Perioperative Enhanced Recovery After Surgery (ERAS) Clinical Pathway for Unilateral Biportal Endoscopy with Unilateral Laminotomy for Bilateral Decompression

ABSTRACT

Objective

Unilateral biportal endoscopy with unilateral laminotomy for bilateral decompression (UBE‐ULBD) is a widely utilized minimally invasive surgical technique for treating lumbar spinal stenosis (LSS). This study aimed to evaluate the effectiveness of the enhanced recovery after surgery (ERAS) clinical pathway in improving perioperative and short‐term clinical outcomes for patients undergoing UBE‐ULBD for LSS.

Methods

A retrospective cohort study was conducted on the clinical data of patients who underwent UBE‐ULBD surgery for LSS from May 2022 to April 2024. Since the implementation of the ERAS clinical pathway in our department in May 2023, all eligible patients were divided into the ERAS group (May 2023–April 2024) and the traditional group (May 2022–April 2023). The two groups were analyzed for Visual Analog Scale (VAS) scores for lower extremities at preoperative, 6, 24, and 48 h postoperatively and on the day of discharge. In addition, the Oswestry Disability Index (ODI) and walking distances were assessed preoperatively, at 3 months postoperatively, and at 6 months postoperatively. Other parameters evaluated included the time to first ambulation after surgery, total length of hospital stay (LOS), postoperative LOS, perioperative opioid consumption, postoperative rehydration volume, and the incidence of postoperative complications.

Result

Compared to the traditional group, patients in the ERAS group demonstrated significantly lower pain scores at 6 and 24 h postoperatively, earlier ambulation, shorter total LOS and postoperative LOS, reduced postoperative rehydration volume, and perioperative opioid application (p < 0.05). No statistically significant differences were observed between the two groups in terms of lower extremities VAS scores before surgery, at 48 h postoperatively, and on the day of discharge. No statistically significant differences were observed in ODI scores before surgery, at 3 months postoperatively, and at 6 months postoperatively, as well as walking distances (p > 0.05). Furthermore, the incidence of complications was comparable between the two groups (p > 0.05).

Conclusion

The UBE‐ULBD surgery under the guidance of the ERAS program, through multidisciplinary collaboration and comprehensive measures, can significantly optimize perioperative management, improve postoperative recovery quality, and achieve satisfactory perioperative and short‐term clinical outcomes.

For patients undergoing UBE‐ULBD surgery, the application of the ERAS clinical program can lead to satisfactory clinical outcomes.

1. Introduction

Lumbar spinal stenosis (LSS) is a clinical syndrome caused by the narrowing of the lumbar spinal canal, nerve root canal, or intervertebral foramen. It is primarily characterized by symptoms such as lower extremity radicular pain or neurogenic intermittent claudication, resulting from nerve root or spinal cord compression [1, 2], and may be accompanied by or without low back pain. When conservative treatment fails or progressive nerve damage occurs, surgery is required. The main surgical treatments include traditional open surgeries (e.g., laminectomy, spinal fusion, or non‐fusion techniques) and various minimally invasive spinal endoscopic procedures. In recent years, unilateral biportal endoscopy with unilateral laminotomy for bilateral decompression (UBE‐ULBD), as an emerging technique for LSS, has been attracting more and more attention and favor from spine surgeons because of its advantages of both minimally invasive, wide field of vision, flexible operation, simple instrumentation requirements, and a gentle learning curve [3, 4, 5]. In patients without preoperative segmental lumbar instability, UBE‐ULBD can achieve satisfactory clinical outcomes [6].

The program of enhanced recovery after surgery (ERAS) [7] aims to optimize clinical pathways during the perioperative period based on evidence‐based medicine. Through a multidisciplinary collaboration involving surgery, anesthesia, nursing, rehabilitation, and other disciplines, ERAS seeks to reduce perioperative stress responses, minimize postoperative complications, shorten hospital stays, and promote recovery. Since its introduction, the ERAS program has been widely adopted in various surgical fields [8, 9, 10] (e.g., gastrointestinal surgery, bariatric surgery, and orthopedics), yielding significant results. In the field of spinal surgery, the ERAS concept has been gradually applied to certain surgical procedures, such as posterior lumbar short‐segment surgery, posterior cervical surgery, and percutaneous lumbar endoscopic surgery, Open Thoracolumbar Fusion for Adult Degenerative Deformity [11, 12, 13, 14]. However, there is still a lack of clinical research reports on the application of the ERAS clinical pathway in UBE‐ULBD.

