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Background and Objectives: Only limited qualitative research concerning instrumented spine surgeries has been published, despite the increasing number of these surgeries and the evident importance of qualitative analysis of the processes surrounding these complex interventions. Current qualitative research is mainly limited to the experiences, emotions and expectations of patients. Insight into the full process, including experiences from the perspective of informal caregivers and healthcare professionals, remains scarce. Materials and Methods: Data were gathered by means of semi-structured face-to-face interviews. In total, there were 27 participants, including 11 patients, 7 informal caregivers and 9 healthcare professionals. The interview process was audiotaped, and each interview was transcribed verbatim. To systematically analyse the gathered data, software for qualitative analysis (NVivo) was used. After immersion in the raw data of transcripts and field notes, a list of broad categories for organising the data into meaningful clusters for analysis was developed. All interviews were coded by the first author, and 25% was independently assessed by the second author. Results: The results of our study describe several promoting and limiting factors concerning the process of lumbar fusion surgery from the perspective of patients, informal caregivers and healthcare providers. The most frequently mentioned promoting factors were: information and opportunities to ask questions during consultations; multidisciplinary consultations; good communication and guidance during hospitalization; and follow-up appointments. The most frequently mentioned limiting factors were: lack of educational material; lack of guidance and communication prior to, during and after hospitalisation. Conclusion: Overall, participants were satisfied with the current healthcare-process in lumbar fusion surgery. However, we found that lack of educational material and guidance during the process led to insecurity about complaints, surgery and recovery. To improve the process of lumbar interbody fusion and to increase patient satisfaction, healthcare providers should focus on guiding and educating patients and informal caregivers about the pre-operative trajectory, the surgery and the recovery. From the healthcare providers' perspective, the process could be improved by multidisciplinary consultations and a dedicated spine team in the operation room. Although this study focusses on lumbar fusion surgery, results could be translated to other fields of spine surgery and surgery in general.

The aim of this thesis was to describe three aspects of lumbar spine (lower back) and slippage of the lumbar vertebrae due to degeneration or surgery, called spondylolisthesis. The first part is about the normal motion of the lumbar spine, of which a firm definition has not yet been discovered. Inter- and intra-individual differences should be taken into account to determine a method for defining normality in motion of the lumbar spine.In the second part, the risk of developing spondylolisthesis after decompression surgery has been discussed in which part of the vertebral arc has to be resected to decompress the nerves. Female sex, spondylolisthesis before decompression surgery and level of surgery are associated with symptomatic spondylolisthesis after decompression surgery. High BMI and larger facet angles (the two joints in the lumbar spine at the back) have a lower probability to develop spondylolisthesis.In the third part, different aspects regarding the treatment of spondylolisthesis were reviewed. The most common surgical techniques - TLIF versus PLIF – were compared. No differences in effect, blood loss, duration of surgery or hospitalization, and complications were demonstrated. The cost-effectiveness review illustrates the knowledge gap of cost-effectiveness in spine surgery, with high heterogeneity among studies. Finally, image-guided techniques used during screw insertion during fusion surgeries were compared. Fluoroscopy led to the highest radiation exposure for surgeon and patients, but still has advantages of short learning curve and wide availability. Furthermore, it resulted in novel postoperative neurological complaints in only 3.25% of the study population.