An enhanced recovery after surgery pathway: LOS reduction, rapid discharge and minimal complications after anterior cervical spine surgery

Abstract

Background Enhance recovery after surgery (ERAS) is a new and promising paradigm for spine surgery. The purpose of this study is to investigate the effectiveness and safety of a multimodal and evidence-based ERAS pathway to the patients undergoing anterior cervical discectomy and fusion (ACDF). Methods The patients treated with the ACDF-ERAS pathway were compared with a historical cohort of patients who underwent ACDF before ERAS pathway implementation. Primary outcome was length of stay (LOS). Secondary outcomes included cost, MacNab grading, complication rates and 90-day readmission and reoperation. And perioperative factors and postoperative complications were reviewed. Results The ERAS protocol was composed of 21 components. More patients undergoing multi-level surgery (n ≥ 3) were included in the ERAS group. The ERAS group showed a shorter LOS and a lower cost than the conventional group. The postoperative satisfaction of patients in ERAS group was better than that in conventional group. In addition, the rate of overall complications was significantly higher in the conventional group than that in the ERAS group. There were no significant differences in operative time, postoperative drainage, or 90-day readmission and reoperation. Conclusions The ACDF-tailored ERAS pathway can reduce LOS, cost and postoperative complications, and improve patient satisfaction without increasing 90-day readmission and reoperation.

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

“…In our quality assessment for spine surgery the 44% [ 15 , 23 , 27 , 29 , 32 – 38 , 40 – 42 , 46 – 49 , 51 , 55 , 56 , 61 , 67 , 68 , 70 ] of the studies were rated strong, 25% [ 17 , 18 , 21 , 22 , 25 , 28 , 31 , 39 , 43 , 44 , 60 , 62 , 63 , 65 ] were rated moderate, and 32% [ 16 , 19 , 20 , 24 , 26 , 30 , 45 , 50 , 52 – 54 , 57 – 59 , 64 , 66 , 69 , 71 ] were rated weak. Methodological weaknesses that led to moderate or weak quality scores often included the lack of a sample size justification, power description, or variance and effect estimates, the lack of subjects selected or recruited from the same population, the lack of results evaluation more than once over in time, the lack of blinded assessor and the lack of measurement of potential confounding variables.…”

“…3.51 ± 0.88), ODI score at day 3 (37.43 ± 10.22 vs. 41.19 ± 8.29), and ↑satisfaction (89.29% vs. 77.89%) in fast-track group vs. non-fast-track group. =wound infection, venous thrombosis, fever, urinary tract infection, paravertebral hematoma, delirium, operative time, 30-day readmission rate, 30-day reoperation rate Leng et al 2022 [ 66 ] Retrospective 143 patients: -Fast-track group ( n = 70, mean age 53.2 ± 9.3, 44% females); −Non-fast-track group ( n = 73, mean age 52.07 ± 10.6, 61% females) Yes ACDF for cervical spondylosis, spondylotic myelopathy and radiculopathy ≥3 Diabetes mellitus, hypertension, chronic cardiovascular disease NR 4 days 2.9% prolonged dysphagia, 1.4% hardware failure, 8.6% dysphagia/dysphonia, 1.4% nausea and vomiting No 90-day readmission and reoperation 90 days ↓LOS (4 vs. 5 days), operative time, surgical drainage at day 1, costs, complications (dysphagia/dysphonia, hardware failure, nausea and vomiting), and ↑satisfaction, BMD in fast-track group vs. non-fast-track group. =prolonged dysphagia Porche et al b2022 [ 67 ] Retrospective 114 patients: -Fast-track group (n = 57, mean age 66.1 ± 11.7, 53% females); −Non-fast-track group ( n = 57, mean age 63.4 ± 13.3, 49% females) Yes 1- or 2-level open TLIF for degenerative disease (spondylolisthesis, spinal stenosis, nerve root compression, recurrent disc herniation, pseudoarthrosis, or adjacent segment disease) NR NR NR 3.6 ± 1.6 days NR 2 reoperation within 30 days (3.5%, 1 hardware failure and 1 wound dehiscence) 30 days ↓Operative time (141 ± 37 vs. 170 ± 44 min), LOS (3.6 ± 1.6 vs. 4.6 ± 1.7 days), opioid consumption (8 ± 9 vs. 36 ± 38 MME), drains placed (40.4% vs. 96.5%), catheters placed (21% vs. 61%), PCA use (1.8% vs. 86%), and ↑first day of ambulation (0.6 vs. 1.3 days), bowel movement (2.2 vs. 3.0), bladder voiding (0.3 vs. 1.1 days) in fast-track group vs. non-fast-track group.…”

