria for entry
into the study included those patients with single-level lumbar
disc herniation (L4-L5 or L5-S1 level), primary surgery, and
age limitation between 20 and 60 years old. Those cases with
revision surgery, multi-level lumbar disc herniation, cauda equina
syndrome, operation with instrumentation or fusion, or followup
period not limited to 6 to 24 months were excluded from the
After the patient was admitted, informed consent assigned
and all the preoperative measures were carried out, they
underwent microlumbar discectomy. The main operating surgeon
and surgical technique were the same in both hospitals. The
orthopaedic resident who was present during the operation in
the teaching hospital only acted as an assistant surgeon and did
not perform surgery independently. After surgery, the patient was
usually kept hospitalized one night and discharged the next day
after he/she could freely walk and urinate.
Pain and disability at preoperative period and the last followup
visit were assessed by two questionnaires: Visual Analogue
Scale (VAS) and Oswestry Disability Index (ODI), respectively
[9,10]. In evaluating pain based on VAS, we used a linear range
of 0 to 10 that the patient should mark the appropriate level
based on the severity of the pain. Mousavi et al. has already
cross cultural translated and validated ODI questionnaire for
Iranian patients . Patient satisfaction at the last session was
also assessed by Macnab questionnaire and graded as excellent,
good, fair, or poor . As the intervertebral disc degeneration
is an age-related process and this process continues throughout
the life, we chose only 6 months to 2 years after surgery as a
postoperative period for evaluating our patients’ satisfaction and
surgical outcome. Statistical analysis- After data collection with
the statistical package for social sciences (SPSS) version 16 (SPSS
Inc., Chicago, IL, USA), the data were analysed. Quantitative data,
such as age, weight, height, BMI, ODI and pain were evaluated by
the student’s t-test method. Qualitative data, such as gender and
surgical satisfaction were analysed by the X2 test (Chi-Square). P
< 0.05 was assessed as significant.
Finally, 176 patients were eligible for our study, of which 88
belonged to public (group 1) and 88 to private (group 2) hospital.
Demographic characteristics of the patients were depicted in Table
1. Preoperatively, the two groups were homogenous in terms of
age, gender, body mass index (BMI), and pain, but preoperative
disability was more severe in teaching hospital patients (p: 0.007).
Pain and disability were improved in both groups (Table 2). At the
last follow-up visit, both pain and disability were more pleasant
in private group, statistically. The amount of pain and disability
improvement were also greater in private group, although the
pain improvement only showed a statistical difference. The status
of subjective satisfaction with surgery was also more favourable
in the group of private patients.
In this retrospective study, we studied the surgical outcome
and satisfaction rate of microlumbar discectomy as the most
prevalent spine surgery among private and public teaching
hospitals and found that at the last follow-up visit, postoperative
pain and disability were higher while satisfaction rate was lower
in teaching group.
In this study, although the main operating surgeon, surgical
technique and equipment were the same, but the surgical outcome
and satisfaction rate showed significant differences. Previous
studies have shown that just having a resident during surgeries
does not increase the risk of complications [2-4]. It seems that
other issues comprising insurance status, mental, marital, income,
educational level, heavy physical occupation, smoking, and the
patients’ level of cooperation in following the postoperative
orders should be effective in outcome of microlumbar discectomy
[5-8]. On the other hand, intraoperative complications including
length of operation, intraoperative blood loss, dural tear, wrong
level, wrong side, and neurologic injury may have important
effects on surgical outcome of microlumbar discectomy [13,14].
In the patients with lumbar disc surgery, appropriate following
of the postoperative protocols comprising lifestyle modifications,
body mass index correction, and proper rehabilitation program is
mandatory to improve the clinical outcome . It is probable that
a lower level of psychological state, culture and literacy associated
with lack of appropriate financial and insurance level were
effective in increasing postoperative illness and dissatisfaction in
the teaching hospital patients . In this study we did not assess
these important details and just investigated the surgical outcome
and satisfaction rate.
Chua et al. in a prospective study evaluated the effect
of public and private hospital systems on 420 cases with
pancreatoduodenectomy . They found that although the
length of operation, intraoperative blood loss, and perioperative
blood transfusion were higher in teaching hospital, hospital
type had no significant relation with morbidity, mortality, or
perioperative outcomes. This study mainly assessed perioperative
outcome of pancreatoduodenectomy, while our study focused
on long-term postoperative results and satisfaction rate of the
operated patients and in that sense, public hospital patients had a
worse prognosis in our study.
Like our study, Spaziani and co-authors compared the
outcome of elective laparoscopic cholecystectomy in teaching
versus private hospital . According to their findings, length
of operation and postoperative complications were higher
in teaching hospital patients. We did not assay the length of
operation or postoperative complications, but the postoperative
morbidity including pain and disability were similarly higher in
Unger et al. in another comparative study, measured surgical
outcome of hysterectomy three months after surgery by a healthrelated
quality-of-life outcomes questionnaire in two groups
of women: 50 underinsured teaching versus 50 insured private
hospital patients . They found that although, most of the
patients achieved complete symptom relief for the conditions for
which they underwent hysterectomy, the high-income insured
patients at the private hospital had a more pleasant outcome
satisfaction score than the teaching hospital. Three months after
surgery, the women in teaching hospital reported more tired,
moody, depressed, less satisfied with preoperative information
they had received, and less eager to recommend hysterectomy to a
friend with similar problems. The results of this study were in line
with our study; both of them showed that surgical outcomes were
better in private hospital patients than in public ones, although
we did not assess insurance, educational, and cultural status of
Our study has several major shortcomings. First, this
study was a retrospective study and naturally has the inherent
disadvantages of retrospective studies. Second, we did not assess
intraoperative complications. Logistically, the difference between
incidence of intraoperative complications in private versus public
hospital may create differences in postoperative surgical outcome
and patients’ satisfaction. Third, we did not pay attention to the
personal characteristics of these two groups of patients including
literacy level, insurance, income, marital, and mental status.
These indices may have substantial role in ultimate postoperative
outcome and the patient satisfaction with this peculiar type of
In conclusion, comparison of surgical outcome and satisfaction
rate of microlumbar discectomy between private non-teaching
versus public teaching hospital showed that postoperative pain
and disability, and satisfaction rate were all more pleasant in
non-teaching private hospital. It seems that surgical outcome
and patient’s satisfaction rate of these patients may be at least
partially affected by some non-surgical issues.
The authors would like to thank the Vice Chancellor for
Research and Technology of Mashhad University of Medical
Sciences, Mashhad, Iran for their financial support. This project
was the result of Zahra Akbari’s general medical dissertation with
research code number of 970252.
Omidi-Kashani F, Baradaran A, Golhasani-Keshtan F, Rahimi MD, Hasankhani EG (2016) Identifying predisposing factors for recurrence after successful surgical treatment of lumbar disc herniation. Med J DY Patil Univ9(4): 469-473.