Elsevier

The Spine Journal

Volume 19, Issue 1, January 2019, Pages 121-130
The Spine Journal

Clinical Study
Patient-reported allergies predict postoperative outcomes and psychosomatic markers after spine surgery

https://doi.org/10.1016/j.spinee.2018.05.032Get rights and content

Abstract

Background Context

Prior studies have shown that patient-reported allergies can be prognostic of poorer postoperative outcomes.

Purpose

The objective of this study was to investigate the correlation between self-reported allergies and outcomes after cervical or lumbar spine surgery.

Study Design/Setting

This is a retrospective cohort study at a single tertiary care institution.

Patient Sample

The patient sample included all patients undergoing cervical or lumbar spine surgery from 2009 to 2014.

Outcome Measures

The primary outcome measure was change in the EuroQol-5 Dimensions (EQ-5D) after surgery. Secondary outcomes included changes in the Pain Disability Questionnaire (PDQ) and in the Patient Health Questionnaire-9 (PHQ-9), achievement of the minimal clinically important difference (MCID) in these measures, and cost of admission.

Methods

Before and after surgery, EQ-5D, PDQ, and PHQ-9 were recorded for patients with available data. Paired Student t tests were used to compare changes in these measures after surgery. Multivariable linear and logistic regressions were used to assess the relationship between the log transformation of the total number of allergies and outcomes.

Results

A total of 592 cervical patients and 4,465 lumbar patients were included. The median number of reported allergies was two. The EQ-5D index increased from 0.539 to 0.703 for cervical patients and from 0.530 to 0.676 for lumbar patients (p<.01 for both). Patients experienced significant pain improvement by the PDQ (80.1–58.2 for cervical patients and 79.4–58.1 for lumbar patients, p<.01). Using multivariable logistic regression, the log transformation of the number of allergies predicted significantly higher odds of achieving the PDQ MCID (odds ratio [OR]=2.09, 95% confidence interval [CI] 1.05–4.15, p=.02, for cervical patients; OR=1.30, 95% CI 1.03–1.68, p=.03, for lumbar patients). However, this relationship was not durable for patients with follow-up exceeding 1 year. The log transformation of the number of allergies for lumbar patients predicted a significantly increased cost of admission (β=$3,597, p<.01) and trended toward significance among cervical patients (β=$1,842, p=.10).

Conclusions

Patient-reported allergies correlate with subjective improvement in pain and disability after spine surgery and may serve as a marker of postoperative outcomes. The relationship between allergies and PDQ improvement may be secondary to the short-term expectation-actuality discrepancy, as this relationship was not durable beyond 1 year.

Introduction

Collecting an accurate list of allergies from the medical history is critical for patient care. Importantly, it is unclear whether patient-reported allergies represent true allergic reactions, adverse effects, or other factors. For example, the most common patient-reported drug allergy is penicillin allergy. However, in one hospital cohort, only a minority of patients who have reported or have had a documented penicillin allergy in the medical record have been proven to be positive for penicillin via allergy testing or drug challenge [1]. Even if patient-reported allergies have not been verified through testing, they can still influence patient care. For example, patients who report penicillin allergies have increased broad-spectrum antibiotic use, greater antibiotic costs, and more frequent drug-resistant infections compared with those without the allergy as less optimal antimicrobial therapies may be used in treatment because of this reported allergy. These patients also experience longer hospital stays, more complicated hospital courses, increased likelihood of an intensive care unit admission, and increased risk of mortality during the hospitalization [1], [2], [3].

In addition, patient-reported allergies are also correlated with significant underlying psychosomatic burden. In a Canadian cohort, patient-reported allergies correlated with Axis I psychological disorders, including major depression, bipolar and panic disorders, and social phobia [4]. Other studies have shown a correlation between drug hypersensitivity reactions and anxiety [5], as well as between allergies and suicide mortality. The association between allergies and non-fatal suicidal behaviors is still unclear [6]. Finally, a cohort study of patients suffering from drug intolerance or insect venom allergies has shown that patients reporting these reactions have scored significantly higher on questionnaires measuring somatization and have worse health-related quality of life (QOL), frequently reporting higher levels of anxiety relative to the normal population [7].

In the present study, we investigated whether or not patients who self-report more allergies before undergoing cervical or lumbar spine surgery have worse outcomes after surgery. We hypothesized that patient-reported allergies are associated with poorer postoperative outcomes and higher admission costs and thus may serve as a prognostic factor for outcomes after spinal surgery.

Section snippets

Data collection

Institutional review board approval was obtained before study initiation. No patient consent was required, given the retrospective nature of the present study. A retrospective cohort study of all patients undergoing cervical or lumbar spine surgery at a tertiary care center between January 2009 and December 2014 was performed. Queried data were collected from institutional audited data warehouses and included demographics, comorbidities, insurance status, length of hospital stay, and operative

Results

Five hundred ninety-two cervical spine patients and 4,465 lumbar spine patients were included in the present study (Table 1). Patients had an average age of 56.2 and 60.8 years for cervical and lumbar procedures, respectively. The patient demographics were slightly predisposed toward men in both cervical (43% women) and lumbar (48% women) patient groups. However, when subset by the presence of allergies, women less often had no allergies among cervical (26%) and lumbar (29%) patients (Table S1,

Discussion

In the present study of over 5,000 patients undergoing cervical and lumbar spine surgeries, we identified numerous patients with extensive self-reported allergies. In this cohort, the number of patient-reported allergies was associated with superior postoperative improvements in pain-related QOL as measured by the PDQ. Additionally, the total number of allergies significantly correlated with higher admission costs and longer lengths of stay.

Previous studies have identified potential

Conclusions

In conclusion, patient-reported allergy burden is significantly correlated with reductions in postoperative pain burden, as well as increased costs of care during the hospital admission and longer lengths of stay, and thus may serve as a useful prognostic factor for these postsurgical outcomes. The relationship between patient-reported allergies and reduction in PDQ may be secondary to the effects of the expectation-actuality discrepancy, as this relationship was observed for patients with

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    FDA device/drug status: Not applicable.

    Author disclosures: DDX: Nothing to disclose. WY: Nothing to disclose. RX: Nothing to disclose. JAM: Nothing to disclose. TEM: Stock Ownership: PearlDiver Inc (none); Consulting: Globus Medical (B); Speaking and/or Teaching Arrangements: AOSpine (B), outside the submitted work. MPS: Nothing to disclose. SJN: Nothing to disclose. AGM: Stock Ownership: ATI (none), Cardionomics (none), Enspire (none); Consulting: Functional Neuromodulation (B), Spinal Modulation (B), St. Jude (B), outside the submitted work.

    The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

    This study was not supported by any kind of funding.

    The authors declare no conflicts of interest associated with the study.

    Institutional review board approval (16–153) was obtained before the start of the study.

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