“…Chlorhexidine for skin, screening for diabetes mellitus, malnutrition and methicillin- Staphylococcus aureus colonization, neuropsychology clinic, multidisciplinary anesthesia pain management Yes Standard bowel regimen, diet NR Analgesia (1 g acetaminophen, 600-1200 mg gabapentin 60 min before surgery), infection prophylaxis (2 g cefazolin or clindamycin/vancomycin 30-60 min before incision) Local anesthetic (bupivacaine, and epidural morphine sulfate in nonfusion cases), catheter NR 10 mg dexamethasone Band et al 2022 [ 64 ] Optimization of chronic disease management (diabetes, hypertension), discussion regarding weight loss, no smocking, preoperative education, counseling, and hospital orientation session NR NR Oral analgesics (acetaminophen 1 g, baclofen 10 mg, oxycontin 20 mg, gabapentin 300 mg) NR General anesthesia (midazolam, ketamine 0.5 mg/kg bolus up to max of 50 mg followed by 0.5 mg/kg/h, and/or dexmedetomidine infusion 0.4mcg/kg/h), dexamethasone 10 mg), subfascial drains, peri-incisional bupivacaine 0.5% 20Ml, urinary catheters NR Zofran 4 mg Chen et al 2022 [ 65 ] Education, assessment, diet management, smoking and alcohol cessation, psychological evaluation NR Fasting (6 h for liquids and 8 h for solid food), clear fluids, including carbohydrate drinks up to 2 h before Oral celecoxib 200 mg and pregabalin 150 mg within 1 h before surgery IV first-generation cephalosporin for 30 min before Local anesthesia, long-acting opioids, anesthetic agents, and large doses of muscle relaxants avoided Normothermia (heating device, 36 °C), goal-directed fluid administration, IV tranexamic acid (10-20 mg/kg load dose before resection followed by infusion at 1 mg/kg/h maintenance dose) NR Leng et al 2022 [ 66 ] Education, consultation, smoking cessation NR Modern fasting (solids within 6 h and carbohydrate beverages within 2 h prior) Oral celecoxib 200 mg, pregabalin 75 mg, acetaminophen 1 g, 1 h before Antimicrobial prophylaxis (cefuroxime 1.5 g, 30 min before) Anesthesia, local analgesia (5 mg/mL ropivacaine hydrochloride), catheter TXA (1 g bolus followed by 0.5 g/h infusion), dexamethasone 10 mg, normovolemia (goal-directed fuid administration, vasopressors), normothermia (36 °C, convective warming device) 5-HT receptor antagonist (ramosetron) Porche et al b2022 [ 67 ] Physical capacity, cognitive, cardiac, pulmonary, renal, pain, nutrition and risk evaluation, anemia and diabetes control, education, medical optimization, smoking cessation …”

Enhanced recovery after surgery (ERAS) protocol in spine surgery

“…The applicability of ERAS in multilevel disease (n 3) was also established. 9 The cost benefit of application of ERAS protocol has been noted by multiple authors across various types of spine surgeries. 9,23 It leads to significant savings in hospital days and reduction in cost.…”

“…9 The cost benefit of application of ERAS protocol has been noted by multiple authors across various types of spine surgeries. 9,23 It leads to significant savings in hospital days and reduction in cost. 24 However, the initial cost of implementation and further maintenance of ERAS programs can be a costly affair.…”