Eur Spine J DOI 10.1007/s00586-015-3788-2
ORIGINAL ARTICLE
Preoperative anxiety about spinal surgery under general anesthesia Jun-Seok Lee • Yong-Moon Park • Kee-Yong Ha Sung-Wook Cho • Geun-Hyeong Bak • Ki-Won Kim
•
Received: 24 December 2013 / Revised: 29 January 2015 / Accepted: 29 January 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose No study has investigated preoperative anxiety about spinal surgery under general anesthesia. The purposes of this study were (1) to determine how many patients have preoperative anxiety about spinal surgery and general anesthesia, (2) to evaluate the level of anxiety, (3) to identify patient factors potentially associated with the level of anxiety, and (4) to describe the characteristics of the anxiety that patients experience during the perioperative period. Methods This study was performed in 175 consecutive patients undergoing laminectomy for lumbar stenosis or discectomy for herniated nucleus pulposus under general anesthesia. Demographic data, information related to surgery, and characteristics of anxiety were obtained using a questionnaire. The level of anxiety was assessed using a visual analog scale of anxiety (VAS-anxiety). Patient factors potentially associated with the level of anxiety were investigated using multiple stepwise regression analysis.
Results Of 157 patients finally included in this study, 137 (87 %) had preoperative anxiety (VAS-anxiety [ 0). The mean VAS-anxiety score for spinal surgery was significantly higher than that for general anesthesia (4.6 ± 3.0 vs. 3.2 ± 2.7; P \ 0.001). Sex and age were significant patient factors related to the level of anxiety about spinal surgery (P = 0.009) and general anesthesia (P = 0.018); female patients had a higher level of anxiety about spinal surgery, and elderly patients had a higher level of anxiety about general anesthesia. The most helpful factors in overcoming anxiety before surgery and in reducing anxiety after surgery were faith in the medical staff (48.9 %) and surgeon’s explanation of the surgery performed (72.3 %), respectively. Conclusions Patients awaiting laminectomy or discectomy feared spinal surgery more than general anesthesia. This study also found that medical staff and surgeons play important roles in overcoming and reducing patient anxiety during the perioperative period. Keywords Preoperative anxiety Laminectomy Discectomy Spinal surgery General anesthesia
J.-S. Lee S.-W. Cho G.-H. Bak K.-W. Kim (&) Department of Orthopaedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 62 Yeouido-dong, Youngdeungpo-ku, Seoul 150-010, Korea e-mail: [email protected]; [email protected] Y.-M. Park Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea K.-Y. Ha Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Introduction Preoperative anxiety is common in patients awaiting surgery [1, 10, 18, 24]. Preoperative anxiety is an unpleasant emotion and may even cause patients to avoid a planned surgery [24]. A high preoperative anxiety state may lead to adverse psychological and physiological outcomes [3]. In addition, increased preoperative anxiety has been suggested to correlate with increased postoperative pain, increased postoperative analgesic requirements, and prolonged recovery and hospital stay [1, 2, 7]. It is thus
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necessary for medical staff and surgeons to understand and manage preoperative anxiety in their patients who are scheduled for spinal surgery. Previous studies have reported the importance of preoperative anxiety in patients undergoing spinal surgery [7, 14, 27, 30, 31]. Most of these studies have focused on the correlation between preoperative anxiety and the outcome of spinal surgery. Although a high level of preoperative anxiety has been found to be associated with a poor outcome after spinal surgery [7, 14, 30], to our knowledge, no reported study has documented preoperative anxiety about spinal surgery under general anesthesia and which patient factors affect the level of anxiety. The purposes of this study were (1) to determine how many patients have preoperative anxiety about spinal surgery and general anesthesia, (2) to evaluate the level of anxiety, (3) to identify patient factors potentially associated with the level of anxiety, and (4) to describe the characteristics of the anxiety that patients experience during the perioperative period.
Materials and methods Subjects From February 2012 to March 2013, 175 consecutive patients diagnosed with spinal stenosis or herniated nucleus pulposus (HNP) of the lumbar spine who were to undergo spinal surgery under general anesthesia at our institution were recruited. Decompressive laminectomy was performed for patients with spinal stenosis and open discectomy for HNP. Patients underwent preanesthetic assessments before surgery, in which the exact details of the planned anesthesia were explained. They also received information from the treating surgeon about the impending surgery. The same surgeon performed all of the procedures. The inclusion criteria were age greater than 20 years, elective spinal surgery, and the ability to complete the questionnaire. The exclusion criteria were emergency or urgent spinal surgery precluding recruitment and investigations, cognitive impairment prohibiting completion of the questionnaire, history of a psychiatric disorder, and refusal to participate in the study. An institutional review board approved the study. All patients provided informed consent. Questionnaire We designed the questionnaire based on those used in previous studies of preoperative anxiety [20, 24] and focused primarily on the patient’s preoperative anxiety about the spinal surgery. The questionnaire consisted of four
