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Influence of Catastrophizing, Anxiety, and Depression on In-Hospital Opioid Consumption, Pain, and Quality of Recovery After Adult Spine Surgery

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Influence of Catastrophizing, Anxiety, and Depression on In-Hospital Opioid Consumption, Pain, and Quality of Recovery After Adult Spine Surgery CLINICAL ARTICLE J Neurosurg Spine 28:119–126, 2018 Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery Lauren K. Dunn, MD, PhD,1 Marcel E. Durieux, MD, PhD,1,2 Lucas G. Fernández, MD, DSc,1 Siny Tsang, PhD,3 Emily E. Smith-Straesser, MD,1 Hasan F. Jhaveri,1 Shauna P. Spanos, MD,1 Matthew R. Thames, MD, MBA,1 Christopher D. Spencer, MD, MSc,1 Aaron Lloyd, MD,1 Russell Stuart, MD,1 Fan Ye, MD, MPH,1 Jacob P. Bray, MD,1 Edward C. Nemergut, MD,1,2 and Bhiken I. Naik, MBBCh1,2 Departments of 1Anesthesiology and 2Neurosurgery, University of Virginia, Charlottesville, Virginia; and 3Department of Epidemiology, Columbia University, New York, New York OBJECTIVE Perception of perioperative pain is influenced by various psychological factors. The aim of this study was to determine the impact of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain scores, and quality of recovery in adults who underwent spine surgery. METHODS Patients undergoing spine surgery were enrolled in this study, and the preoperatively completed question- naires included the verbal rating scale (VRS), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), and Oswestry Disability Index (ODI). Quality of recovery was assessed using the 40-item Quality of Recovery questionnaire (QoR40). Opioid consumption and pain scores according to the VRS were recorded daily until discharge. RESULTS One hundred thirty-nine patients were recruited for the study, and 101 completed the QoR40 assessment postoperatively. Patients with higher catastrophizing scores were more likely to have higher maximum pain scores postoperatively (estimate: 0.03, SE: 0.01, p = 0.02), without increased opioid use (estimate: 0.44, SE: 0.27, p = 0.11). Preoperative anxiety (estimate: 1.18, SE: 0.65, p = 0.07) and depression scores (estimate: 1.06, SE: 0.71, p = 0.14) did not correlate with increased postoperative opioid use; however, patients with higher preoperative depression scores had lower quality of recovery after surgery (estimate: -1.9, SE: 0.56, p < 0.001). CONCLUSIONS Catastrophizing, anxiety, and depression play important roles in modulating postoperative pain. Preop- erative evaluation of these factors, utilizing a validated tool, helps to identify patients at risk. This might allow for earlier psychological intervention that could reduce pain severity and improve the quality of recovery. https://thejns.org/doi/abs/10.3171/2017.5.SPINE1734 KEY WORDS pain catastrophizing; anxiety; depression; spine surgery ERCEPTION and severity of perioperative pain are nation, and helplessness.11 High levels of catastrophizing influenced by various biological, cultural, and psy- are correlated with increased reported pain intensity and chological factors.31 The psychological factors that a greater incidence of chronic pain and are an indepen- Pimpact postoperative recovery include catastrophizing, dent determinant of disability in patients with chronic pain anxiety, and depression.4 Catastrophizing is an exagger- syndromes.1,8,14,20,22,32,35 Subsets of patients who tend to dis- ated behavioral response to anticipated or actual pain and play higher levels of catastrophizing include women and influences the perception of pain.10,33 It can account for younger patients.9,10,12,34 between 7% and 13% of variation in pain scores.31 Cata- Patients with spine disease have a high incidence of strophizing includes 3 components: magnification, rumi- chronic pain, increased disability, and poor quality of life.21 ABBREVIATIONS ASA = American Society of Anesthesiologists; CBT = cognitive behavioral therapy; HADS = Hospital Anxiety and Depression Scale; ICU = intensive care unit; LMM = linear mixed effects model; ODI = Oswestry Disability Index; PACU = post-anesthesia care unit; PCA = patient-controlled analgesia; PCS = Pain Catastroph- izing Scale; QoR40 = 40-item quality of recovery questionnaire; VRS = verbal rating scale. SUBMITTED January 7, 2017. ACCEPTED May 22, 2017. INCLUDE WHEN CITING Published online November 10, 2017; DOI: 10.3171/2017.5.SPINE1734. ©AANS 2018, except where prohibited by US copyright law J Neurosurg Spine Volume 28 • January 2018 119 Unauthenticated | Downloaded 09/26/21 07:48 PM UTC L. K. Dunn et al. Interestingly, perceived back and leg pain and the level of ketamine, dexmedetomidine, intravenous acetamino- disability are not correlated with objective markers of the phen). Surgery-specific data included primary versus re- severity of spinal disease.16,27 Psychological factors may peat surgery, site of surgery (cervical, thoracic, or