Design and Implementation of an Enhanced Recovery After Surgery Protocol in Elective Lumbar Spine Fusion by Posterior Approach

Abstract

Objective. The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care. Summary of Background Data. Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes. Methods. Hospital records of adult patients who underwent one-to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016-dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals.Results. A total of 812 patients were included -496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 AE 12.0 vs. 44 AE 10.8, ODI: 31.6 AE 14.2 vs. 28 AE 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months). Conclusion. Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.

Perioperative Care of Patients Undergoing Major Complex Spinal Instrumentation Surgery: Clinical Practice Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

“…[6][7][8][9] ERAS pathways have been published to guide the management of patients undergoing different surgery types, including colorectal, 10 gynecologic, 11 and thoracic surgeries. 12 Also, outside of published institutional protocols, 9,[13][14][15][16][17][18][19][20][21][22][23][24] the ERAS Society recently published evidence-based ERAS pathway recommendations for lumbar fusion. 25 For a specific ERAS pathway, the individual elements of the pathway may not improve measurable outcomes.…”

Enhanced Recovery After Surgery Protocol in Minimally Invasive Lumbar Fusion Surgery Reduces Length of Hospital Stay and Inpatient Narcotic Use

“…For one, ERAS has been shown to be more cost effective than traditional care approaches. 3 , 13 , 19 , 20 It has also been found to significantly reduce LOS 3 , 8 , 9 , 10 , 13 , 14 , 19 , 21 , 22 , 23 , 24 , 25 , 26 length of intensive care unit stay, 3 , 19 postoperative pain scores, 9 , 20 , 21 amount of opioids used postoperatively in the hospital, 9 , 12 , 21 , 22 , 23 , 27 , 28 and postoperative catheterization. 22 , 26 , 27 Evidence also suggests that ERAS in spine surgery may reduce the amount of rescue antiemetic medications used, 29 readmission rate, 25 , 30 and reoperation rate.…”

“… 3 , 13 , 19 , 20 It has also been found to significantly reduce LOS 3 , 8 , 9 , 10 , 13 , 14 , 19 , 21 , 22 , 23 , 24 , 25 , 26 length of intensive care unit stay, 3 , 19 postoperative pain scores, 9 , 20 , 21 amount of opioids used postoperatively in the hospital, 9 , 12 , 21 , 22 , 23 , 27 , 28 and postoperative catheterization. 22 , 26 , 27 Evidence also suggests that ERAS in spine surgery may reduce the amount of rescue antiemetic medications used, 29 readmission rate, 25 , 30 and reoperation rate. 25 Finally, ERAS has been shown to significantly increase patient and staff satisfaction, 9 allow patients to mobilize/ambulate sooner or better, 9 , 21 , 22 , 23 , 25 , 26 , 27 , 28 , 31 and take food sooner.…”

“… 22 , 26 , 27 Evidence also suggests that ERAS in spine surgery may reduce the amount of rescue antiemetic medications used, 29 readmission rate, 25 , 30 and reoperation rate. 25 Finally, ERAS has been shown to significantly increase patient and staff satisfaction, 9 allow patients to mobilize/ambulate sooner or better, 9 , 21 , 22 , 23 , 25 , 26 , 27 , 28 , 31 and take food sooner. 26 …”

Enhanced recovery after surgery (ERAS) protocol in spine surgery

“…However, the last decade has seen a change in this regard and adoption of ERAS in spine surgery has been growing leaps and bounds. 7,8 While initially the lumbar spine formed the main area for application of ERAS, 8 over the years the span of surgeries incorporating ERAS have expanded to include cervical spine surgery, deformity surgery, spinal tumors, and even elderly patients undergoing spine surgery. 9e12 In this narrative review we discuss the various benefits of ERAS protocols in spine surgery, the major components of ERAS, and the potential challenges in implementation of ERAS in spine surgery.…”