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topic areas: patient demographic background, questions related to spinal surgery, questions related to anxiety about spinal surgery, and the visual analog scale of anxiety (VAS-anxiety) (Table 1). All patients admitted to the hospital for spinal surgery received the questionnaire, which was completed in two parts: partially, on admission and in full at 7 days after surgery (‘‘Appendix’’). Patient demographic background The following demographic data were collected: (1) age, (2) sex, (3) education level (less than high school graduate, high school graduate, or college graduate), and (4) residential area (urban or rural). Questions related to spinal surgery The spinal surgery questions related to (1) preoperative diagnosis (lumbar spinal stenosis or HNP), (2) previous experience with surgery under general anesthesia, (3) the number of previous spinal surgeries, (4) the number of previous non-spinal surgeries, and (5) whether the surgery was a revision spinal surgery. In cases of revision surgery, previous spinal surgeries were confirmed from medical records. Questions related to anxiety about spinal surgery The following five questions were used to evaluate characteristics of the patient’s anxiety: (1) presence or absence of preoperative anxiety, (2) main cause of anxiety (spinal surgery vs. general anesthesia), (3) the most helpful factor in overcoming anxiety before surgery (family or supporting persons, religion, faith in medical staff, or other), (4) the moment of the highest level of anxiety (when spinal surgery was recommended, at the time of the decision to undergo surgery, the night before surgery, while waiting for surgery in the waiting/operating room, or other), and (5) the most helpful factor in reducing anxiety after surgery (surgery completion, surgeon’s explanation of the surgery performed, improvement of symptoms, or other). Questions (3), (4), and (5) were enquired about 7 days after surgery. Visual analog scale of anxiety (VAS-anxiety) Patient preoperative anxiety was assessed using an anxiety score based on an 11-point VAS-anxiety scale (range 0–10). The VAS-anxiety scale has been used widely as a self-reported measure of fear and anxiety [4, 6, 20]. A VAS-anxiety score of 0 was defined as no anxiety, and a score of 10 was defined as the worst anxiety imaginable by the patient. Patients assessed their anxiety level
Eur Spine J Table 1 Content of the questionnaire for anxiety assessment regarding spinal surgery Questions Before spinal surgery (on admission) Q1-1. Age Q1-2. Sex Q1-3. What is your highest level of education? Q1-4. What is your current residential area? Q2-1. What is your preoperative diagnosis? Q2-2. Have you undergone previous surgeries under general anesthesia? Q2-3. If you answered yes to question Q2-2, how many surgeries (other than spinal surgeries) have you experienced? Q2-4. Have you undergone previous spinal surgeries? If so, how many? Q2-5. If you have undergone spinal surgeries, are you expecting to have a revision spinal surgery at the same level as the previous time? Q3-1. Do you have any anxiety about the surgery or general anesthesia? Q3-2. If you answered yes to question Q3-1, which is your main cause of anxiety? Q4-1. If you have any anxiety about spinal surgery, how anxious do you feel?a Q4-2. If you have any anxiety about general anesthesia, how anxious do you feel?a 7 days after spinal surgery Q3-3. What helped you to overcome the anxiety and decide to have surgery? Q3-4. When did you experience the most anxiety? Q4-3. If you had any anxiety about spinal surgery before the operation, how did it change after surgery?a Q3-5. If your preoperative anxiety about spinal surgery was reduced after the operation, what was your main reason for reduction in anxiety? The questionnaire consists of four topic areas: patient demographics (Q1), questions related to spinal surgery (Q2), questions related to anxiety about spinal surgery (Q3), and the visual analog scale of anxiety (Q4) a
A score of 0 indicates no anxiety; 10, the worst anxiety imaginable. See more detail in the ‘‘Appendix’’
subjectively. Patients who rated their anxiety as greater than 0 on the VAS-anxiety scale were considered to have anxiety. Preoperative anxiety about spinal surgery and general anesthesia was assessed using the VAS-anxiety scale (‘‘Appendix’’). The level of anxiety that the patients had about spinal surgery before the operation was reassessed about 7 days after surgery. Patient factors To identify patient factors potentially associated with the level of anxiety, we defined patient factors as follows: (1) age, (2) sex, (3) educational level, (4) residential area, (5) preoperative diagnosis, (6) previous surgical experience, (7) the number of previous spinal surgeries, (8) the number of previous non-spinal surgeries, and (9) whether or not the surgery was a revision spinal surgery (Table 2). Statistical analyses Paired t test was used to compare the preoperative mean VAS-anxiety scores for spinal surgery with general anesthesia and to compare the mean VAS-anxiety scores for spinal surgery before and after the operation. Univariate
analyses using independent t test and one-way analysis of variance (ANOVA) were performed to compare the preoperative mean VAS-anxiety scores between/among the groups categorized within each patient factor. A multiple stepwise regression analysis was performed to determine which patient factors affected the level of preoperative anxiety about spinal surgery. Ten variables were entered into the multiple stepwise regression analysis with preoperative VAS-anxiety score for spinal surgery as a dependent variable and age, sex, educational level, residential area, preoperative diagnosis, previous surgical experience, number of previous spinal surgeries, number of previous non-spinal surgeries, and whether the surgery was a revision spinal surgery as independent variables. VAS-anxiety score and age were entered as continuous variables and others were entered as dummy variables. The multiple regression variable inclusion criterion was P \ 0.05, whereas the exclusion criterion was P [ 0.1. A multiple stepwise regression analysis was also performed to determine which patient factors affected the level of preoperative anxiety about general anesthesia. P values were considered to indicate statistical significance at \0.05. All statistical analyses were performed using the SPSS software (ver. 12.0; SPSS Corp., Chicago, IL, USA).
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Results Of the initial 175 patients, 18 patients who returned incomplete questionnaires were excluded. Thus, 157 patients were finally included in this study. Among them, 137 patients (87 %) had preoperative anxiety (VAS-anxiety score [ 0) for either spinal surgery, general anesthesia, or both. The main cause of preoperative anxiety was spinal surgery in 101 patients (74 %) and general anesthesia in 36 patients (26 %).