Through multidisciplinary collaboration, literature review, and consensus‐based guideline development, the ERAS clinical pathway for UBE‐ULBD at Beijing Friendship Hospital (BFH‐ERAS‐UBE‐ULBD) was established (Table 1). The objectives of this study are: (i) to evaluate the clinical efficacy of the BFH‐ERAS‐UBE‐ULBD pathway through retrospective clinical analysis and (ii) to provide scientific evidence and clinical guidance for optimizing perioperative management in such surgeries.

TABLE 1.

Perioperative clinical pathway between two groups.

	ERAS group	Traditional group
Preoperative
Education	Through oral explanations and QR codes, the process became more systematic and standardized, emphasizing the participation of patients and their families	Routine education on disease diagnosis, treatment options, and the risks and benefits of surgery
Analgesic	Emphasize preemptive analgesia and multimodal analgesia, routine application of celecoxib + pregabalin + mecobalamin + eperisone hydrochloride	Continued patients' preadmission medication habits and was only temporarily added
Functional trainings	Collaborative guidance by medical, nursing, and rehabilitation staff	Collaborative guidance by medical and nursing
Preoperative fasting	Preoperative fasting: 6 h for solids, drinking “outfast” 2 h before surgery, no routine intravenous rehydration	Fasting at 24:00 before surgery, preoperative rehydration fluid 500–1000 mL
Intraoperative
Anesthesia	General anesthesia	General anesthesia
Antibiotic	Single‐dose antibiotic, within 1 h of incision	Single‐dose antibiotic, within 1 h of incision
Tranexamic acid	Routine intravenous infusion	Not routinely used
Intraoperative temperature	Medical warm air blowers were used to keep warm and prevent low temperature	Blanket were used to keep warm and prevent low temperature
Blood pressure control	Systolic blood pressure maintained at 90–100 mmHg	Systolic blood pressure maintained at 90–100 mmHg
Postoperative
ECG monitoring	6 h	6 h
Antibiotic	Not applicable	Single‐dose antibiotic, within 24 h postoperatively
Early oral intake	Postoperative 6 h	Postoperative 6 h
Rehydration	Not applicable	Postoperative rehydration 500–1000 mL
Drainage tube	Remove the drain if the drainage volume is less than 30 mL	Remove the drain if the drainage volume is less than 30 mL
Foley catheter	Remove upon first ambulation	Postoperative Day 1
Ambulation	Recommended 6 h postoperatively	Postoperative Day 1
Functional trainings	Same as preoperative	Same as preoperative
Analgesia	Same as preoperative	Same as preoperative
Discharge criteria	No wound redness or swelling, oral analgesics (e.g., COX‐2 inhibitors) can effectively control pain without interfering with sleep and functional exercise	No clear discharge criteria
Postoperative follow‐up	Rehabilitation clinic follow‐up 1 month after surgery, continued functional exercises	Not required

Abbreviations: ERAS, enhanced recovery after surgery; QR codes, quick response code.

2. Methods

2.1. Patients Populations

From May 2022 to April 2024, 127 LSS patients were enrolled in this retrospective clinical study at Beijing Friendship Hospital (BFH), Capital Medical University. Inclusion criteria were: (1) patients aged 30–80 years with single‐level degenerative LSS; (2) patients experiencing radiating pain to the lower extremities and diagnosed with definite lumbar central stenosis (Schizas grade ≥ B) on magnetic resonance imaging (MRI) [15]; (3) complete clinical data and imaging data, including X‐ray, CT, and MRI, with symptoms and signs consistent with imaging findings; (4) ineffective conservative treatment for at least 3 months; (5) preoperative Visual Analog Scale (VAS) scores for low back pain ≤ 3 and VAS scores for lower extremity pain ≥ 5; (6) possessing clear cognitive and communication abilities, able to understand questionnaire questions or educational content, and can accurately express their own thoughts. Exclusion criteria were: (1) preoperative imaging suggesting lumbar instability or more than Grade I spondylolisthesis; (2) history of previous lumbar surgery; (3) stenosis caused by a herniated intervertebral disc; (4) other spinal diseases (e.g., lumbar tuberculosis, lumbar tumor, ankylosing spondylitis); (5) lack of informed consent; (6) patients with severe comorbidities or other contraindications.

