If you live with MCAD (also known as MCAS), it’s normal to feel uneasy about spine surgery: medications, contrast agents, antibiotics, stress, pain, and temperature changes can all act as triggers. The good news is that, with a well-coordinated perioperative plan, many people go through major procedures with greater safety and fewer scares.
- MCAD does not mean “I can’t have surgery”, but it does mean “I need a plan”.
- Your personal history of reactions and triggers matters more than any generic medication list.
- True coordination between anesthesia, surgery, and (when needed) allergy/immunology is the cornerstone.
- Multimodal pain control and minimizing opioids can help in selected profiles, but it’s neither a promise nor a requirement.
- The postoperative period is a risk window: nausea, pain, constipation, sleep, and restarting medications should be planned.
- There are warning signs that require urgent care, whether you have MCAD or not.
1) MCAD/MCAS in two minutes: what it is and why it matters in the OR
MCAD (mast cell activation disorder) refers to a group of conditions in which mast cells release mediators (such as histamine and others) too strongly or inappropriately. This can cause symptoms across multiple systems: skin (hives, itching, flushing), gastrointestinal (abdominal pain, diarrhea), respiratory (bronchospasm), cardiovascular (lightheadedness, low blood pressure), and neurological (brain fog, headache).
In the perioperative setting, several potential “triggers” come together: stress, pain, temperature shifts, skin manipulation, new medications, antibiotics, antiseptics, latex, and sometimes contrast agents. Not every person with MCAD reacts to everything, and not every reaction is anaphylaxis. But the goal is the same: reduce the chance of massive mediator release and be ready in case it happens.
2) Symptoms and indications: when a “reinforced” perioperative plan makes sense
You don’t need a formal “label” to take precautions. In practice, it’s worth stepping up planning if you recognize yourself in any of these situations:
You’ve had prior reactions during medical procedures
For example: severe hives, bronchospasm, low blood pressure, fainting, uncontrollable vomiting, or a picture compatible with anaphylaxis after antibiotics, painkillers, anesthesia, contrast agents, antiseptics, or injections.
You have multiple drug sensitivities or hard-to-explain “intolerances”
Especially if there’s a repeated pattern (flushing, palpitations, itching, diarrhea, chest tightness) with different medications or situations.
There are coexisting conditions that make surgical stress harder to tolerate
Such as dysautonomia, hypermobility, sleep disorders, widespread chronic pain, or severe fatigue. These aren’t “contraindications”, but they do change the plan.
The planned surgery is long or physiologically demanding
In general, longer procedures mean more medications and more stimuli: the need to anticipate (pain, nausea, temperature, hydration) increases.
3) Diagnosis: what to review before moving toward surgery
In MCAD/MCAS, diagnosis often combines symptoms, episode patterns, response to treatment, and ruling out other causes. For surgical planning, the most useful thing isn’t “a label”, but a risk map:
Your reaction history, written clearly
A chronological list including: what medication or exposure it was, approximate dose, how fast it started, what symptoms occurred, what treatment was used, and how it resolved. If you have ER or allergy/immunology notes, even better.
Non-drug triggers
Heat, cold, friction, adhesives, intense anxiety, prolonged fasting, exercise, high-histamine foods, hormonal shifts. In the OR, these details matter.
Current daily meds and the “rescue” meds you know you tolerate
Which antihistamines, H2 blockers, mast-cell stabilizers, or leukotriene modifiers you take and how you respond. And which rescue medications you’ve tolerated during past episodes.
If mastocytosis or another condition is suspected, the right specialist should lead
MCAD and mastocytosis are not the same. In some patients, confirming or ruling out mastocytosis changes perioperative strategy. This should be handled by a clinician experienced in the field.
4) Alternatives to surgery: options while you decide
MCAD shouldn’t push you to “just endure” a serious structural problem, but it does call for clear-headed decision-making. Depending on the spine diagnosis, there may be alternatives or bridge strategies:
Well-structured conservative treatment
Tailored physiotherapy, progressive therapeutic exercise, pain education, ergonomics, and a sleep plan. For people with sensitivities, “more intensity” isn’t always better: what matters is what you can sustain.
Pain control with a multimodal approach
When drug tolerance is limited, the key is individualization and avoiding unsupervised trial-and-error. Sometimes non-pharmacological measures and previously tolerated medications are prioritized.
Injections or interventional procedures
They can help in some cases, but in MCAD the risk of reacting to local anesthetics, contrast agents, or excipients must be weighed carefully. They aren’t automatically “forbidden”: they’re planned.
Shared decision-making
If there’s progressive neurological deficit, spinal cord compression, meaningful instability, or intractable pain with functional decline, the balance may favor surgery. The key is managing MCAD risk, not ignoring it.