Table 2 Characteristics of patients (n = 157)
The preoperative mean VAS-anxiety score for spinal surgery was significantly higher than that for general anesthesia (4.6 ± 3.0 vs. 3.2 ± 2.7; P \ 0.001). Figure 1 shows the levels of preoperative anxiety about spinal surgery and general anesthesia in the patients. The mean VAS-anxiety score for spinal surgery decreased significantly to 1.2 ± 1.5 after surgery (P \ 0.001). Univariate analyses using t test and ANOVA revealed that female patients had a significantly higher level of preoperative anxiety about spinal surgery than male
Patient factors
Number
Age (mean years ± SD, range)
59.5 ± 13.8, 20–88
Sex Male/female Educational level \High school graduate/high school graduate/college graduate
77/80 63/53/41
Residential area Urban/rural
136/21
Preoperative diagnosis Lumbar stenosis/lumbar HNP
96/61
Previous surgical experience Yes/no
106/51
Number of previous spinal surgeries 0/1/C2
128/22/7
Number of previous non-spinal surgeries 0/1/2/3/C4
51/47/32/20/7
Revision spinal surgery at the same level Yes/no
Fig. 1 Levels of patient preoperative anxiety about spinal surgery and general anesthesia
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patients (5.2 ± 3.0 vs. 4.0 ± 2.8; P = 0.009). Additionally, stenosis patients had a significantly higher level of preoperative anxiety about general anesthesia than HNP patients (3.6 ± 2.6 vs. 2.6 ± 2.8; P = 0.022). However, there was no significant difference in the comparison of preoperative mean VAS-anxiety scores according to other patient factors (Table 3). Multiple stepwise regression analysis was performed to identify patient factors potentially associated with the level of preoperative anxiety about spinal surgery and about general anesthesia. Finally, in the data for spinal surgery, only one patient factor, sex, was retained (R2 = 0.043, F = 6.904, P = 0.009), while in the data for general anesthesia, the patient factor of age was retained (R2 = 0.036, F = 5.710, P = 0.018; Table 4).
Table 5 shows the characteristics of patient anxiety about spinal surgery. The most helpful factor in overcoming anxiety before surgery was faith in the medical staff (48.9 %). The moment of the highest level of anxiety occurred while waiting for surgery in the waiting/operating room (35 %). The most helpful factor in reducing anxiety after surgery was surgeon’s explanation of the surgery performed (72.3 %).
Discussion Various types of spinal surgeries have been performed for patients with spinal disease [8, 29, 33]. Among them, decompression surgery such as laminectomy or discectomy is
Table 3 Univariate comparison of the preoperative mean VAS-anxiety score for spinal surgery and for general anesthesia Patient factors
VAS-anxiety for spinal surgery
P value
VAS-anxiety for general anesthesia
P value
4.0 ± 2.8 5.2 ± 3.0
0.009*
2.8 ± 2.5 3.7 ± 2.8
0.063
\High school graduate
4.9 ± 2.8
0.063
3.7 ± 2.7
0.251
High school graduate
3.7 ± 3.1
3.0 ± 2.6
College graduate
4.5 ± 2.7
3.0 ± 2.8
Sex Male Female Educational level
Residential area Urban
4.5 ± 3.0
Rural
5.0 ± 2.6
0.561
3.3 ± 2.7
0.716
3.0 ± 2.7
Preoperative diagnosis Lumbar stenosis
4.7 ± 2.7
Lumbar HNP
4.4 ± 3.3
0.542
3.6 ± 2.6
0.022*
2.6 ± 2.8
Previous surgical experience Yes
4.5 ± 3.1
No
4.8 ± 2.7
0.644
3.3 ± 2.8
0.610
3.1 ± 2.5
Number of previous spinal surgeries 0 1
4.6 ± 3.0 4.5 ± 2.7
C2
4.8 ± 3.6
0.971
3.3 ± 2.7 2.4 ± 2.7
0.072
5.1 ± 2.4
Number of previous of non-spinal surgeries 0
4.8 ± 2.7
0.364
3.1 ± 2.5
1
4.9 ± 2.9
2
4.5 ± 3.0
3.5 ± 3.0
3
4.3 ± 3.2
3.3 ± 3.1
C4
2.5 ± 3.8
3.5 ± 2.6
0.960
3.2 ± 2.6
Revision spinal surgery at the same level Yes
4.6 ± 3.0
No
4.4 ± 3.0
0.695
3.3 ± 2.7
0.766
3.1 ± 2.9
Independent t test and one-way analysis of variance were used to compare the preoperative mean VAS-anxiety scores between/among the groups categorized within each patient factor. All values are mean ± SD VAS-anxiety visual analog scale of anxiety *P \ 0.05
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Eur Spine J Table 4 Multiple stepwise regression analysis of patient factors and preoperative anxiety level about spinal surgery and general anesthesia Variables (patient factors)
B
b
P
0.206
0.009
0.188
0.018
Spinal surgery (constant)
2.776
Sexa
1.237
General anesthesia (constant)
1.057
Age
0.038
B unstandardized coefficient, b standardized coefficient a
Variables assignment: 1 = male, 2 = female
the most commonly performed procedure [9, 16, 19, 21, 33]. As such, we studied preoperative anxiety about lumbar laminectomy or discectomy. In our study, 87 % of the patients awaiting laminectomy or discectomy had preoperative anxiety with a VAS-anxiety score greater than 0. Among them, 74 % of the patients considered spinal surgery to be the main cause of anxiety. One of the aims of this study was to identify patient factors that might potentially affect the level of preoperative anxiety about spinal surgery. In univariate and multivariate analyses, female patients had a higher level of anxiety about spinal surgery than male patients. This result was consistent with previous studies reporting preoperative anxiety in general [1, 17], otolaryngology [10], oral [26], and open-heart surgery [32]. However, no other patient Table 5 Characteristics of patient anxiety about spinal surgery
factors had a significant influence on the level of anxiety about spinal surgery. Our results differed from the results of previous studies reporting that younger patients [12, 20], patients with a higher level of education [5, 10], and patients with no previous surgical experience [1, 5, 20] had higher anxiety levels. This can perhaps be explained by differences in study populations. Our study population consisted only of patients who underwent laminectomy or discectomy under general anesthesia. However, previous studies conducted surveys targeting patients who were scheduled to be submitted to a variety of elective surgeries either classified as minor, intermediate, or major according to invasiveness, blood loss, and length of hospital stay [5, 10] or that were classified according to surgical subspecialty, e.g., orthopedics or gynecology [1, 12, 20]. These divergent results indicate that preoperative anxiety may vary depending on the specific issue and the associated surgical procedures, outcomes, and risks. Thus, it may be difficult to generalize our results to other populations undergoing different kinds of surgery. Additionally, in univariate analysis, the level of anxiety about general anesthesia was higher in patients with spinal stenosis than HNP. However, this result merely reflected differences in patient age, as shown by the finding that only age was a significant predictor in the multiple regression analysis. Elderly patients might be aware that their morbidity related to general anesthesia is higher than that of younger patients. Thus, it appears that the level of anxiety about general anesthesia increases with patient age.
