Design and Implementation of an Enhanced Recovery After Surgery (ERAS) Program for Minimally Invasive Lumbar Decompression Spine Surgery

Abstract

Study Design. A retrospective cohort study of prospectively collected data. Objective. The aim of this study was to describe the development of and early experience with an evidence-based enhanced recovery after surgery (ERAS) pathway for lumbar decompression. Summary of Background Data. ERAS protocols have been consistently associated with improved patient experience and outcomes, and reduced cost and length of hospital stay (LoS). Despite successes in other orthopedic subspecialties, ERAS has yet to be established in spine surgery. Here, we report the development of and initial experience with the first comprehensive ERAS pathway for MIS lumbar spine surgery. Methods. An evidence-based review of the literature was performed to select components of the ERAS pathway. The pathway was applied to 61 consecutive patients presenting for microdiscectomy or lumbar laminotomy/laminectomy between dates. Data collection was performed by review of the electronic medical record. We evaluated compliance with individual ERAS process measures, and adherence to the overall pathway. The primary outcome was LoS. Demographics, comorbidities, perioperative course, prevalence of opioid tolerance, and factors affecting LoS were also documented. Results. The protocol included 15 standard ERAS elements. Overall pathway compliance was 85.03%. Median LoS was 279 minutes [interquartile range (IQR) 195–398 minutes] overall, 298 minutes (IQR 192–811) for lumbar decompression and 285 minutes (IQR 200–372) for microdiscectomy. There was no correlation between surgical subtype or duration and LoS. Overall, 37% of the cohort was opioid-tolerant at the time of surgery. There was no significant effect of baseline opioid use on LoS, or on the total amount of intraoperative or PACU opioid administration. There were four complications (6.5%) resulting in extended LoS (>23 hours). Conclusion. This report comprises the first description of a comprehensive, evidence-based ERAS for spine pathway, tailored for lumbar decompression/microdiscectomy resulting in short LoS, minimal complications, and no readmissions within 90 days of surgery. Level of Evidence: 3

Reductions in length of stay, narcotics use, and pain following implementation of an enhanced recovery after surgery program for 1- to 3-level lumbar fusion surgery

“…To date, there have been few peer-reviewed publications regarding spine ERAS programs that have actually been implemented. 1,2,8,[11][12][13][14] Given that spinal fusion surgeries can be painful, morbid, and costly, the implementation of a spine ERAS program would be a major advancement in the field. In an effort to develop evidence-driven protocols for ERAS, we embarked on a quality improvement project to address the challenges spinal surgeons face in the postoperative period.…”

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

“…Our group previously reported our experience with an MIS-ERAS pathway for lumbar decompression. 31 Using the lumbar decompression pathway as a template, we reviewed the evidence for components of care that positively affect outcomes after anterior cervical spine surgery, tailored the pathway, and then applied it to 33 patients undergoing elective ACDF or CDA with an MIS approach. Here we report a retrospective analysis of all cases performed in the first 6 months postimplementation, and found high…”

“…We previously described the development and implementation of an evidence-based ERAS pathway for lumbar decompression. 31 Patient demographics, comorbidities, and procedural details are presented in Table 1. Using this pathway as a template, we adjusted components of care to address the distinct perioperative needs of patients undergoing ACDF or CDA via an MIS approach ( Table 2).…”

“…8 Two retrospective series described ERAS for spine surgery performed using minimally invasive surgery (MIS) techniques: one as applied to lumbar fusion, 35 and the other to lumbar decompression. 31 Both reports associated ERAS with short LOS and minimal complications, but each pathway included different care elements, different numbers of elements, and divergent rationales for the selection of included elements.…”

Early Discharged Lumbar Spine Fusion Reduced Postoperative Readmissions: A Retrospective Cohort Study

“…There have been many emerging technologies, such as minimally invasive approaches, low profile instrumentations, and biologics, to facilitate the process of recovery during the past couple of decades [1][2][3][4][5][6]. The concept of early discharge (ED) has also been introduced into the field of spine surgery in the past several years [7][8][9][10][11]. By incorporation of strategic management peri-operatively, the early discharge (ED) approach has aimed to raise the efficiency of the entire treatment process so that the patients could recover better [12][13][14].…”