An enhanced recovery after surgery pathway: association with rapid discharge and minimal complications after anterior cervical spine surgery

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Enhanced recovery after surgery (ERAS) pathways are associated with improved outcomes, lower morbidity and complications, and higher patient satisfaction in multiple surgical subspecialties. Despite these gains, there are few data to guide the application of ERAS concepts to spine surgery. The authors report the development and implementation of the first ERAS pathway for patients undergoing anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA).</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>This was a retrospective cohort study of prospectively collected data. The authors created a multidisciplinary pathway based on best available evidence for interventions that positively influence outcomes after anterior cervical spine surgery. Patients were followed prospectively up to postoperative day 90. Patient data were collected via electronic medical record review and included demographics, comorbidities, baseline and perioperative opioid use, postoperative complications, and length of hospital stay (LOS). ERAS process measures and compliance with pathway elements were also tracked.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Thirty-three patients were cared for under the pathway (n = 25 ACDF; n = 8 CDA). The median LOS was 416 minutes (interquartile range [IQR] 210–1643 minutes). Eight patients required an extended stay—longer than 23 hours. Reasons for extended admission included pain (n = 4), dyspnea (n = 1), hypoxia (n = 1), hypertension (n = 1), and dysphagia (n = 1). The median LOS for the 8 patients who required extended monitoring prior to discharge was 1585 minutes (IQR 1423–1713 minutes). Overall pathway compliance with included process measures was 85.6%. The median number of ERAS process elements delivered to each patient was 18. There was no strong association between LOS and number of ERAS process elements provided (Pearson’s r = −0.20). Twelve percent of the cohort was opioid tolerant on the day of surgery. There were no significant differences between total intraoperatively or postanesthesia care unit–administered opioid, or LOS, between opioid-tolerant and opioid-naïve patients. There were no complications requiring readmission.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>An ERAS pathway for anterior cervical spine surgery facilitates safe, prompt discharge. The ERAS pathway was associated with minimal complications, and no readmissions within 90 days of surgery. Pain and respiratory compromise were both linked with extended LOS in this cohort. Further prospective studies are needed to confirm the potential benefits of ERAS for anterior cervical spine surgery, including longer-term complications, cost, and functional outcomes.</jats:p></jats:sec>

Enhanced Recovery After Surgery Trends in Adult Spine Surgery: A Systematic Review

“…The remaining 22 articles met inclusion criteria. Of the 22 ERAS studies that met criteria, 12 were controlled ''before-and-after'' studies, 22,25-30,32-36 8 were prospective noncontrolled trials, 19,21,23,24,31,37,39,40 1 was a retrospective matched cohort study, 38 and 1 was a retrospective noncontrolled study. 20 Publication dates ranged from 2004 to 2019.…”

“…17 The remaining noncontrolled retrospective study 20 is graded as level of evidence 4. The 8 prospective noncontrolled trials 19,21,23,24,31,37,39,40 are graded as level of evidence 4.…”

“…ERAS patient education for spine surgery includes setting realistic goals and expectations for surgery and recovery, [21][22][23][24][25]28,30,[32][33][34]36,37,39,40 recommending preoperative nutrition and exercise regimens, 25 educating about the ERAS components, 23,34,39 and educating about pain management (perioperative and postoperative MMA, how to grade pain, how pain scores translate to analgesia selection, etc.). 25,33,34,[37][38][39] In addition to providing videos, handouts, and oral presentations to educate patients, some research groups also implemented a helpline and enlisted 24hour on-call nurses to aid in preoperative patient education. 23,28,33 Many of the ERAS patient education guidelines share similar features but differed in their degree of detail and implementation.…”

“…20,21,36,40 For patients who presented with comorbidities or who did not meet the health criteria, one of several forms of intervention were taken. Some studies built in exclusion criteria for surgery, such as cutoff body mass index and American Society of Anesthesiologists classification values 20,31 ; some delayed the procedure and/or offered counseling and medical services for diabetes, weight loss/nutrition, exercise, smoking cessation, obstructive sleep apnea, and narcotics/alcohol use 21,22,28,31,37,40 ; and some developed their own ''pre-habilitation'' exercise regimens for patients to follow. 22,27 Although it is unclear how health assessment and optimization independently contributed to patient outcomes, previous studies in other surgical specialties have shown a link between preoperative comorbidities and postoperative outcomes.…”

“…2 As such, several spine ERAS protocols modified their preoperative fasting guidelines, instead permitting consumption of solid foods up to 6 to 12 hours prior to surgery and liquids up to 2 to 8 hours prior to surgery. 24,25,33,34,37,39 There is evidence that clear fluids are safe to ingest up to 2 hours prior to surgery, and so fasting guidelines have been changing accordingly since the mid-1990s. 2 Additionally, carbohydrate loading-which involves the oral (PO) or intravenous (IV) administration of a carbohydrate fluid (eg, Nutricia preOp)-usually 2 hours prior to surgery-was incorporated into many spine ERAS protocols ( Table 2).…”