Acta Neurochir

DOI 10.1007/s00701-016-2802-8

CLINICAL ARTICLE - SPINE

The influence of lunar phases and zodiac sign Leo

on perioperative complications and outcome in elective
spine surgery
Holger Joswig 1 & Martin N. Stienen 2 & Carolin Hock 1 & Gerhard Hildebrandt 1 &
Werner Surbeck 1

Received: 10 March 2016 / Accepted: 4 April 2016

# Springer-Verlag Wien 2016

Abstract Conclusions We found no influence of unfavorable lunar or

Background Many people believe that the moon has an influ- zodiac constellations on the 4-week responder status or the
ence on daily life, and some even request elective surgery revision rate that would justify a moon calendar-based selec-
dates depending on the moon calendar. The aim of this study tion approach to elective spine surgery dates. However, the
was to assess the influence of unfavorable lunar or zodiac fact that patients undergoing surgery during the waxing moon
constellations on perioperative complications and outcome in were more likely to suffer from an intraoperative complication
elective surgery for degenerative disc disease. is a surprising curiosity and defies our ability to find a rational
Methods Retrospective database analysis including 924 pa- explanation.
tients. Using uni- and multivariate logistic regression, the like-
lihood for intraoperative complications and re-do surgeries as Keywords Complications . Lunar phase . Moon phase .
well as the clinical outcomes at 4 weeks was analyzed for Neurosurgery . Spine surgery . Superstition
surgeries performed during the waxing moon, full moon,
and dates when the moon passed through the zodiac sign
Leo. Introduction
Results In multivariate analysis, patients operated on during
the waxing moon were 1.54 times as likely as patients who
were operated on during the waning moon to suffer from an Seht ihr den Mond dort stehen? Behold the moonand wonder
intraoperative complication (OR 1.54, 95 % CI 1.072.21, Er ist nur halb zu sehen Why half of her stands yonder,
p = 0.019). In contrast, there was a trend toward fewer re-do Und ist doch rund und schn! Yet she is round and fair!
surgeries for surgery during the waxing moon (OR 0.51, 95 % So sind wohl manche Sachen We follow empty visions
CI 0.231.16, p = 0.109), while the 4-week responder status Die wir getrost belachen And artisans ambitions
was similar (OR 0.73, 95 % CI 0.471.14, p = 0.169). A full Weil unsre Augen sie nicht sehn. Because our minds are unaware.
moon and the zodiac sign Leo did not increase the likelihood
for complications, re-do surgeries or unfavorable outcomes. From Abendlied (Evening Song), Matthias Claudius, eighteenth
century.

It is undeniable that human behavior and physiology are to

* Holger Joswig a certain extent subject to circadian rhythms [4]. Early civili-
Holger.Joswig@gmail.com zations based their calendars on the moon, and even today
lunar phases (LP; Fig. 1) are still part of human culture.
1
Department of Neurosurgery, Cantonal Hospital St. Gallen,
However, profound evidence that the LP potentially affects
Rorschacher Str. 95, 9007 St. Gallen, Switzerland human health is lacking [4]. In the literature, the influence of
2
Department of Neurosurgery and Faculty of Medicine, University
the LP on total hip arthroplasty [2, 3, 5], radical cystectomy
Hospital Geneva, Rue Gabrielle Perret-Gentil 4, [11], surgery for breast [14] or lung cancer [9], general,
1205 Geneva, Switzerland visceral or vascular surgery (excluding neurosurgery) [14],

