JMIR Publications

ABSTRACT

Background:

Patients undergoing lower limb orthopedic surgery under spinal anesthesia remain conscious throughout the procedure, which can generate substantial perioperative anxiety and amplify pain perception. Virtual reality (VR) is a non-pharmacological distraction technique that may reduce anxiety and improve the perioperative experience, but evidence specific to lower limb orthopedic surgery under spinal anesthesia remains limited.

Objective:

This study assessed whether perioperative VR exposure reduces anxiety, measured with the 6-item State-Trait Anxiety Inventory (STAI-6), compared with standard care in patients undergoing lower limb orthopedic surgery under spinal anesthesia. Secondary objectives addressed anxiety on the Amsterdam Preoperative Anxiety and Information Scale (APAIS) and a visual analog scale (VAS), pain intensity, sedative and analgesic consumption, hemodynamic stability, postoperative complications, and satisfaction of patients and clinical teams.

Methods:

This prospective, single-center, randomized controlled trial allocated 180 patients (1:1) to a VR group (perioperative VR exposure plus standard care, n=90) or a control group (standard care alone, n=90). Blinding of participants and clinical staff was not feasible given the visible nature of the intervention. Between-group comparisons used the χ² or Fisher exact test for categorical variables and Student t test or Mann-Whitney U test for continuous variables, according to distribution. Repeated STAI-6 and VAS-anxiety/pain measurements were analyzed with two-way mixed-design analysis of variance (ANOVA; group × time), with Greenhouse-Geisser correction where sphericity was violated. Significance was set at P<.05.

Results:

Baseline characteristics and STAI-6 scores were comparable between groups (48.9 [SD 9.3] VR vs 47.4 [SD 9.6] control on the 20–80 normalized scale, P=.32). Postoperatively, STAI-6 scores were markedly lower in the VR group (36.8 [SD 8.2]) than in the control group (47.2 [SD 8.8], P<.001), with a significant group × time interaction (F1,178=47.8, P<.001, partial η²=0.21). VAS-anxiety showed a comparable interaction (F4.2,744.5=10.0, P<.001), with lower scores in the VR group from the post-incision assessment onward. VAS-pain likewise diverged after incision, favoring the VR group at hour 6 (3.5 [SD 2.7] vs 6.4 [SD 3.0], P<.001). Midazolam was required in 20.0% of VR patients versus 56.7% of controls (P<.001). Postoperative nausea (18.9% vs 36.7%, P=.01) and headache (15.6% vs 35.6%, P=.004) were less frequent in the VR group. Very high patient satisfaction was reported by 81.1% of VR patients versus 16.7% of controls (P<.001), with comparable patterns for the anesthesia and surgical teams. Time from spinal anesthesia to full motor recovery was longer in the VR group (median 226 vs 190 minutes, P<.001).

Conclusions:

Perioperative VR distraction was associated with lower anxiety and pain scores, reduced midazolam requirements, fewer postoperative complications, and higher satisfaction among patients and clinical teams, without adverse effects on hemodynamic stability. These findings support VR as a feasible adjunct to standard perioperative care in patients undergoing lower limb orthopedic surgery under spinal anesthesia. Clinical Trial: NCT07134764