Characteristics of patient anxiety
Patients (n = 137)a n (%)
Rank
Family or supporting persons
43 (31.4)
2
Religion
21 (15.3)
3
Faith in medical staff
67 (48.9)
1
6 (4.4)
4
30 (24.8)
2
The most helpful factor in overcoming anxiety before surgery
Others The moment of the highest level of anxiety When spinal surgery was recommended
a
Among 157 patients, 20 patients who had no preoperative anxiety about both spinal surgery and general anesthesia were excluded from this analysis
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At the time of the decision to undergo surgery
17 (12.4)
4
The night before surgery
26 (19.0)
3
While waiting for surgery in the waiting/operating room
48 (35.0)
1
4 (8.8)
5
8 (5.8)
3
Others The most helpful factor in reducing anxiety after surgery The fact that the surgery ended Surgeon’s explanation of the surgery performed
99 (72.3)
1
Improvement of symptoms
28 (20.4)
2
2 (1.5)
4
Others
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In our study, more than one-third of patients experienced the highest level of anxiety while in the waiting/operation room. This suggests that preoperative anxiety care is needed for patients in the waiting/operation room before the induction of general anesthesia. In fact, previous studies have reported that premedication, such as diazepam [35, 36], benzodiazepine [11] and beta-blockers [25], and distractions, such as listening to music [22], television viewing [13] and relaxation using audiotapes [23], were effective methods of addressing preoperative anxiety in the waiting/operating room. Additionally, it is worth noting that many other patients (24.8 %) also experienced the highest level of anxiety when spinal surgery was recommended. This result shows that surgeons should be considerate of patient anxiety when recommending spinal surgery. Given that most patients awaiting spinal surgery experienced preoperative anxiety, an examination of ways for patients to overcome this anxiety and to make the decision to receive spinal surgery under general anesthesia is needed. Surprisingly, in our study, the most helpful factor in overcoming anxiety before surgery was neither family support nor religious belief but faith in the medical staff. This suggests that the patient-medical staff relationship is the most important factor in reducing anxiety before surgery. A previous study reported that this relationship can be achieved through sincere and open communication, adequate treatment explanation, and expected outcome [15]. Additionally, in our study, the most helpful factor in reducing anxiety after surgery was the surgeon’s explanation of the surgery. This suggests that providing information about the operation, even if the surgery has already been performed, is still an important part of anxiety prevention. This information could include an explanation of procedures performed during the operation, surgical findings, and the likelihood of possible outcomes and effects. These results showed that the medical staff and surgeon play important roles in overcoming and reducing patient anxiety throughout the perioperative period. In our study, we reassessed the level of anxiety that the patients had about spinal surgery before the operation 7 days after surgery. It was difficult to reassess the level of anxiety immediately after surgery because the patients and medical staff had to concentrate on the recovery. For that reason, when we reassessed the level of anxiety, we asked the patients to reflect on the situation immediately after surgery.
There are some drawbacks and limitations in our study. Firstly, a self-reported measure of anxiety was used that had not been previously validated. It was based on measures used in previous studies of preoperative anxiety but all the items were simply developed by the authors themselves. The test–retest reliability and external validity of the instrument were not evaluated in any way. We chose the VAS-anxiety scale to provide patients with an easy and familiar method of assessing anxiety level. This may not reflect actual physiological anxiety level, such as arterial pressure, heart rate, skin contracture, and cortisol level [28, 34], but rather patients’ subjective willingness to express anxiety. In addition, another point to be considered is that any response 1 or above on the VAS-anxiety was considered to indicate the presence of anxiety. A very low score on the VAS-anxiety may not indicate clinically significant anxiety; there may be a significant difference between evaluating one’s anxiety as 2 vs. 10. Thus, further studies are necessary to determine cutoff scores for a more precise measure of anxiety. It would have been of interest to use a modality with well-established cutoff scores. However, many previous studies have confirmed the validity of the VAS-anxiety scale to detect anxiety level and have reported that it is a useful and easy to use tool for assessing perioperative anxiety [4, 6, 20]. Secondly, although sex and age were statistically significant in our multiple regression model, R2 values were only approximately 0.04, which is a very low effect size. In other words, our multiple regression model accounted for approximately 4 % variance in either type of preoperative anxiety. However, considering the fact that all of the other factors that might affect preoperative anxiety were insignificant, this result is an important finding that could help medical staff or surgeon to reduce patient preoperative anxiety. In conclusion, the present study found that patients fear spinal surgery more than general anesthesia, and that sex and age are significant patient factors related to the level of anxiety about spinal surgery and general anesthesia. This study also suggests that medical staff and surgeons play very important roles in overcoming and reducing patient anxiety during the perioperative period. We recommend that medical staff and surgeons understand patient anxiety about spinal surgery and pay more attention to anxiety care. Conflict of interest
The authors declare no conflict of interest.