Fig. 1 Woodcut from 1492 illustrating the lunar phases from the chapter
Liber de coelo et mundo of the book Introductiones in Aristotelis libros
naturales by the French theologian and Greek scholar Jacques Lefvre
d'taples (Abbey Library of St. Gallen)
and miscellaneous ambulatory surgery [7] was found to be nil.
The same held true for postoperative survival in oncology [9,
11, 14]. Regardless of this lack of evidence, we frequently face
patients in our neurosurgery clinics who request elective spine
surgery for degenerative disc disease (DDD) on dates that fall
into what they consider a favorable LP. In our tri-country
region of Switzerland, Austria and Germany, popular moon
calendar-related activities of daily life and surgery date pref-
erences are based on regional moon calendars [15, 18, 19, 23].
Besides giving advice on when to do the laundry, clean the
windows, mow the lawn, water the flowers, and cut one's
fingernails and hair [15, 18, 19, 23], moon calendars can help
to choose the best date for elective surgery in the minds of
quite a few patients. The consensus is that surgery should best
be performed during the waning moon [2, 7, 11, 14, 24] and
by no means during the full moon [15] because blood is ap-
parently drawn out by the lunar gravitational forces, which can
result in excessive blood loss [15]. One popular moon calen-
dar [15] includes a special section dedicated to the link be-
tween the moons transit through the zodiac signs and surgery
dates: Surgery should not be performed on a day when the
moon passes through the respective body parts zodiac sign
except for cases of absolute emergency. If possible, the sur-
gery should take place when the zodiac represents a body part
Acta Neurochir
that is furthest away from the respective body part that un-
dergoes surgery [15]. Previous studies have investigated this
commonly accepted iatromathematical model of unfavor-
able zodiac signs [24], surgical complications [11, 16] and
outcome [11] and have not been able to find any correlations.
To the best of our knowledge, there are no studies on the
reliability of moon calendars when it comes to predicting
complications or outcomes in the field of neurosurgery.
In the current study, we tested the null hypothesis that rates
of intraoperative complications, re-do surgeries and positive
4-week response to elective spine surgery for DDD are similar
when the procedure is done on a day with an unfavorable
lunar or zodiac constellation.
Materials and Methods
Data collection
In this study, a database was created from a combination of
previously published clinical data from our prospective stud-
ies [21, 22] and retrospective electronic patient chart analyses
[8, 20] on elective spine surgery for DDD. Patients baseline
characteristics (age, gender), type of surgery, single vs. multi-
ple level surgery, operation time, intraoperative complications
(incidental dural tear, nerve root injury, vascular injury and
other non-specified complications), estimated blood loss
(EBL) as recorded in the operative note, level of experience
of the primary surgeon (supervised resident vs. staff consul-
tant), length of hospitalization and discharge modality were
extracted. Patient outcomes were assessed 4 weeks after sur-
gery in outpatient clinics. As described previously [8, 2022],
outcomes were categorized as a binary responder (excellent,
good and some relief) and non-responder variable (un-
changed, worsened), as recommended by Guyatt et al. [6].
Any re-do surgeries due to complications (e.g., surgical site
hematoma, wound infection, CSF fistula) or insufficient de-
compression were recorded.
Study groups
The study cohort was divided into patients undergoing elec-
tive spine surgery during the waxing and waning phase of the
moon. Further analyses specifically looked at surgical cases
performed on dates with a full moon as well as on dates when
the moon passed through an unfavorable zodiac sign. For
spine surgery, the unfavorable zodiac sign would be Leo
because it represents the body part back [15]. The exact LP
and respective dates of Leo's moon transit were obtained from
the moon calendars [15, 18, 19, 23] that are commonly refer-
enced by our patients.
Acta Neurochir

