A perspective on the use of an enhanced recovery program in open, non-instrumented day surgery for degenerative lumbar and cervical spinal conditions

Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery

“…8-15, 19, 28-31,33 Reasons for exclusion were being abstracts only (n = 19), failing to present primary data (n = 12), describing results in a pediatric population (n = 7), failing to describe the ERAS protocol (n = 1), and lacking full-text English-language translation (n = 1). Of the included studies, 1 article was level II evidence, 7 while the remainder were level III [8][9][10][11][12][13][14][15][16]19,[27][28][29][30][31][32][33] (n = 17) or level IV 17,18,[20][21][22][23][24][25][26] (n = 9) evidence. Nine studies described ERAS protocols applied to all elective spine patients, 8,[17][18][19][27][28][29][30][31] 2 described protocols for cervical spine surgery patients, 21,32 14 described lumbar-specific surgery protocols, 9-15, 20, 22-26,33 and 2 described protocols for patients undergoing spine tumor surgery.…”

“…Of the included studies, 1 article was level II evidence, 7 while the remainder were level III [8][9][10][11][12][13][14][15][16]19,[27][28][29][30][31][32][33] (n = 17) or level IV 17,18,[20][21][22][23][24][25][26] (n = 9) evidence. Nine studies described ERAS protocols applied to all elective spine patients, 8,[17][18][19][27][28][29][30][31] 2 described protocols for cervical spine surgery patients, 21,32 14 described lumbar-specific surgery protocols, 9-15, 20, 22-26,33 and 2 described protocols for patients undergoing spine tumor surgery. 7,16…”

“…The most common elements in the described ERAS protocols were patient education (6 protocols [7 studies, with 2 from the same practice 28,30 ]); 8,[17][18][19][28][29][30] smoking cessation (4 studies); 8,18,19,27 multimodal opioid-sparing analgesia during the intraoperative or postoperative period (9 studies); 8,[17][18][19][27][28][29][30][31] tranexamic acid (TXA) use to reduce intraoperative blood loss (3 studies); 27,28,30 goal-directed fluid replacement intraoperatively (2 studies); 18,27 urinary catheter discontinuation within 24-48 hours postoperatively (4 studies); 18,27,28,30 early drain removal (2 studies); 18,31 mechanical venous thromboembolism (VTE) prophylaxis (2 studies); 27,31 early resumption of enteral feeding (2 studies); 18,30 and early postoperative mobilization (4 studies). 17,18,29,31 Seven studies 8,19,[27][28]…”

Fast-track protocols for patients undergoing spine surgery: a systematic review

“…↑PROMs, D ODI, EQ-5D index, EQ-VAS, discharge at day 1 (from 90 to 96%), 1-night hospital stays (from 26 to 85%), and ↓operative time (from 38.8 ± 36.1 to 29.0 ± 22.8 min), complication, nursing costs (by 46.8%), LOS (from 2.4 ± 1.2 to 1.5 ± 0.3 days). =pain Venkata et al 2018 [ 57 ] Prospective Fast-track group: 237 patients (mean age: 57, 40% females) No Elective, open, non-instrumented lumbar and cervical spinal decompression and discectomy surgery for degenerative lumbar and cervical spinal conditions causing neural compression 1, 2, 3 NR NR < or > 24 h 1.6% disc prolapses, 0.8% hematomas 2.5% readmission (n = 7), reoperation (n = 6) 18 months ↓LOS: short stay = 12 patients (5%), ambulatory = 225 (95%) and day surgery after admission = 126 (53.2%) Wang et al 2017 [ 58 ] Retrospective Fast-track group: 42 patients (mean age 66.1 ± 11.7, 52% females) No 1- or 2-level unilateral open TLIF (endoscopic decompression, expandable cage with allograft matrix, 2.1 mg rhBMP-2, bilateral pedicle percutaneous screws with 20 ml Exparel and bilateral rods) for spondylolisthesis or a severely degenerated disc with nerve root impingement, radiculopathy from neural compression, back pain from instability L1–2, L2–3, L3–4, L4–5, L5-S1 NR NR 1.29 ± 0.9 nights 1 cage displacement, 2 infection of interbody graft with sepsis, 1 atrial fibrillation, 1 upper-extremity DVT, 2 transient radiculitis 1 reoperation (graft migration at 2 months after surgery) 6 weeks, 3, 6, 12, and 24 months Operative time = 94.6 ± 22.4 min; EBL = 66 ± 30 ml; LOS = 1.29 ± 0.9 nights. ↓ODI score (from 40 ± 13 to 17 ± 11) Wang et al 2020 [ 59 ] Retrospective 190 patients: -Fast-track group ( n = 95, 72.39 ± 6.12 age, 52.6% females); −Non-fast-track, ( n = 95, mean age 70.81 ± 6.27, 57.8% females) Yes Lumbar fusion surgery for lumbar disk herniation or spinal stenosis 1 or 2 Hypertension, heart disease, diabetes, osteoporosis, gastrointestinal, psychological symptoms NR 12.30 ± 3.03 1 spinal fluid leakage, 1 neurological 1 30 days readmission 30 days ↓LOS (12.30 ± 3.03 vs. 15.50 ± 1.88) in fast-track group vs. non-fast-track group.…”

Reply to “Letter to the Editor Regarding – Design and Implementation of an Enhanced Recovery After Surgery (ERAS) Protocol in Elective Lumbar Spine Fusion by Posterior Approach: A Retrospective, Comparative Study”

“…The study designed an ERAS protocol for elective lumbar spine fusion by posterior approach and compared the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care. 2,3 The study drew a conclusion that implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter length of hospital stay (LOS) and improved early pain and functional outcome scores. However, we wish to bring a few points which we think are extremely relevant to the notice of this journal's readership which would send out the message expounded in this study with more clarity.…”