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Appendix: Questionnaire for anxiety assessment regarding spinal surgery
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ORIGINAL ARTICLE
Preoperative anxiety about spinal surgery under general anesthesia Jun-Seok Lee • Yong-Moon Park • Kee-Yong Ha Sung-Wook Cho • Geun-Hyeong Bak • Ki-Won Kim
•
Received: 24 December 2013 / Revised: 29 January 2015 / Accepted: 29 January 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose No study has investigated preoperative anxiety about spinal surgery under general anesthesia. The purposes of this study were (1) to determine how many patients have preoperative anxiety about spinal surgery and general anesthesia, (2) to evaluate the level of anxiety, (3) to identify patient factors potentially associated with the level of anxiety, and (4) to describe the characteristics of the anxiety that patients experience during the perioperative period. Methods This study was performed in 175 consecutive patients undergoing laminectomy for lumbar stenosis or discectomy for herniated nucleus pulposus under general anesthesia. Demographic data, information related to surgery, and characteristics of anxiety were obtained using a questionnaire. The level of anxiety was assessed using a visual analog scale of anxiety (VAS-anxiety). Patient factors potentially associated with the level of anxiety were investigated using multiple stepwise regression analysis.
Results Of 157 patients finally included in this study, 137 (87 %) had preoperative anxiety (VAS-anxiety [ 0). The mean VAS-anxiety score for spinal surgery was significantly higher than that for general anesthesia (4.6 ± 3.0 vs. 3.2 ± 2.7; P \ 0.001). Sex and age were significant patient factors related to the level of anxiety about spinal surgery (P = 0.009) and general anesthesia (P = 0.018); female patients had a higher level of anxiety about spinal surgery, and elderly patients had a higher level of anxiety about general anesthesia. The most helpful factors in overcoming anxiety before surgery and in reducing anxiety after surgery were faith in the medical staff (48.9 %) and surgeon’s explanation of the surgery performed (72.3 %), respectively. Conclusions Patients awaiting laminectomy or discectomy feared spinal surgery more than general anesthesia. This study also found that medical staff and surgeons play important roles in overcoming and reducing patient anxiety during the perioperative period. Keywords Preoperative anxiety Laminectomy Discectomy Spinal surgery General anesthesia
J.-S. Lee S.-W. Cho G.-H. Bak K.-W. Kim (&) Department of Orthopaedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 62 Yeouido-dong, Youngdeungpo-ku, Seoul 150-010, Korea e-mail: [email protected]; [email protected] Y.-M. Park Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea K.-Y. Ha Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Introduction Preoperative anxiety is common in patients awaiting surgery [1, 10, 18, 24]. Preoperative anxiety is an unpleasant emotion and may even cause patients to avoid a planned surgery [24]. A high preoperative anxiety state may lead to adverse psychological and physiological outcomes [3]. In addition, increased preoperative anxiety has been suggested to correlate with increased postoperative pain, increased postoperative analgesic requirements, and prolonged recovery and hospital stay [1, 2, 7]. It is thus
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necessary for medical staff and surgeons to understand and manage preoperative anxiety in their patients who are scheduled for spinal surgery. Previous studies have reported the importance of preoperative anxiety in patients undergoing spinal surgery [7, 14, 27, 30, 31]. Most of these studies have focused on the correlation between preoperative anxiety and the outcome of spinal surgery. Although a high level of preoperative anxiety has been found to be associated with a poor outcome after spinal surgery [7, 14, 30], to our knowledge, no reported study has documented preoperative anxiety about spinal surgery under general anesthesia and which patient factors affect the level of anxiety. The purposes of this study were (1) to determine how many patients have preoperative anxiety about spinal surgery and general anesthesia, (2) to evaluate the level of anxiety, (3) to identify patient factors potentially associated with the level of anxiety, and (4) to describe the characteristics of the anxiety that patients experience during the perioperative period.
Materials and methods Subjects From February 2012 to March 2013, 175 consecutive patients diagnosed with spinal stenosis or herniated nucleus pulposus (HNP) of the lumbar spine who were to undergo spinal surgery under general anesthesia at our institution were recruited. Decompressive laminectomy was performed for patients with spinal stenosis and open discectomy for HNP. Patients underwent preanesthetic assessments before surgery, in which the exact details of the planned anesthesia were explained. They also received information from the treating surgeon about the impending surgery. The same surgeon performed all of the procedures. The inclusion criteria were age greater than 20 years, elective spinal surgery, and the ability to complete the questionnaire. The exclusion criteria were emergency or urgent spinal surgery precluding recruitment and investigations, cognitive impairment prohibiting completion of the questionnaire, history of a psychiatric disorder, and refusal to participate in the study. An institutional review board approved the study. All patients provided informed consent. Questionnaire We designed the questionnaire based on those used in previous studies of preoperative anxiety [20, 24] and focused primarily on the patient’s preoperative anxiety about the spinal surgery. The questionnaire consisted of four