Taking May 2023 as the time point when the ERAS clinical management pathway was implemented. According to the above inclusion and exclusion criteria, all 127 patients were divided into the traditional group (54 cases) and the ERAS group (73 cases).

The study was approved by the Ethics Committee of BFH, Capital Medical University (Ethics No. 2025‐P2‐178), and all patients signed an informed consent form.

2.2. Surgical Technique

Take a case of L_4–5 LSS left lateral approach as an example. The patient was placed in the prone position on the surgical table, with the body adjusted to align the L_4–5 intervertebral space as perpendicular to the floor as possible. Using the intersection of the line connecting the inferior edge of the L₄ vertebral body and the medial margin of the left L_4–5 pedicle as the midpoint, two horizontal incisions approximately 1‐cm long were made 1.5 cm above and below this point. The skin and fascia were incised, expansion tubes were inserted and gradually dilated, establishing both an observation channel and an operating channel. Under endoscopic visualization, the target area was identified, and soft tissue on the bony structures was cleared using a radiofrequency device (BONSS, Jiangsu, China), achieving hemostasis. Beginning at the junction of the L₄ spinous process base and the lamina, a 4.0 mm burr was used to gradually thin the left lower lamina of L₄ from the inside out. A Kerrison rongeur was then used to remove part of the lower lamina of L₄ until the proximal attachment of the ligamentum flavum was exposed. The base of the L₄ spinous process was further drilled to reveal the “V‐shaped” structure formed by the ipsilateral and contralateral ligamentum flavum. Next, the left upper lamina of L₅ and the corner region were treated using the burr and rongeur until the attachment of the ligamentum flavum was reached. A small portion of the bone at the root of the superior margin of the L₅ spinous process was removed to expose the right upper lamina of L₅. Subsequently, a 4.0 mm burr was used to thin the right lower lamina of L₄ and the inner edge of the inferior articular process, while addressing the right upper lamina of L₅ and its corner region until the ligamentum flavum attachment was exposed. Finally, both superficial and deep layers of the ligamentum flavum on both sides were separated and excised, fully exposing the bilateral L₅ nerve roots and the inner wall of the facet joints. After verifying satisfactory decompression of both nerve roots, meticulous hemostasis was performed, and a drainage tube was routinely placed to ensure smooth postoperative drainage (Figure 1).

FIGURE 1.

UBE‐ULBD for lumbar spinal stenosis (LSS) of L4/5. (A–C) Preoperative MRI and CT demonstrating the LSS at the L4/5 level. (D) General image of the surgical incision. (E) Preoperative segmental confirmation under C‐arm fluoroscopy. (F) Establishment of the surgical tunnel. (G) Images of the incision after surgery. (H, I) Postoperative plain and three‐dimensional reconstruction CTs indicated adequate decompression.

2.3. Perioperative Management

In the traditional group, patients received standard perioperative education upon admission, including information on hospitalization procedures, surgical methods, associated risks, and potential postoperative complications. Preoperative analgesia was managed based on each patient's prior medication habits, with additional pain relief administered as needed. From 24:00 on the day before surgery, patients fasted from both food and water. Routine bowel preparation was performed using glycerin enemas. For patients who were not scheduled as the first case of the day, 500–1000 mL of glucose‐saline solution was routinely administered preoperatively. A single prophylactic dose of antibiotics was administered within 24 h postoperatively. Routine intravenous fluid supplementation was provided after surgery. Oral intake began with clear liquids 6 h postoperatively and gradually progressed to a regular diet. Functional rehabilitation exercises were performed under the guidance of medical staff, though there were no specific requirements regarding the frequency or duration of activity.

In the ERAS group, patients received structured, multidisciplinary perioperative management. A four‐stage education program was implemented to enhance patient engagement. Education was delivered during outpatient consultation, upon hospital admission, 1 day before surgery, and at discharge, covering disease knowledge, surgical procedures, perioperative precautions, pain management, rehabilitation, and discharge planning. To reinforce learning, QR codes linking to key educational materials were posted in clinics and wards for repeated access. Preoperative carbohydrate loading was achieved using Outfast (Yichang Renford Medical Food Co. Ltd., Wuhan, China), a clear maltodextrin‐based solution. Patients consumed one 355 mL bottle at 6:00 a.m. on the day of surgery, with a second dose at 10:00 a.m. if surgery was scheduled after noon. Multimodal analgesia was administered pre‐ and postoperatively, including celecoxib, pregabalin, mecobalamin, and eperisone hydrochloride. Patients were allowed to drink water 4 h postoperatively and resume a normal diet by 6 h. Intravenous fluids were not routinely given postoperatively. Early ambulation was encouraged within 6 h after surgery under lumbar brace protection. Functional rehabilitation was guided collaboratively by attending physicians, nurses, and rehabilitation specialists to ensure safe and effective recovery.