lumbar), play an important role in pain perception and the manage- anterior versus posterior approach, number of interver- ment of patients with spine-related chronic pain.1,12,13 tebral procedures (transforaminal lumbar interbody fu- The aim of this study was to determine the impact of sions), and number of osteotomies performed. catastrophizing, anxiety, and depression on in-hospital Collected postoperative data included total daily opioid opioid consumption, pain scores, and quality of recovery consumption, nonopioid medications (including lidocaine, in adults who underwent spine surgery. ketamine, dexmedetomidine, and acetaminophen), daily VRS score (including the highest, lowest, and median Methods scores), time to first ambulation, intensive care unit (ICU) length of stay, and hospital length of stay. This prospective single-center observational study of adults undergoing spine surgery was approved by the Uni- Perioperative Analgesia versity of Virginia Institutional Review Board for Health Science Research, and the need for written consent was Postoperatively, all study participants were admitted waived. We enrolled patients between 18 and 80 years of to either the post-anesthesia care unit (PACU) or the ICU age who were scheduled for cervical, thoracic, and/or lum- based on the extent of surgery and consistent with our in- bar spine surgery and could read and speak English. We stitutional practice. Postoperative opioid analgesia was excluded patients undergoing emergency surgery, preg- administered according to a standardized protocol. This nant females, and prisoners. Subjects were enrolled from included the use of a hydromorphone patient-controlled April 2015 to April 2016. analgesia (PCA) pump with a patient-controlled bolus dose of 0.1 mg with a lockout period of 8 minutes. If pain Study Protocol control was inadequate, the PCA pump could be adjusted according to standardized institutional practice. In addi- After verbal consent was obtained, demographic data tion to the intravenous opioid regimen, oral oxycodone were collected (patient sex, age, and American Society was initiated when oral intake was commenced and was of Anesthesiologists [ASA] physical status classification increased if pain control remained inadequate. [Arabic numbers were used for the classification to per- form statistical analysis]). The preoperative use of opioid Statistical Analysis and nonopioid medications, including nonsteroidal anti- inflammatory drugs, gabapentinoids, benzodiazepines, Continuous variables are presented as the mean and and muscle relaxants was recorded. All opioids used dur- standard deviation. Dichotomous variables are presented ing the perioperative period were converted to morphine as percentages, whereas count variables are presented as equivalents to facilitate analysis (http://www.uptodate. the median and range. Linear regression models were used com/contents/cancerpain-management-with-opioids- to examine the associations between preoperative and optimizing-analgesia). An 11-point verbal rating scale postoperative characteristics. (VRS) was used to quantify pre- and postoperative pain. The effects of preoperative characteristics (catastroph- izing, anxiety, and depression) on repeatedly measured Questionnaires postoperative characteristics were examined using mixed effects models, controlling for patient demographic char- In addition to the VRS, other questionnaires complet- acteristics, preoperative morphine use, surgical proce- ed prior to surgery included the 1) Pain Catastrophizing dures, and intraoperative characteristics. Linear mixed Scale (PCS), a 13-item scale that evaluates rumination, effects models (LMMs) were used for continuous post- magnification, and helplessness associated with pain, with operative characteristics (opioid use and pain scores). The each item rated on a 5-point scale: 0 (not at all) to 4 (all the LMMs are adopted to take into account the correlated time); 2) Hospital Anxiety and Depression Scale (HADS), observations within subjects. For each observation j in pa- a 14-item scale (7 items each for anxiety and depression), tient i, the general form of the LMM is written as follows: with each item scored from 0 to 3; and 3) Oswestry Dis- yij = β0 + β1x1ij + β2x2ij . βnxnij + bi0 + bi1z1ij + . binznij + ability Index (ODI).6,11,27 εij, where yij is the outcome variable, βn are the fixed effect Quality of recovery after surgery was assessed using coefficients associated with the fixed effect predictors xnij, the 40-item quality of recovery questionnaire (QoR40), bin are the random effect coefficients associated with the which measures 5 aspects (dimensions) of recovery: emo- random effect predictors znij, and εij is the random error. tional state (9 items), physical comfort (12 items), psycho- In this study, the preoperative characteristic of inter- logical support (7 items),
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