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topic areas: patient demographic background, questions related to spinal surgery, questions related to anxiety about spinal surgery, and the visual analog scale of anxiety (VAS-anxiety) (Table 1). All patients admitted to the hospital for spinal surgery received the questionnaire, which was completed in two parts: partially, on admission and in full at 7 days after surgery (‘‘Appendix’’). Patient demographic background The following demographic data were collected: (1) age, (2) sex, (3) education level (less than high school graduate, high school graduate, or college graduate), and (4) residential area (urban or rural). Questions related to spinal surgery The spinal surgery questions related to (1) preoperative diagnosis (lumbar spinal stenosis or HNP), (2) previous experience with surgery under general anesthesia, (3) the number of previous spinal surgeries, (4) the number of previous non-spinal surgeries, and (5) whether the surgery was a revision spinal surgery. In cases of revision surgery, previous spinal surgeries were confirmed from medical records. Questions related to anxiety about spinal surgery The following five questions were used to evaluate characteristics of the patient’s anxiety: (1) presence or absence of preoperative anxiety, (2) main cause of anxiety (spinal surgery vs. general anesthesia), (3) the most helpful factor in overcoming anxiety before surgery (family or supporting persons, religion, faith in medical staff, or other), (4) the moment of the highest level of anxiety (when spinal surgery was recommended, at the time of the decision to undergo surgery, the night before surgery, while waiting for surgery in the waiting/operating room, or other), and (5) the most helpful factor in reducing anxiety after surgery (surgery completion, surgeon’s explanation of the surgery performed, improvement of symptoms, or other). Questions (3), (4), and (5) were enquired about 7 days after surgery. Visual analog scale of anxiety (VAS-anxiety) Patient preoperative anxiety was assessed using an anxiety score based on an 11-point VAS-anxiety scale (range 0–10). The VAS-anxiety scale has been used widely as a self-reported measure of fear and anxiety [4, 6, 20]. A VAS-anxiety score of 0 was defined as no anxiety, and a score of 10 was defined as the worst anxiety imaginable by the patient. Patients assessed their anxiety level
Eur Spine J Table 1 Content of the questionnaire for anxiety assessment regarding spinal surgery Questions Before spinal surgery (on admission) Q1-1. Age Q1-2. Sex Q1-3. What is your highest level of education? Q1-4. What is your current residential area? Q2-1. What is your preoperative diagnosis? Q2-2. Have you undergone previous surgeries under general anesthesia? Q2-3. If you answered yes to question Q2-2, how many surgeries (other than spinal surgeries) have you experienced? Q2-4. Have you undergone previous spinal surgeries? If so, how many? Q2-5. If you have undergone spinal surgeries, are you expecting to have a revision spinal surgery at the same level as the previous time? Q3-1. Do you have any anxiety about the surgery or general anesthesia? Q3-2. If you answered yes to question Q3-1, which is your main cause of anxiety? Q4-1. If you have any anxiety about spinal surgery, how anxious do you feel?a Q4-2. If you have any anxiety about general anesthesia, how anxious do you feel?a 7 days after spinal surgery Q3-3. What helped you to overcome the anxiety and decide to have surgery? Q3-4. When did you experience the most anxiety? Q4-3. If you had any anxiety about spinal surgery before the operation, how did it change after surgery?a Q3-5. If your preoperative anxiety about spinal surgery was reduced after the operation, what was your main reason for reduction in anxiety? The questionnaire consists of four topic areas: patient demographics (Q1), questions related to spinal surgery (Q2), questions related to anxiety about spinal surgery (Q3), and the visual analog scale of anxiety (Q4) a
A score of 0 indicates no anxiety; 10, the worst anxiety imaginable. See more detail in the ‘‘Appendix’’
subjectively. Patients who rated their anxiety as greater than 0 on the VAS-anxiety scale were considered to have anxiety. Preoperative anxiety about spinal surgery and general anesthesia was assessed using the VAS-anxiety scale (‘‘Appendix’’). The level of anxiety that the patients had about spinal surgery before the operation was reassessed about 7 days after surgery. Patient factors To identify patient factors potentially associated with the level of anxiety, we defined patient factors as follows: (1) age, (2) sex, (3) educational level, (4) residential area, (5) preoperative diagnosis, (6) previous surgical experience, (7) the number of previous spinal surgeries, (8) the number of previous non-spinal surgeries, and (9) whether or not the surgery was a revision spinal surgery (Table 2). Statistical analyses Paired t test was used to compare the preoperative mean VAS-anxiety scores for spinal surgery with general anesthesia and to compare the mean VAS-anxiety scores for spinal surgery before and after the operation. Univariate
analyses using independent t test and one-way analysis of variance (ANOVA) were performed to compare the preoperative mean VAS-anxiety scores between/among the groups categorized within each patient factor. A multiple stepwise regression analysis was performed to determine which patient factors affected the level of preoperative anxiety about spinal surgery. Ten variables were entered into the multiple stepwise regression analysis with preoperative VAS-anxiety score for spinal surgery as a dependent variable and age, sex, educational level, residential area, preoperative diagnosis, previous surgical experience, number of previous spinal surgeries, number of previous non-spinal surgeries, and whether the surgery was a revision spinal surgery as independent variables. VAS-anxiety score and age were entered as continuous variables and others were entered as dummy variables. The multiple regression variable inclusion criterion was P \ 0.05, whereas the exclusion criterion was P [ 0.1. A multiple stepwise regression analysis was also performed to determine which patient factors affected the level of preoperative anxiety about general anesthesia. P values were considered to indicate statistical significance at \0.05. All statistical analyses were performed using the SPSS software (ver. 12.0; SPSS Corp., Chicago, IL, USA).
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Results Of the initial 175 patients, 18 patients who returned incomplete questionnaires were excluded. Thus, 157 patients were finally included in this study. Among them, 137 patients (87 %) had preoperative anxiety (VAS-anxiety score [ 0) for either spinal surgery, general anesthesia, or both. The main cause of preoperative anxiety was spinal surgery in 101 patients (74 %) and general anesthesia in 36 patients (26 %).