5) The 10 decisions that most reduce risk (and scares) in MCAD
Decision 1: turn your history into a surgical document
“It’s complicated, I’m allergic to many drugs” isn’t enough. What helps is a short 1-2 page document listing: confirmed reactions, suspected reactions, tolerated drugs, triggers, daily medications, and tolerated rescue medications. This prevents last-minute improvisation.
Decision 2: ensure real coordination between surgery, anesthesia, and (if needed) allergy/immunology
With MCAD, risk drops when everyone shares the same plan: what to avoid, what to prioritize, what to do if a reaction occurs, and how to manage pain and nausea. If you’ve had anaphylaxis, this coordination matters even more.
Decision 3: treat premedication as “risk reduction”, not a lucky charm
Some protocols use combinations of H1 and H2 antihistamines and, in selected cases, steroids or other agents. Evidence isn’t perfect and there’s no one-size-fits-all recipe. The idea is simple: if you and your team choose premedication, use drugs you’ve tolerated (or do it under supervision) and define clear goals (for example, reducing hives, bronchospasm, or flushing).
Decision 4: minimize “small” triggers that aren’t small in MCAD
Temperature control (avoid extreme cold or heat), avoid unnecessary friction, protect the skin, reduce stress, avoid longer fasting than necessary, and control pain early. For sensitive patients, small details add up.
Decision 5: design multimodal analgesia from minute zero
Pain is a strong trigger for mediator release. Instead of relying on one drug, multimodal analgesia combines tools (for example, acetaminophen, regional techniques when appropriate, adjuvants, physical measures, and a rescue plan). The goal is to prevent pain spikes, not to “tough it out”.
Decision 6: talk about opioids without extremes: neither demonize them nor use them on autopilot
Some opioids can promote histamine release or MCAD-like symptoms in susceptible people, but patients vary widely, and in some situations opioids are necessary. One possible strategy (when the team considers it appropriate) is opioid minimization or an opioid-sparing approach. In other cases, the best-tolerated opioid (based on your history) is chosen and paired with antiemetics and close monitoring.
Decision 7: plan for nausea and vomiting as part of the strategy, not “we’ll see”
Nausea and vomiting aren’t just unpleasant: they increase stress and pain and can complicate recovery. In MCAD, some antiemetics or excipients may be poorly tolerated. Practically, the team should agree on a prevention plan and a rescue plan using options you’ve previously tolerated.
Decision 8: review antibiotics, antiseptics, latex, and adhesives
Many perioperative reactions come not from the “main” anesthetic drug but from antibiotics, chlorhexidine, latex, or adhesives. With MCAD, it helps to specify: which antiseptics you tolerate, whether chlorhexidine is a concern, which dressings work for you, and whether a latex-free environment is needed.
Decision 9: define an acute reaction plan before entering the OR
This isn’t alarmist, it’s professional: what signs are monitored, which rescue meds are used, who makes decisions, and whether you need extra monitoring based on your history. Having it written reduces delays if an episode occurs.
Decision 10: a postoperative plan that covers the “blind spots”
Many preventable problems happen after surgery: constipation from pain meds, dehydration, poor sleep, chaotic restarting of daily meds, or discharge without clear instructions. In MCAD, the postoperative plan should include: hydration, temperature control, diet and tolerances, realistic mobilization guidelines, and a clear list of “if X happens, we do Y”.
6) Benefits vs risks: what may improve and what no one can promise
Potential benefits (when the surgical indication is right): reduced nerve or spinal cord compression, improvement in radicular pain, stabilization of unstable segments, functional recovery, and prevention of neurological deterioration in certain cases.
General risks of spine surgery: infection, bleeding, neurological injury (rare but important), thrombosis, anesthetic complications, persistent pain or recurrence, and prolonged rehabilitation.
Risks added or shaped by MCAD: higher likelihood of reactions to drugs or materials, flares triggered by stress/pain, and more postoperative “variability”. Important: increased risk isn’t a fixed destiny. It means planning.
7) Realistic recovery: rough timelines (and why MCAD adds variability)
Timing depends on the type of surgery (simple decompression, fusion, cervical surgery, lumbar surgery, revision surgery, etc.). As a general orientation:
First 48-72 hours
Goal: stability, control of pain and nausea, hydration, and safe early mobilization. In MCAD, special attention is paid to flushing, hives, bronchospasm, hypotension, diarrhea, or disproportionate abdominal pain.
Week 1 to week 2
Goal: walk several times a day, care for the wound, adjust analgesia without spikes, normalize sleep and bowel function. Many people improve day by day, not in a straight line.
Weeks 3-6
Goal: regain tolerance for basic activities, start or progress prescribed rehab, and taper medication as recovery allows. In MCAD, setbacks often have a trigger: overexertion, poor sleep, medication changes, or an intercurrent infection.