All patients underwent UBE‐ULBD surgery following the same surgical protocol as the traditional group.

2.4. Data Collection

Demographic data for all patients were collected, including age, gender, height, weight, BMI, American Society of Anesthesiologists (ASA) classification, operative time, and surgical segments. Clinical symptoms and outcomes were assessed by reviewing patients' medical records and follow‐up data. Specifically, the collected data included VAS scores for lower extremities at preoperative, 6, 24, 48 h postoperatively, and on the day of discharge. The ODI scores at preoperative, 3 and 6 months postoperatively. Time to first ambulation postoperatively. Total length of hospital stays, postoperative hospital stay, and walking distances at preoperative, 3 and 6 months postoperatively. Perioperative complications, postoperative rehydration volume, and perioperative opioid consumption.

2.5. Statistical Analysis

SPSS 25.0 software was used for statistical analysis. Measurement data were expressed as mean ± standard deviation; comparisons between groups were made by independent samples t‐test or Mann–Whitney U test. Count data were expressed as the number of cases (rate), and comparisons were made by the χ ² test or Fisher's exact probability method. p < 0.05 was taken as a statistically significant difference.

3. Result

3.1. Baseline Data

There was no statistical significance between the two groups in terms of age, height, weight, BMI, ASA classification, operative time, surgical segment, and postoperative complications (Table 2).

TABLE 2.

Basic characteristics of patients in two groups.

Variables	ERAS group	Traditional group	p
Age (years)	67.16 ± 8.15	67.54 ± 7.66	0.794
Female (%)	46 (63.0)	36 (66.7)	0.670
Weight (kg)	69.70 ± 12.84	66.90 ± 10.90	0.198
Height (m)	1.63 ± 0.07	1.62 ± 0.07	0.263
BMI (kg/m2)	26.08 ± 4.00	25.48 ± 3.34	0.372
ASA			0.903
II (%)	52 (71.2)	39 (72.2)
III (%)	21 (28.8)	15 (27.8)
Operative time (min)	121.55 ± 23.95	124.17 ± 39.32	0.666
Surgical segment			0.155
L2–3 (%)	2 (2.7)	2 (3.7)
L3–4 (%)	5 (6.8)	6 (11.1)
L4–5 (%)	64 (87.7)	40 (74.1)
L5–S1 (%)	2 (2.7)	6 (11.1)
Complications (%)	1 (1.4)	3 (5.6)	0.311
Opioid application	2 (2.7)	7 (13.0)	0.036

Abbreviations: ASA, American society of Anesthesiologists physical status classification system; BMI, body mass index; ERAS, enhanced recovery after surgery; operative time, defined as from the start of induction of anesthesia to the end of suture incision.

3.2. Early Postoperative Outcomes

Compared with the traditional group, patients in the ERAS group had an earlier first ambulation time, shorter total LOS and postoperative LOS, fewer postoperative rehydration volumes, lower opioid application, and lower VAS scores at 6 and 24 h postoperatively, and the differences were statistically significant (p < 0.05). The differences between the two groups were not statistically significant in terms of VAS scores at preoperative, 48 h postoperative, and on the day of discharge, ODI scores, and walking distances at preoperative, 3 months postoperative, and 6 months postoperative (p > 0.05). (Table 3; Figure 2).

TABLE 3.

Comparison of clinical outcomes between two groups.