Table 1 Baseline variables experience. Additional analyses were run for operations per-
Parameter Waxing moon Waning moon p-value formed on dates with a full moon and on dates when the moon
passed through the Leo zodiac sign. Results are presented in
Age (mean SD) 64.2 13.6 63.4 14.0 0.358 odds ratios (ORs) and 95 % confidence intervals (CIs).
Gender
Male 237 (48.4 %) 228 (52.5 %) 0.206
Female 253 (51.6 %) 206 (47.5 %) Results
Type of surgery
ACDF 131 (26.7 %) 150 (34.6 %) 0.036 Data of a total of 924 patients who previously had undergone
Lumbar microdisc. 56 (11.4 %) 45 (10.4 %) elective surgery for DDD were available. Male and female
Lumbar decompr. 303 (61.9 %) 239 (55.0 %) genders were equally represented (n = 465, 50.3 %; n = 459,
Extent of surgery 49.7 %), and the mean age of the whole cohort was 63.8
1 level 304 (62.0 %) 233 (53.7 %) 0.010 13.8 years (standard deviation). Anterior cervical
2 levels 186 (38.0 %) 201 (46.3 %) discectomy and fusion (ACDF) was performed in 281
Primary surgeon (30.4 %), microdiscectomy for lumbar disc herniation
Senior surgeon 299 (61.0 %) 291 (67.0 %) 0.057 (LDH) in 101 (10.9 %) and microscopic lumbar decompres-
Junior surgeon 191 (39.0 %) 143 (33.0 %) sion for lumbar spinal stenosis (LSS) in 542 (58.7 %).
Discharge A total of 490 patients underwent surgery during a waxing
Home 367 (74.9 %) 329 (75.8 %) 0.749 moon and 434 during a waning moon. Among these cases,
Rehabilitation 123 (25.1 %) 105 (24.2 %) surgery was performed on a full moon in 26 (2.8 %) and on
n = 490 n = 434 days when the moon passed through the unfavorable zodiac
sign Leo in 65 (7.0 %).
SD = Standard deviation Table 1 shows that important baseline variables such as age
and gender were equally distributed among the study groups.
Statistical methods At the time of the waxing moon, more lumbar decompression
procedures and fewer ACDFs were performed than at the time
The null hypothesis was that the rates of intraoperative com- of the waning moon, and those were also more often single
plications and re-do surgeries as well as the postoperative 4- level. There was also a trend toward a higher number of pro-
week outcomes are similar for operations performed during cedures performed by junior surgeons during the waxing
waxing and waning moons. First, patients operated on during moon (Table 1).
a waxing moon were compared to those operated on during a The relationship between the occurrence of intraoperative
waning moon for important baseline variables using Pearson complications and a waxing moon is demonstrated in Table 2.
2 tests for categorical and rank-sum tests for continuous Patients operated on during a waxing moon were 1.73 times as
variables. Rates of intraoperative complications, the need for likely as patients operated on during a waning moon to suffer
re-do surgery until 4 weeks after surgery and the 4-week re- from an intraoperative complication (OR 1.73, 95 % CI 1.25
sponder status to surgery were the dependent variables of in- 2.38, p = 0.001). This relationship was slightly attenuated
terest. The waxing moon was our independent variable. when corrected for the above-mentioned baseline group dif-
Univariate logistic regression was used to estimate the rela- ferences (OR 1.54, 95 % CI 1.072.21, p = 0.019). The likeli-
tionship between any of the dependent and independent vari- hood of intraoperative complications was similar on days with
ables. As the study groups turned out to differ in some impor- a full moon or unfavorable zodiac sign. Figure 2 is a graph-
tant baseline variables, an additional multivariate model was ical display of the likelihood of intraoperative complications
built in order to adjust estimates for the parameters type of in relation to each day of the lunar cycle as described by
surgery, single vs. multilevel surgery and surgeons Kuehnl et al. [9]. As becomes evident, there is no phase of

Table 2 Estimation of the

relationship between Intraoperative complication Univariate Multivariate
intraoperative complications
during elective spine surgery and OR 95 % CI p-value OR 95 % CI p-value
a waxing moon, full moon or
unfavorable zodiac sign Waxing moon 1.73 1.252.38 0.001 1.54 1.072.21 0.019
Full moon 0.86 0.322.31 0.762 0.60 0.201.76 0.349
Unfavorable zodiac sign 1.42 0.812.51 0.222 1.43 0.742.76 0.281

Multivariate analysis was corrected for type of surgery, experience of the primary surgeon and extent of surgery
 Acta Neurochir

Fig. 2 Graphical display of the

odds ratio (OR; rhombi) and 95 %
confidence interval (CI; vertical
lines) for an intraoperative
complication (y-axis) in relation
to each phase of the 30-day lunar
cycle (x-axis). Absolute numbers
of patients operated on during any
phase of the lunar cycle are
indicated at the bottom of the
x-axis

the 30-day lunar cycle where this likelihood is significantly
elevated (all CI bars cross the reference line at y = 1).
However, the trend to higher odds at a waxing moon and
lower odds at a waning moon is deducible.
Table 3 describes the relationship between a favorable 4-
week responder status to surgery and a waxing moon. The
likelihood of responding positively to surgical treatment was
the same for patients who were operated on during a waxing
moon. Similarly, the likelihood of a favorable 4-week re-
sponder status was equal on days with a full moon or the
unfavorable zodiac sign.
Table 4 estimates the relationship of the need for re-do
surgery within 4 weeks after surgery and the independent
variables. Note that patients operated on during a waxing
moon were not more likely to undergo re-do surgery during
the follow-up. In multivariate analysis, there was even a ten-
dency toward a lower revision rate during a waxing moon (OR
0.51, 95 % CI 0.231.16, p = 0.109).
Figure 3ac shows that operation time (Fig. 3a; 103.7 vs.
105.4 min; p = 0.697), EBL (Fig. 3b; 109.1 vs. 115.7 ml;
p = 0.451) and length of postoperative hospitalization
(Fig. 3c; 5.9 vs. 6.1 days; p = 0.234) were not different during
the LP.
In this series, two patients were operated on under the con-
stellation of a full moon in addition to the zodiac sign Leo. No
intraoperative complications occurred. One of these two pa-
tients underwent re-do surgery, but both were considered pos-
itive responders to surgery at 4-week follow-up.
Discussion
Based on the moon calendar for Eastern Switzerland, we
assessed the complication rates and outcomes in 924 elective
spine surgery cases to challenge common superstitious beliefs
about the influence of LP on surgery. We found no significant
association whatsoever between a waxing moon and clinical
outcomes or re-do surgery rates or between a full moon and an
unfavorable zodiac sign for any of the primary or secondary
outcomes except for one: Much to our own surprise, patients
undergoing surgery during a waxing moon were 73 % more
likely to experience an intraoperative complication (OR 1.73,