Table 2 Characteristics of patients (n = 157)
The preoperative mean VAS-anxiety score for spinal surgery was significantly higher than that for general anesthesia (4.6 ± 3.0 vs. 3.2 ± 2.7; P \ 0.001). Figure 1 shows the levels of preoperative anxiety about spinal surgery and general anesthesia in the patients. The mean VAS-anxiety score for spinal surgery decreased significantly to 1.2 ± 1.5 after surgery (P \ 0.001). Univariate analyses using t test and ANOVA revealed that female patients had a significantly higher level of preoperative anxiety about spinal surgery than male
Patient factors
Number
Age (mean years ± SD, range)
59.5 ± 13.8, 20–88
Sex Male/female Educational level \High school graduate/high school graduate/college graduate
77/80 63/53/41
Residential area Urban/rural
136/21
Preoperative diagnosis Lumbar stenosis/lumbar HNP
96/61
Previous surgical experience Yes/no
106/51
Number of previous spinal surgeries 0/1/C2
128/22/7
Number of previous non-spinal surgeries 0/1/2/3/C4
51/47/32/20/7
Revision spinal surgery at the same level Yes/no
Fig. 1 Levels of patient preoperative anxiety about spinal surgery and general anesthesia
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patients (5.2 ± 3.0 vs. 4.0 ± 2.8; P = 0.009). Additionally, stenosis patients had a significantly higher level of preoperative anxiety about general anesthesia than HNP patients (3.6 ± 2.6 vs. 2.6 ± 2.8; P = 0.022). However, there was no significant difference in the comparison of preoperative mean VAS-anxiety scores according to other patient factors (Table 3). Multiple stepwise regression analysis was performed to identify patient factors potentially associated with the level of preoperative anxiety about spinal surgery and about general anesthesia. Finally, in the data for spinal surgery, only one patient factor, sex, was retained (R2 = 0.043, F = 6.904, P = 0.009), while in the data for general anesthesia, the patient factor of age was retained (R2 = 0.036, F = 5.710, P = 0.018; Table 4).
Table 5 shows the characteristics of patient anxiety about spinal surgery. The most helpful factor in overcoming anxiety before surgery was faith in the medical staff (48.9 %). The moment of the highest level of anxiety occurred while waiting for surgery in the waiting/operating room (35 %). The most helpful factor in reducing anxiety after surgery was surgeon’s explanation of the surgery performed (72.3 %).
Discussion Various types of spinal surgeries have been performed for patients with spinal disease [8, 29, 33]. Among them, decompression surgery such as laminectomy or discectomy is
Table 3 Univariate comparison of the preoperative mean VAS-anxiety score for spinal surgery and for general anesthesia Patient factors
VAS-anxiety for spinal surgery
P value
VAS-anxiety for general anesthesia
P value
4.0 ± 2.8 5.2 ± 3.0
0.009*
2.8 ± 2.5 3.7 ± 2.8
0.063
\High school graduate
4.9 ± 2.8
0.063
3.7 ± 2.7
0.251
High school graduate
3.7 ± 3.1
3.0 ± 2.6
College graduate
4.5 ± 2.7
3.0 ± 2.8
Sex Male Female Educational level
Residential area Urban
4.5 ± 3.0
Rural
5.0 ± 2.6
0.561
3.3 ± 2.7
0.716
3.0 ± 2.7
Preoperative diagnosis Lumbar stenosis
4.7 ± 2.7
Lumbar HNP
4.4 ± 3.3
0.542
3.6 ± 2.6
0.022*
2.6 ± 2.8
Previous surgical experience Yes
4.5 ± 3.1
No
4.8 ± 2.7
0.644
3.3 ± 2.8
0.610
3.1 ± 2.5
Number of previous spinal surgeries 0 1
4.6 ± 3.0 4.5 ± 2.7
C2
4.8 ± 3.6
0.971
3.3 ± 2.7 2.4 ± 2.7
0.072
5.1 ± 2.4
Number of previous of non-spinal surgeries 0
4.8 ± 2.7
0.364
3.1 ± 2.5
1
4.9 ± 2.9
2
4.5 ± 3.0
3.5 ± 3.0
3
4.3 ± 3.2
3.3 ± 3.1
C4
2.5 ± 3.8
3.5 ± 2.6
0.960
3.2 ± 2.6
Revision spinal surgery at the same level Yes
4.6 ± 3.0
No
4.4 ± 3.0
0.695
3.3 ± 2.7
0.766
3.1 ± 2.9
Independent t test and one-way analysis of variance were used to compare the preoperative mean VAS-anxiety scores between/among the groups categorized within each patient factor. All values are mean ± SD VAS-anxiety visual analog scale of anxiety *P \ 0.05
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Eur Spine J Table 4 Multiple stepwise regression analysis of patient factors and preoperative anxiety level about spinal surgery and general anesthesia Variables (patient factors)
B
b
P
0.206
0.009
0.188
0.018
Spinal surgery (constant)
2.776
Sexa
1.237
General anesthesia (constant)
1.057
Age
0.038
B unstandardized coefficient, b standardized coefficient a
Variables assignment: 1 = male, 2 = female
the most commonly performed procedure [9, 16, 19, 21, 33]. As such, we studied preoperative anxiety about lumbar laminectomy or discectomy. In our study, 87 % of the patients awaiting laminectomy or discectomy had preoperative anxiety with a VAS-anxiety score greater than 0. Among them, 74 % of the patients considered spinal surgery to be the main cause of anxiety. One of the aims of this study was to identify patient factors that might potentially affect the level of preoperative anxiety about spinal surgery. In univariate and multivariate analyses, female patients had a higher level of anxiety about spinal surgery than male patients. This result was consistent with previous studies reporting preoperative anxiety in general [1, 17], otolaryngology [10], oral [26], and open-heart surgery [32]. However, no other patient Table 5 Characteristics of patient anxiety about spinal surgery
factors had a significant influence on the level of anxiety about spinal surgery. Our results differed from the results of previous studies reporting that younger patients [12, 20], patients with a higher level of education [5, 10], and patients with no previous surgical experience [1, 5, 20] had higher anxiety levels. This can perhaps be explained by differences in study populations. Our study population consisted only of patients who underwent laminectomy or discectomy under general anesthesia. However, previous studies conducted surveys targeting patients who were scheduled to be submitted to a variety of elective surgeries either classified as minor, intermediate, or major according to invasiveness, blood loss, and length of hospital stay [5, 10] or that were classified according to surgical subspecialty, e.g., orthopedics or gynecology [1, 12, 20]. These divergent results indicate that preoperative anxiety may vary depending on the specific issue and the associated surgical procedures, outcomes, and risks. Thus, it may be difficult to generalize our results to other populations undergoing different kinds of surgery. Additionally, in univariate analysis, the level of anxiety about general anesthesia was higher in patients with spinal stenosis than HNP. However, this result merely reflected differences in patient age, as shown by the finding that only age was a significant predictor in the multiple regression analysis. Elderly patients might be aware that their morbidity related to general anesthesia is higher than that of younger patients. Thus, it appears that the level of anxiety about general anesthesia increases with patient age.