Variables	ERAS group	Traditional group	p
VAS
Admission day	6.36 ± 1.08	6.50 ± 0.99	0.444
Postoperative 6 h	2.99 ± 0.70	3.26 ± 0.73	0.036
Postoperative 24 h	2.60 ± 0.66	2.91 ± 0.56	0.006
Postoperative 48 h	2.30 ± 0.46	2.37 ± 0.56	0.462
Discharge day	2.15 ± 0.40	2.24 ± 0.55	0.308
ODI
Admission day	58.36 ± 8.65	57.78 ± 7.81	0.699
Postoperative 3 months	25.97 ± 3.74	26.38 ± 4.10	0.557
Postoperative 6 months	17.87 ± 2.26	18.44 ± 2.65	0.208
Total LOS (days)	7.44 ± 1.41	8.48 ± 1.92	0.001
Postoperative LOS (days)	3.74 ± 1.00	4.50 ± 1.68	0.004
First ambulation time (h)	8.44 ± 2.09	16.52 ± 2.63	< 0.001
Walking distance
Postoperative (m)	368.49 ± 109.13	359.26 ± 135.31	0.681
Postoperative 3 months	2356.16 ± 733.52	2240.74 ± 888.82	0.425
Postoperative 6 months	4493.15 ± 603.77	4351.85 ± 872.16	0.309
Postoperative rehydration volume [M(IQR), mL]	0.00 (0.00)	500.00 (500.00)	< 0.001

Abbreviations: ERAS, enhanced recovery after surgery; LOS, length of hospital stay; ODI, Oswestry Disability Index; VAS, Visual Analog Scale.

FIGURE 2.

(A) ERAS group and traditional group VAS scores at each time period. (B) ERAS group and traditional group ODI scores at each time period. (C) ERAS group and traditional group walking distances at each time period. Data are presented as mean ± SD. Error bars represent the standard deviation (ERAS group n = 73, traditional group n = 54). p values were calculated by independent samples t‐test; ^NS p > 0.05, *p < 0.05.

3.3. Opioid Utilization

In this study, 73 patients were included in the ERAS group, of which 2 patients had a lower extremities VAS score > 8 upon admission. After receiving the ERAS pain management protocol, their pain relief was inadequate, so preoperative administration of acetaminophen–hydrocodone was added. In the traditional group, 54 patients were included, with 7 patients having a lower extremities VAS score > 8 upon admission. After receiving the traditional pain management protocol, pain relief was also inadequate, and preoperative acetaminophen–hydrocodone was added. Postoperatively, both groups showed significant pain relief, with no additional use of opioid analgesics. The difference in opioid application between the two groups during the perioperative period was statistically significant (p < 0.05) (Table 2).

3.4. Postoperative Complications

One patient in the ERAS group and two patients in the traditional group experienced minor dural tears during surgery, resulting in a delay of 1 day in the removal of the postoperative negative pressure drainage tube. However, this did not affect the patients' early postoperative ambulation. In the traditional group, one patient developed an epidural hematoma, and their muscle strength decreased compared to preoperative levels. After conservative treatment, muscle strength was restored, and the patient was discharged. The total complication rates were 1.4% (1/73) in the ERAS group and 5.6% (3/54) in the traditional group. The difference between the two groups was not statistically significant (p > 0.05) (Table 2).

4. Discussion

Guided by ERAS principles, the BFH‐ERAS‐UBE‐ULBD pathway integrates structured, multidisciplinary strategies to optimize perioperative management. This approach has been associated with improved pain control, accelerated functional recovery, and reduced hospitalization duration, thereby enhancing short‐term clinical outcomes and patient satisfaction. While the traditional group followed standard perioperative protocols, the absence of such coordinated interventions may account for the differences in clinical results.

4.1. Patient Education

Patients with LSS often experience psychological challenges, such as anxiety and depression [13, 16], due to reduced mobility and chronic low back pain. In addition, a lack of medical knowledge and poor understanding of lumbar UBE‐ULBD techniques, coupled with concerns about surgical trauma and potential complications, further exacerbate their psychological burden. A previous cross‐sectional study involving 629 patients undergoing lumbar fusion surgery found that those who received adequate preoperative education reported higher postoperative satisfaction and shorter hospital stays compared to those with insufficient education [17]. Through structured perioperative education, the BFH‐ERAS program encourages the active involvement of patients and their families. It transforms the traditional healthcare model, where medical staff lead and patients passively comply, into one of shared participation in the entire diagnostic and treatment process. This not only enhances patients' trust in healthcare providers and alleviates their anxiety about the disease but also motivates them to engage more proactively in postoperative functional rehabilitation exercises, thereby accelerating the recovery process.