Table 3 Estimation of the relationship between the 4-week responder status after elective spine surgery and a waxing moon, full moon or
unfavorable zodiac sign. Multivariate analysis was corrected for type of surgery, experience of the primary surgeon and extent of surgery

4-week responder status Univariate Multivariate

OR 95 % CI p-value OR 95 % CI p-value

Waxing moon 0.74 0.481.14 0.173 0.73 0.471.14 0.169

Full moon 0.84 0.252.86 0.785 0.85 0.252.91 0.797
Unfavorable zodiac sign 2.38 0.737.77 0.148 2.39 0.747.79 0.147
Acta Neurochir
Table 4 Estimation of the
relationship between the need for Re-do surgery
re-do surgery within 4 weeks after
elective spine surgery and a
waxing moon, full moon or
unfavorable zodiac sign Waxing moon
Full moon
Unfavorable zodiac sign
Multivariate analysis was corrected for type of surgery, experience of the primary surgeon and extent of surgery
95 % CI 1.252.38, p = 0.001). From the unadjusted model it
cannot be concluded with certainty that the observed effect
was exclusively due to the waxing moon as the study groups
were unbalanced. Patients operated on during a waxing moon
were more often subject to a lumbar decompression and more
often operated on by a supervised resident, which per se could
explain the higher complication rate. However, when account-
ing for these imbalances in a multivariate analysis, patients
who underwent surgery during a waxing moon were 54 %
more likely to experience an intraoperative complication
(OR 1.54, 95 % CI 1.072.21, p = 0.019). This finding is in
line with moon experts recommendations not to undergo
elective surgery during a waxing moon, but other findings of
the study put this into perspective: The likelihood of re-do
surgery until the 4-week follow-up tended to be lower in pa-
tients operated on during a waxing moon (OR 0.51, 95 % CI
0.231.16, p = 0.109), and the 4-week responder status was
equal (Table 3). Thus, our patients who suffered from a com-
plication during a waxing moon apparently had similarly fa-
vorable outcomes at 4-week follow-up at outpatient clinics.
Moreover, in light of the lack of a plausible explanation, we
question the causality. It is conceivable that being operated on
by tired surgeons might lead to more complications because
their night sleep has been disturbed by moonlight, which is
usually brightest during a full moon. However, our data sug-
gest equal or even slightly lower complication rates on dates
with a full moon (Table 2). The theory that lunar gravitational
forces account for higher blood loss during a waxing moon
[15] is refuted by our data as EBL was similar between the
Fig. 3 ac Operation time (3A; 103.7 vs. 105.4 min; p = 0.697), EBL
(3B; 109.1 vs. 115.7 ml; p = 0.451) and length of postoperative
hospitalization (3C; 5.9 vs. 6.1 days; p = 0.234) did not differ during the
Univariate Multivariate
OR 95 % CI p-value OR 95 % CI p-value
0.54 0.241.21 0.137 0.51 0.231.16 0.109
1.39 0.1810.72 0.748 1.02 0.137.98 0.985
1.10 0.264.78 0.894 1.07 0.244.69 0.927
study groups (Fig. 3b). Also, surgical site hematomas in our
series were not more frequent during waxing moons (1.19 %
vs. 1.17 %, Pearson 2 0.0005, p = 0.982), full moons (0.0 %
vs. 1.22 %, Pearson 2 0.2958, p = 0.587) or days with an
unfavorable zodiac sign (2.0 % vs. 1.12 %, Pearson 2
0.3090, p = 0.578). At this point, it should also be mentioned
that on earth the gravitational pull on the human body by the
moon is negligible. It depends on the alignment of the moon,
earth and sun, and not on the actual LP [4]. Andrews often
cited (unblinded) report on increased blood loss during
adenotomy and tonsillectomy around a full moon [1] did not
withstand statistical validation [24], and other studies reported
no significant moon-dependent increased loss of blood [5, 17].
In line with the literature [11, 16], the moons passing
through an unfavorable zodiac signLeo in case of spine
surgery [15]did not increase the rates of surgical complica-
tions or re-do surgeries and had no influence on the 4-week
outcome. Since we could not even observe trends in this con-
siderable number of surgical cases that we analyzed here, we
can confidently refute this theory. Even the two patients who
underwent surgery under the most unfortunate circum-
stances of a full moon passing through Leo at the time did
not have any intraoperative complications, and the 4-week
outcome was favorable in both cases.
To the best of our knowledge, this is the first study to assess
the effects of lunar or zodiac constellations on neurosurgery.
Contrary to our original intention, we cannot completely dis-
count patients beliefs concerning moon calendar-based elec-
tive surgery scheduling as absurd, since we formally have to
waxing and waning moon for elective spine surgery. The figures
display the median with the 25th75th percentile (box), the upper and
lower adjacent values (whiskers) and outliers (dots)

