The Evolution of Enhanced Recovery After Surgery

Abstract

Study Design: Retrospective cohort. Objective: To investigate the impact of evolving Enhanced Recovery After Surgery (ERAS) protocols on outcomes after cervical deformity (CD) surgery. Background: ERAS can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, there remains a paucity of literature assessing how developments have impacted outcomes after adult CD surgery. Methods: Patients with operative CD 18 years or older with pre-baseline and 2 years (2Y) postoperative data, who underwent ERAS protocols, were stratified by increasing implantation of ERAS components: (1) early (multimodal pain program), (2) intermediate (early protocol + paraspinal blocks, early ambulation), and (3) late (early/intermediate protocols + comprehensive prehabilitation). Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through Bonferroni-adjusted means comparison analysis. Results: A total of 131 patients were included (59.4 ± 11.7 y, 45% females, 28.8 ± 6.0 kg/m2). Of these patients, 38.9% were considered “early,” 36.6% were “intermediate,” and 24.4% were “late.” Perioperatively, rates of intraoperative complications were lower in the late group (P= 0.036). Postoperatively, discharge disposition differed significantly between cohorts, with late patients more likely to be discharged to home versus early or intermediate cohorts [χ2(2) = 37.973, P< 0.001]. In terms of postoperative disability recovery, intermediate and late patients demonstrated incrementally improved 6 W modified Japanese Orthopedic Association scores (P= 0.004), and late patients maintained significantly higher mean Euro-QOL 5-Dimension Questionnaire and modified Japanese Orthopedic Association scores by 1 year (P< 0.001, P= 0.026). By 2Y, cohorts demonstrated incrementally increasing SWAL-QOL scores (all domains P< 0.028) domain scores versus early or intermediate cohorts. By 2Y, incrementally decreasing reoperation was observed in early versus intermediate versus late cohorts (P= 0.034). Conclusions: The present study demonstrates that patients enrolled in an evolving ERAS program demonstrate incremental improvement in preoperative optimization and candidate selection, greater likelihood of discharge to home, decreased postoperative disability and dysphasia burden, and decreased likelihood of intraoperative complications and reoperation rates.