4.2. Pain Management Strategy

Perioperative pain management is one of the key aspects of ERAS, and less pain or even no pain is a common target for doctors and patients. To prevent hyperalgesia and peripheral or central sensitization [18], we employ minimally invasive surgical techniques alongside a multimodal analgesic approach throughout the preoperative and postoperative periods to alleviate patients' pain effectively. Celecoxib, a selective COX‐2 inhibitor, minimizes the impact on platelet function while reducing opioid requirements and mitigating gastrointestinal side effects [19]. Pregabalin, targeting the α2‐δ subunit of voltage‐gated calcium channels in the brain and spinal cord, enhances analgesic efficacy by suppressing the release of excitatory neurotransmitters such as glutamate, substance P, and calcitonin gene‐related peptide. A prospective study evaluating the combination of pregabalin and celecoxib in lumbar spine surgery demonstrated significantly lower VAS scores in patients receiving this regimen compared to a placebo group, both at rest and during activity [20]. For patients with LSS, muscle tension is a common contributor to pain exacerbation. Eperisone hydrochloride exerts its muscle‐relaxant effects by selectively inhibiting the activity of γ‐motor neurons in the anterior horn of the spinal cord and the afferent neurons of muscle spindles [21], effectively breaking the spasm‐pain cycle and providing pain relief. Furthermore, chronic nerve root compression caused by reduced spinal canal volume can lead to an increased inward flow of sodium ions, resulting in ectopic discharges and radicular pain. Mecobalamin addresses this by blocking the inward sodium ion flow, promoting sensory restoration, and alleviating radicular pain in patients with LSS [22]. In this study, all the included patients had radiating pain in the lower extremities through a comprehensive multimodal analgesic program that can stabilize postoperative pain at a consistently low level. Compared to the traditional group, patients in the ERAS group demonstrated significantly lower pain scores at 6 and 24 h postoperatively (p < 0.05). The early and effective relief of pain not only reduces postoperative discomfort and opioid use but also creates favorable conditions for early ambulation, ultimately supporting a smoother recovery process for patients.

4.3. Perioperative Functional Exercises

Under the premise of ensuring safety and avoiding additional pain, early rehabilitation exercises can help patients return to normal work and daily life as soon as possible [23, 24]. Compared to the traditional model, where guidance is provided solely by medical staff, incorporating rehabilitation physicians with their professional expertise into a collaborative approach with medical and nursing teams significantly enhances the clinical efficacy of perioperative functional training. For patients undergoing UBE‐ULBD surgery, preoperative and postoperative rehabilitation guidance from rehabilitation physicians not only helps patients master correct exercise techniques but also boosts their confidence in engaging in active postoperative movement. For example, breathing and coughing exercises can effectively reduce the risk of postoperative pulmonary infections [25]. In addition, instructing patients on the proper use of lumbar braces lays a solid foundation for early ambulation after surgery. Postoperatively, patients can perform ankle pump exercises and straight leg raises in bed to promote lower limb blood circulation, reduce venous stasis, and lower the risk of deep vein thrombosis. Exercises such as bridging and the five‐point support method can strengthen the core muscles of the lumbar and back regions, alleviating symptoms of back pain. Rehabilitation physicians design a personalized home rehabilitation program for patients post‐discharge, outlining specific exercise routines and their recommended frequency. Furthermore, 1 month after discharge, patients are advised to visit the rehabilitation clinic, where rehabilitation physicians can develop personalized recovery plans based on their recovery progress. This approach ensures long‐term and stable postoperative outcomes.

4.4. Application of the “Outfast”

Lumbar UBE‐ULBD surgery is performed under general anesthesia. Traditionally, patients were required to fast from midnight the night before surgery to reduce the volume and acidity of gastric contents during surgery, thereby preventing adverse events such as aspiration pneumonia or choking caused by vomiting or reflux [26]. However, the 2023 guidelines from the ASA on preoperative fasting recommend that healthy patients undergoing elective surgery may safely consume clear, nonalcoholic fluids up to 2 h before general anesthesia without increasing the risk of reflux or aspiration [27]. A systematic review of 22 randomized controlled trials found no evidence that shortening the duration of preoperative fasting increased the risk of complications such as aspiration or reflux when compared with a traditional fasting protocol [28]. As part of the preoperative optimization strategy, the BFH‐ERAS program incorporates targeted oral carbohydrate loading to improve metabolic stability and reduce the need for routine intravenous fluid administration. The BFH‐ERAS program maintains the patient's normal energy supply, meets intraoperative energy requirements, and eliminates the need for routine preoperative intravenous infusions. This not only reduces the workload of nursing staff but also spares patients the discomfort associated with infusions. Compared to the traditional group, it also reduced the amount of postoperative rehydration for patients in the ERAS group (0.00 vs. 500.00, p < 0.05). Among 73 patients in the ERAS group, no complications such as reflux or aspiration were observed. Preoperative thirst was identified as the primary source of discomfort, followed by anxiety, insomnia, and hunger [29]. The use of “Outfast” effectively alleviated preoperative hunger and improved patient comfort. In addition, it reduced postoperative insulin resistance and minimized physiological dysfunction, contributing to enhanced patient outcomes [30].