reject the null hypothesis of the current study. However, in the
absence of any rational explanations and in light of a missing
negative influence of a waxing moon on any of the other
outcomes, we suspect that this finding is due to a type II error.
This error might result from group imbalances with respect to
the type of surgery and level of training, despite statistical
adjustment [12]. It would be interesting to re-test the null
hypothesis with larger databases from spine registries and in
a prospective fashion to build balanced study groups and pos-
sibly also to take into account the physiologic data in addition
to LP, for example, the surgeons previous nights sleep hours.
The present work might confirm the superstition of moon
believers and foster socioeconomic problems in terms of sur-
gical logistics concerning staff and operating room capacities
[7, 11, 16]. At the end of the day, patients beliefs and con-
cerns should be respected [9] regardless of how irrational they
may seem to a rational mind. In our opinion, anxious patients
should be advised that surgery during a waxing moon is safe
and reassured by quoting primarily studies that disprove an
influence of the LP on surgical complications and outcomes.
Limitations
Most of the present data stem from retrospective studies,
which carry uncertainties related to underreporting of adverse
events and complications [10] or inaccurate estimation of EBL
[13] in both study groups alike. In this retrospective approach,
however, surgeons are blinded, and a nocebo effect is thus
eliminated [24]. Patients who might have already planned
surgery according to the LP should not bias the study results,
as patient numbers were quite large and equally distributed
among the groups. Our single-center data might not be appli-
cable to different regions. Furthermore, disagreement among
esoteric authors regarding the optimal LP for surgery as crit-
ically discussed by Wunder et al. [24] limits the generaliza-
tion. One could argue that basing our methods on regional
moon calendars [15, 19, 23] is unscientific and does not take
into account accurate measurements such as the actual moon
illumination measured on earth or the moon-earth distance, as
is neatly laid out in the thesis of Angermann [2]. Indeed, this
criticism would be justified, and we believe that it should be
passed on to the roots of superstition [15, 18, 19, 23].
Conclusions
The present analysis reveals no influence of unfavorable lunar
or zodiac constellations on the 4-week responder status or the
revision rate after elective spine surgery for DDD. A 54 %
higher risk for an intraoperative surgical complication per-
formed during a waxing moon defies a rational explanation
and most likely represents a type-II error rather than a causal
effect. Judging from the current results, there is no role for
Acta Neurochir
moon calendars in surgical scheduling, which alleviates the
burden on operation planning logistics. Nevertheless, patients
beliefs and concerns should always be taken seriously. To reas-
sure anxious patients and to better estimate the influence of the
moon on surgical complications and outcomes, more data
preferably from prospective spine registriesare desirable.
Acknowledgments The authors thank Dario Jucker, medical student at
the University of Zurich, for helping with the data acquisition. We thank
Dr. Nicolas Smoll for his advice on the statistical part of the manuscript.
Figure 1 was obtained from the Abbey Library of St. Gallen (UNESCO
World Heritage Site). We thank U5 for editing Fig. 2.
Compliance with ethical standards
Funding No funding was received for this study.
Conflict of Interest None.
Ethical approval For this type of study formal consent is not required.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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