Navigating Cognitive Biases and Surgical Decision-Making: Unraveling the Causes of Persistent Spinal Pain Syndrome After Spine Surgery.

OBJECTIVE

Persistent spinal pain syndrome (PSPS) affects up to 40% of patients after spine surgery, yet the interplay between technical factors, diagnostic accuracy, and cognitive biases remains poorly characterized. This study examines contributors to PSPS in a single-institution cohort, emphasizing preventable causes and surgeon cognitive biases in decision-making.

METHODS

A retrospective review of 482 PSPS patients (2009-2023) at a tertiary spine center evaluated clinical data, procedures, and complications. A blinded multidisciplinary team classified etiologies using standardized criteria and identified cognitive biases via pre-specified operational definitions. Chi-square analysis assessed associations between surgical approach and PSPS etiology.

RESULTS

Technical errors were the most frequent category (48%), followed by diagnostic errors (15%), wrong operations (14%), and disease progression (11%). Insufficient neural decompression was the most common technical finding (36%). Preventable factors accounted for 82% of cases. Cognitive biases contributed in 73% of patients, including heuristic shortcuts, anchoring bias (55%), confirmation bias (48%), and therapeutic illusion (33%). Fusion surgery was strongly associated with wrong operations (Cramer's V = 0.623). Only 49% of surgical decisions met evidence-based criteria per North American Spine Society guidelines.

CONCLUSIONS

PSPS was predominantly associated with modifiable factors-technical deficiencies, diagnostic inaccuracies, and cognitive biases-rather than disease progression alone. Decision-making patterns shaped by heuristics, anchoring, and therapeutic optimism may perpetuate ineffective interventions despite surgical expertise. Improvements in training, diagnostic protocols, cognitive de-biasing education, and evidence-based practice adherence could plausibly reduce PSPS incidence. These hypothesis-generating findings, derived from a single tertiary referral center, warrant confirmation through prospective, controlled, multicenter studies.