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Prospective study.The present study compared different theories on the role of expectations in a group of patients undergoing lumbar decompression surgery.Patients’ expectations of treatment are a potentially important predictor of self-rated outcome after surgery. Some studies suggest that high baseline expectations per se yield better outcomes, others maintain that the fulfillment of prior expectations is paramount, and still others assert that it is the actual improvement in symptom status that governs outcome, regardless of prior expectations.Hundred patients took part (33 F, 67 M; mean [SD] age, 65  yrs). Before surgery, they completed a booklet containing the Roland-Morris (RM) disability questionnaire, 0–10 pain graphic rating scales (back and leg separately), and Likert-scales about the degree of improvement expected in various domains. Two and 12 months after surgery, questions were answered regarding the perceived improvement for each of these domains, the RM and pain scales were completed again, and the patients rated the global outcome on a 5-point Likert-scale.Compared with the actual improvement recorded at 12 months, prior expectations had been overly optimistic in about 40% patients for the domains leg pain, back pain, walking capacity, social life, mental well-being, and independence, and in 50% patients for everyday activities and sport. There was no significant relationship between baseline expectations and follow-up scores for back pain, leg pain, RM-disability (corrected for baseline values), or global outcome. Hierarchical multiple regression analysis revealed that “expectations being fulfilled” was the most significant predictor of global outcome.In this patient group, expectations of surgery were overly optimistic. Having one’s expectations fulfilled was most important for a good outcome. The results emphasize the importance of assessing patient-orientated outcome in routine practice, and the factors that might influence it, such that realistic expectations can be established for patients before surgery.