The implementation of enhanced recovery after surgery (ERAS) in complex spinal surgery

Angus, Michelle; Jackson, Kelly A.; Smurthwaite, Glyn; Carrasco, Roberto; Mohammad, Saeed; Verma, Rajat; Siddique, Irfan

doi:10.21037/jss.2019.01.07

Cited by 53 publications

(46 citation statements)

References 11 publications

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“…Whether improving the post-operative outcomes through prehabilitation has beneficial effects on mortality is not yet clear [ 94 ]. Multimodal prehabilitation in spinal surgery has been associated with improved recovery milestones, earlier discharge and appreciable improvement in patient satisfaction scores in the study group [ 95 , 96 ]. Health-economic benefits have been greater in patients having prehabilitation [ 96 , 97 ].…”

Section: Discussionmentioning

confidence: 99%

“…Multimodal prehabilitation in spinal surgery has been associated with improved recovery milestones, earlier discharge and appreciable improvement in patient satisfaction scores in the study group [ 95 , 96 ]. Health-economic benefits have been greater in patients having prehabilitation [ 96 , 97 ]. Patient reported outcomes such as readiness for surgery and perceived quality of life, were found to be improved by pre-operative neuroscience education and physiotherapy [ 98 – 100 ].…”

Section: Discussionmentioning

confidence: 99%

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Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

et al. 2021

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Background Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review. Methods We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway. Results We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components. Conclusions We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS. Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

et al. 2021

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“…Definitions include: sitting on the edge of the bed [45], sitting out of bed [44], on-bed movement as well as sitting and assisted movement [47], a log roll and walk to the doorway [42], movement from the hospital bed to chair, then chair back to the bed, at a minimum assist level [43], standing and marching on the spot [21], sitting, standing, visiting the toilet and walking to the general ward [41] and “light activity in the room” including bed to chair, bed to bathroom and out of bed to bathroom movements [28]. In some excluded studies, early mobilisation was included within the intervention protocol but was not described in sufficient detail to warrant inclusion within this review [22,52,53,54].…”

Section: Discussionmentioning

confidence: 99%

“…ERAS has recently been applied to spinal surgery [17,18,19,20,21,22,23,24], and has been advocated for accelerating postoperative recovery and improving longer term outcomes [25]. A recent systematic review has summarised the implementation of ERAS to spine surgery, with results demonstrating a reduced length of stay with no increase in rates of readmission or complication [26].…”

Section: Introductionmentioning

confidence: 99%

What Is the Evidence for Early Mobilisation in Elective Spine Surgery? A Narrative Review

Burgess

Wainwright

2019

Healthcare

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Early mobilisation is a cornerstone of Enhanced Recovery after Surgery (ERAS) and is encouraged following spinal procedures. However, evidence of its implementation is limited and there are no formal guidelines on optimal prescription. This narrative review aimed to evaluate the evidence for the effect of early mobilisation following elective spinal surgery on length of stay, postoperative complications, performance-based function and patient-reported outcomes. Four trials (five articles) that compared a specific protocol of early in-hospital mobilisation to no structured mobilisation or bed rest were selected for inclusion. Nine studies that investigated the implementation of a multimodal intervention that was inclusive of an early mobilisation protocol were also included. Results suggest that goal-directed early mobilisation, delivered using an evidence-based algorithm with a clear, procedure-specific inclusion and exclusion criteria, may reduce length of stay and complication rate. In addition, there is evidence to suggest improved performance-based and patient-reported outcomes when compared to bed rest following elective spinal surgery. Whilst this review reveals a lack of evidence to determine the exact details of which early mobilisation protocols are most effective, mobilisation on the day of surgery and ambulation from the first postoperative day is possible and should be the goal. Future work should aim to establish consensus-based, best practice guidelines on the optimal type and timing of mobilisation, and how this should be modified for different spinal procedures.

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“…Enhanced recovery after surgery (ERAS) is a multimodal approach to patient care, introduced to prepare patients for surgery, reduce the surgical stress response, and enable them to recover faster ( 1 ). Enhanced recovery after surgery has recently been applied to spinal surgery, using evidence-based practice and improved pathways, to encourage lower rates of morbidity and improve longer term outcomes ( 2 – 5 ). A recent systematic review has summarized the implementation of ERAS to spine surgery, with results demonstrating a reduced length of stay with no increase in rates of readmission or complication ( 6 ); however, the evidence for its adoption is still limited.…”

Section: Introductionmentioning

confidence: 99%

Patient Information Leaflets for Lumbar Spine Surgery: A Missed Opportunity

Low

Burgess

Wainwright

2019

Journal of Patient Experience

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Background: High-quality patient information is recommended to help reduce procedure-related anxiety and encourage patients to become active participants in their recovery. The objective of this study was to analyze the quality of patient information leaflets (PILs) given to National Health Service (NHS) patients ahead of lumbar spine surgery. Methods: The DISCERN tool was used to evaluate the quality of PILs, sourced from NHS websites. Results: Thirty-two PILs on lumbar surgery were included. Two (6%) leaflets were considered poor, 13 (41%) were marked as fair, 14 (44%) were of good quality, and 3 (9%) were scored as excellent. The total mean score was 55 (30-74), which corresponds to good quality. The lowest scoring questions were sources of information (Q4), balanced/unbiased content (Q6), and explanation of no treatment (Q12). Conclusions: There is considerable variation in the quality of PILs provided ahead of lumbar spine surgery. The scope for improvement is clear, and as the move toward patient-centered, evidence-based care continues, it is important that hospital resources provide recommendations based upon evidence of clinical effectiveness.

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The implementation of enhanced recovery after surgery (ERAS) in complex spinal surgery

Cited by 53 publications

References 11 publications

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

What Is the Evidence for Early Mobilisation in Elective Spine Surgery? A Narrative Review

Patient Information Leaflets for Lumbar Spine Surgery: A Missed Opportunity

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