4.5. Early Postoperative Ambulation

Early postoperative ambulation has become a key component of ERAS protocols across various surgical procedures. In spinal surgery, previous studies have demonstrated that early ambulation reduces the length of hospital stay and decreases the incidence of complications such as urinary retention, bowel obstruction, and deep vein thrombosis [31, 32]. Zakaria et al. conducted a prospective cohort study involving 23,295 patients who underwent spinal surgery for degenerative lumbar spine disease. Their findings revealed that ambulation on Postoperative Day 0 significantly reduced perioperative complication rates, shortened hospitalization, and improved functional outcomes during the perioperative period [33]. Postoperative incisional pain is one of the primary barriers to early mobilization. For patients undergoing UBE‐ULBD surgery, effective perioperative pain management combined with minimally invasive surgical techniques ensures that postoperative pain is well controlled. In both the traditional and ERAS groups, postoperative VAS scores improved significantly compared to preoperative levels and remained stable through the day of discharge. The immediate relief of pain created the conditions necessary for early postoperative ambulation (8.44 ± 2.09 vs. 16.52 ± 2.63, p < 0.05), enabling better patient compliance and contributing to overall recovery.

4.6. Strengths and Limitations

This study is among the few that systematically evaluate the application of an ERAS clinical pathway in UBE‐ULBD surgery, offering important insights into optimizing perioperative management in minimally invasive spine procedures. By comparing outcomes with those of a traditional care group, the clinical benefits of the ERAS pathway are clearly demonstrated. Furthermore, the development of the pathway was based on multidisciplinary collaboration, enhancing its clinical applicability and feasibility for broader implementation across healthcare settings. At the same time, we should acknowledge the limitations of this study. First, this was a single‐center study, which may limit the generalizability of the findings. Patient demographic characteristics and surgical techniques at the single‐center study institution may have resulted in some bias and not be representative of the wider clinical setting. Second, the retrospective nature of the study has inherent limitations, including potential selection bias and incomplete data collection. Further prospective multicenter studies are needed in the future to validate the benefits of ERAS in UBE‐ULBD further.

5. Conclusion

The UBE‐ULBD surgery, guided by the ERAS concept, leverages multidisciplinary collaboration and comprehensive measures to significantly optimize perioperative management. The BFH‐ERAS‐UBE‐ULBD clinical pathway effectively reduces postoperative pain and shortens the average LOS and the time to first postoperative ambulation, leading to highly satisfactory perioperative and short‐term clinical outcomes.

Author Contributions

Zhiwu Zhang: writing – original draft, software, formal analysis, validation, investigation, methodology. Jiashen Shao: writing – original draft, investigation, validation, software, formal analysis, methodology. Shuning Liu: writing – original draft, investigation, methodology, validation, software, formal analysis. Hai Meng: data curation. Zihan Fan: data curation. Jisheng Lin: data curation. Xiang Li: data curation. Qi Fei: writing – review and editing, supervision, resources, project administration, conceptualization.

Ethics Statement

The study was approved by the Ethics Committee of Beijing Friendship Hospital, Capital Medical University (Ethics No. 2022‐P2‐196‐01), and all patients signed an informed consent form.

Conflicts of Interest

The authors declare no conflicts of interest.

Zhang Z., Shao J., Liu S., et al., “Perioperative Enhanced Recovery After Surgery (ERAS) Clinical Pathway for Unilateral Biportal Endoscopy with Unilateral Laminotomy for Bilateral Decompression,” Orthopaedic Surgery 17, no. 9 (2025): 2699–2707, 10.1111/os.70117.

Data Availability Statement

Data will be made available on request.