Benefits of Enhanced Recovery After Surgery for fusion in degenerative spine surgery: impact on outcome, length of stay, and patient satisfaction

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Enhanced Recovery After Surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. Thanks to the improvement in care protocols and the fluidity of the patient pathway, the first goal of ERAS is the improvement of surgical outcomes and patient experience, with a final impact on a reduction in the hospital length of stay (LOS). The implementation of ERAS in spinal surgery is in the early stages. The authors report on their initial experience in applying an ERAS program to several degenerative spinal fusion procedures.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors selected two 2-year periods: the first from before any implementation of ERAS principles (pre-ERAS years 2012–2013) and the second corresponding to a period when the paradigm was applied widely (post-ERAS years 2016–2017). Patient groups in these periods were retrospectively compared according to three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion. Data were collected on patient demographics, operative and perioperative data, LOSs, 90-day readmissions, and morbidity. ERAS-trained nurses were involved to support patients at each pre-, intra-, and postoperative step with the help of a mobile application (app). A satisfaction survey was included in the app.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The pre-ERAS group included 1563 patients (159 ALIF, 749 ACDF, and 655 posterior fusion), and the post-ERAS group included 1920 patients (202 ALIF, 612 ACDF, and 1106 posterior fusion). The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. It was reduced from 6.06 ± 1.1 to 3.33 ± 0.8 days for the ALIF group (p &lt; 0.001), from 3.08 ± 0.9 to 1.3 ± 0.7 days for the ACDF group (p &lt; 0.001), and from 6.7 ± 4.8 to 4.8 ± 2.3 days for posterior fusion cases (p &lt; 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Regarding satisfaction with overall care among 808 available responses, 699 patients (86.5%) were satisfied or very satisfied, and regarding appreciation of the mobile e-health app in the perceived optimization of care management, 665 patients (82.3%) were satisfied or very satisfied.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The introduction of the ERAS approach at the authors’ institution for spinal fusion for three studied conditions resulted in a significant decrease in LOS without causing increased postoperative complications. Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high. According to the study results, which are consistent with those in other studies, the whole concept of ERAS (primarily reducing complications and pain, and then reducing LOS) seems applicable to spinal surgery.</jats:p></jats:sec>

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

“…As per the Centre for Evidence-Based Medicine guidelines for therapeutic studies, 17 the 12 controlled ''before-and-after'' studies 22, [25][26][27][28][29][30][32][33][34][35][36] and the retrospective controlled study 38 are graded as level of evidence 2B. 17 The remaining noncontrolled retrospective study 20 is graded as level of evidence 4.…”

“…A total of 13 of the 22 studies 22, [25][26][27][28][29][30][32][33][34][35][36]38 conducted controlled trials that compared ERAS versus traditional care pathways. The outcomes are variable and are summarized in Table 1.…”

“…A total of 10 studies reported significantly reduced hospital and/or intensive care unit LOS 22,26,[28][29][30][32][33][34][35]38 ; however, some studies found no significant change in LOS compared with control. 25,27,36 Additionally, there was large variation in mean/median LOS, ranging from several hours to several days.…”

“…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.…”

Pain Syndrome and Pain Management After Lumbar Spine Surgery

“…ERAS ïðåäñòàâëÿº ñîáîþ ìóëüòèìîäàëüíèé ï³äõ³ä äî âåäåííÿ ïåð³îïåðàö³é-íîãî ïåð³îäó òà âêëþ÷ຠïåðåäîïåðàö³éíå íàâ÷àííÿ ïàö³ºíòà òà ô³çè÷í³ âïðàâè, ìóëüòèìîäàëüíå ïå-ð³îïåðàö³éíå çíåáîëåííÿ, ìàëî³íâàçèâí³ õ³ðóðã³÷í³ òåõí³êè, ì³í³ì³çàö³þ êðîâîâòðàòè çà ðàõóíîê ââåäåííÿ òðàíåêñàìîâî¿ êèñëîòè, êîðåêö³þ íóòðèòèâíîãî ñòàòóñó òà ðàííÿ ìîá³ë³çàö³ÿ ïàö³ºíòà. ʳíöåâèìè ðåçóëüòàòàìè âïðîâàäaeåííÿ á³ëüø³ñòü àâòîð³â áà÷àòü çíèaeåííÿ ïîòðåáè â îï³î¿äàõ, ï³ñëÿ-îïåðàö³éíî¿ íóäîòè, áëþâîòè òà ñîíëèâîñò³, ñêî-ðî÷åííÿ ë³aeêîäíÿ [4] òà ï³äâèùåííÿ çàäîâîëåííÿ ïàö³ºíòà [5]. Ðåaeèì ï³ñëÿîïåðàö³éíîãî çíåáîëåííÿ ïðè âåðòåáðîëîã³÷íèõ îïåðàö³ÿõ çàëèøàºòüñÿ äèñêóòàáåëüíèì ïèòàííÿì.…”