Characteristics of patient anxiety
Patients (n = 137)a n (%)
Rank
Family or supporting persons
43 (31.4)
2
Religion
21 (15.3)
3
Faith in medical staff
67 (48.9)
1
6 (4.4)
4
30 (24.8)
2
The most helpful factor in overcoming anxiety before surgery
Others The moment of the highest level of anxiety When spinal surgery was recommended
a
Among 157 patients, 20 patients who had no preoperative anxiety about both spinal surgery and general anesthesia were excluded from this analysis
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At the time of the decision to undergo surgery
17 (12.4)
4
The night before surgery
26 (19.0)
3
While waiting for surgery in the waiting/operating room
48 (35.0)
1
4 (8.8)
5
8 (5.8)
3
Others The most helpful factor in reducing anxiety after surgery The fact that the surgery ended Surgeon’s explanation of the surgery performed
99 (72.3)
1
Improvement of symptoms
28 (20.4)
2
2 (1.5)
4
Others
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In our study, more than one-third of patients experienced the highest level of anxiety while in the waiting/operation room. This suggests that preoperative anxiety care is needed for patients in the waiting/operation room before the induction of general anesthesia. In fact, previous studies have reported that premedication, such as diazepam [35, 36], benzodiazepine [11] and beta-blockers [25], and distractions, such as listening to music [22], television viewing [13] and relaxation using audiotapes [23], were effective methods of addressing preoperative anxiety in the waiting/operating room. Additionally, it is worth noting that many other patients (24.8 %) also experienced the highest level of anxiety when spinal surgery was recommended. This result shows that surgeons should be considerate of patient anxiety when recommending spinal surgery. Given that most patients awaiting spinal surgery experienced preoperative anxiety, an examination of ways for patients to overcome this anxiety and to make the decision to receive spinal surgery under general anesthesia is needed. Surprisingly, in our study, the most helpful factor in overcoming anxiety before surgery was neither family support nor religious belief but faith in the medical staff. This suggests that the patient-medical staff relationship is the most important factor in reducing anxiety before surgery. A previous study reported that this relationship can be achieved through sincere and open communication, adequate treatment explanation, and expected outcome [15]. Additionally, in our study, the most helpful factor in reducing anxiety after surgery was the surgeon’s explanation of the surgery. This suggests that providing information about the operation, even if the surgery has already been performed, is still an important part of anxiety prevention. This information could include an explanation of procedures performed during the operation, surgical findings, and the likelihood of possible outcomes and effects. These results showed that the medical staff and surgeon play important roles in overcoming and reducing patient anxiety throughout the perioperative period. In our study, we reassessed the level of anxiety that the patients had about spinal surgery before the operation 7 days after surgery. It was difficult to reassess the level of anxiety immediately after surgery because the patients and medical staff had to concentrate on the recovery. For that reason, when we reassessed the level of anxiety, we asked the patients to reflect on the situation immediately after surgery.
There are some drawbacks and limitations in our study. Firstly, a self-reported measure of anxiety was used that had not been previously validated. It was based on measures used in previous studies of preoperative anxiety but all the items were simply developed by the authors themselves. The test–retest reliability and external validity of the instrument were not evaluated in any way. We chose the VAS-anxiety scale to provide patients with an easy and familiar method of assessing anxiety level. This may not reflect actual physiological anxiety level, such as arterial pressure, heart rate, skin contracture, and cortisol level [28, 34], but rather patients’ subjective willingness to express anxiety. In addition, another point to be considered is that any response 1 or above on the VAS-anxiety was considered to indicate the presence of anxiety. A very low score on the VAS-anxiety may not indicate clinically significant anxiety; there may be a significant difference between evaluating one’s anxiety as 2 vs. 10. Thus, further studies are necessary to determine cutoff scores for a more precise measure of anxiety. It would have been of interest to use a modality with well-established cutoff scores. However, many previous studies have confirmed the validity of the VAS-anxiety scale to detect anxiety level and have reported that it is a useful and easy to use tool for assessing perioperative anxiety [4, 6, 20]. Secondly, although sex and age were statistically significant in our multiple regression model, R2 values were only approximately 0.04, which is a very low effect size. In other words, our multiple regression model accounted for approximately 4 % variance in either type of preoperative anxiety. However, considering the fact that all of the other factors that might affect preoperative anxiety were insignificant, this result is an important finding that could help medical staff or surgeon to reduce patient preoperative anxiety. In conclusion, the present study found that patients fear spinal surgery more than general anesthesia, and that sex and age are significant patient factors related to the level of anxiety about spinal surgery and general anesthesia. This study also suggests that medical staff and surgeons play very important roles in overcoming and reducing patient anxiety during the perioperative period. We recommend that medical staff and surgeons understand patient anxiety about spinal surgery and pay more attention to anxiety care. Conflict of interest
The authors declare no conflict of interest.
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Appendix: Questionnaire for anxiety assessment regarding spinal surgery
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