2-3 months and beyond
After major surgeries, functional recovery and consolidation (if fusion is involved) take time. The useful message is: don’t measure success by “one bad day”, but by the overall trend and function.
8) When to seek urgent care (whether you have MCAD or not)
Seek urgent attention if any of these signs appear:
- Trouble breathing, wheezing, swelling of lips/tongue, widespread hives with feeling unwell, or low blood pressure with intense dizziness (possible severe reaction).
- New or worsening weakness, loss of bowel/bladder control, saddle anesthesia.
- High fever, chills, increasing wound pain, drainage, or expanding redness.
- Chest pain, shortness of breath, painful swelling in one leg (possible thrombosis/embolism).
- Persistent vomiting that prevents hydration or taking essential medication.
9) Myths and realities
Myth: “If I have MCAD, anesthesia is impossible”
Reality: it isn’t impossible. What doesn’t work is improvisation. With a plan, communication, and preparation, risk goes down.
Myth: “There’s a universal list of banned medications”
Reality: lists can help as a reference, but your prior tolerance is what matters. Two people with MCAD can react to different things.
Myth: “The best approach is to avoid all strong painkillers”
Reality: poorly controlled pain can be a stronger trigger. The key is a multimodal plan and rescue options.
Frequently asked questions
Are MCAD and MCAS the same?
They’re often used interchangeably in non-technical language. MCAD is a broad umbrella; MCAS is used for an activation syndrome with clinical criteria. In perioperative practice, what matters is your reaction pattern and the agreed plan.
Can I receive antibiotics if I have MCAD?
Yes, but it should be planned. Many perioperative reactions are antibiotic-related, so the team prioritizes what you’ve tolerated before and prepares an action plan in case a reaction occurs.
Is opioid-free anesthesia mandatory in MCAD?
No. For some patients it’s helpful (especially if they’ve reacted to certain opioids or have a high nausea risk), but it isn’t universal. It’s decided case by case.
What if I’ve never had general anesthesia and don’t know how I’ll react?
Then planning is based on your history with other medications, your triggers, and cautious drug selection, along with monitoring and preventive measures. Pre-op communication reduces uncertainty.
Should I stop my antihistamines before surgery?
Many protocols recommend continuing the “stabilizing” medication that works for you, but the specific decision depends on your situation and the procedure. Don’t change anything without medical guidance.
How long does reaction risk last after surgery?
Risk doesn’t end when you leave the OR. The first 24-72 hours are sensitive because of pain, antibiotics, medication changes, nausea, and stress. That’s why the postoperative plan matters so much.
If I get hives or flushing after surgery, is it always anaphylaxis?
No. It can be a mild reaction, an MCAD flare, or a side effect. But if it comes with breathing difficulty, intense dizziness, low blood pressure, or rapid worsening, treat it as potentially serious and seek urgent care.
Can I do rehabilitation if I have MCAD?
Usually yes, and it’s often essential. The difference is pacing: gradual progression, monitoring tolerance, and avoiding “spikes” that trigger symptoms through physical stress or poor recovery.
Glossary
Mast cell: an immune system cell that releases mediators (such as histamine) in allergies and inflammation.
Mediators: chemical substances that cause symptoms (flushing, itching, bronchospasm, low blood pressure, diarrhea).
Anaphylaxis: a severe, rapid allergic reaction that can compromise breathing or blood pressure.
Multimodal analgesia: pain control using several strategies to reduce pain spikes and adverse effects.
Opioid-sparing: an approach that aims to reduce opioid doses by using alternatives and adjuvants.
Premedication: preventive medication given before a procedure to reduce reaction risk or symptoms.
If you’re considering spine surgery and you have MCAD/MCAS (or a history of hard-to-explain reactions), requesting a specialist evaluation can help you make a safer decision, not only about whether to have surgery, but also about how to plan anesthesia, pain control, and postoperative care with less uncertainty.
References
1) https://complexspineinstitute.com/en/treatments/endoscopic-spine-surgery/
2) https://www.orphananesthesia.eu/rare-diseases/published-guidelines/systemic-mastocytosis/1710-systemic-mastocytosis-2/file.html
3) https://pmc.ncbi.nlm.nih.gov/articles/PMC8518526/
4) https://pmc.ncbi.nlm.nih.gov/articles/PMC9724157/
5) https://pmc.ncbi.nlm.nih.gov/articles/PMC11881543/
6) https://www.aaaai.org/allergist-resources/ask-the-expert/answers/2022/prophylaxis
Health education notice: this content is informational and does not replace medical advice. In MCAD/MCAS, decisions must be individualized and coordinated with your healthcare team, especially if you have had anaphylaxis or severe reactions.
