Evaluation of the Enhanced Recovery After Surgery (ERAS) Guidance for Patients With Spinal Metastasis

ABSTRACT

Surgery continues to remain the most effective treatment for spinal metastasis (SM). As the number of surgeries continues to grow, the need for consensus guidelines for optimal perioperative care is imperative. Enhanced recovery after surgery (ERAS) protocols were created for this purpose. The objective of this study is to review evidence‐based ERAS guidelines for SM surgery. A group of multiple experienced spine surgeons was invited to participate in this study. This group identified 19 ERAS items for SM surgery. The principal literature search utilized MEDLINE, Embase, and Cochrane databases to identify contributions related to the topic published. Systematic reviews, randomized controlled trials (RCTs), and observational cohort studies which reported SM surgery related to the ERAS topics were included. The evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendations were reached by the group after a critical appraisal of the literature. Five articles were included to develop the consensus statements for 19 ERAS items. All recommendations on ERAS protocol items are based on the best available evidence. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented. Based on the best evidence available for each ERAS item within the multidisciplinary perioperative pathways, we presented this comprehensive consensus review for SM surgery. This ERAS elements can be implemented and practiced clinically.

The flow diagram of study.

Abbreviations

ASA

American Society of Anesthesiologists

ERAS

enhanced recovery after surgery

GDFM

goal‐directed fluid management

GRADE

grading of Recommendations, assessment, development, and evaluation

LOS

length of stay

PCA

patient‐controlled analgesic device

PONV

postoperative nausea and vomiting

RCTs

randomized controlled trials

SM

spinal metastases

1. Introduction

Spinal metastasis (SM) has been challenging for several years, affecting up to 30%–70% of cancer patients [1, 2, 3]. There is no doubt that surgical treatment is effective for improving quality of life and relieving symptoms [4, 5, 6, 7].

However, with the process of resection, decompression, and stabilization of SM surgery, the risks of operation and postoperative complications are significantly increased, including: cardiac dysfunction, acute multiple organ failure, thrombosis, pulmonary embolism, pulmonary infection or septicemia, infection of the surgical site, failure of surgical fixation, or reoperation [8]. These complications led to a significant increase in the length of surgery, cost, and even death [9, 10, 11, 12, 13]. According to statistics, the readmission rate within 3 months after discharge due to postoperative complications was 9.7% to 16.8%, and the rate of reoperation due to complications was similar [14]. So, it is important to reduce the intraoperative and postoperative complications and improve the postoperative survival rate of patients. Therefore, our perioperative goals are shortening the operation and hospitalization time and reducing the occurrence of complications.

Enhanced recovery after surgery (ERAS) pathways is a multidisciplinary program that aims to improve patient outcomes and decrease costs after various types of surgery [15, 16, 17, 18, 19]. Although ERAS guidelines had covered many disciplines, it involves the fields of anesthesia, bariatric, breast, cardiac, and so on. However, there have been relatively few studies on the application of ERAS protocols to spinal metastases. The study aimed to (i) summarize the recent studies on ERAS programs of SM, (ii) evaluate the quality of the study by GRADE system, and (iii) make a contribution to the establishment of ERAS guidelines for SM by evaluating these ERAS programs.

2. Methods

2.1. Formation of the Appraised Group and Selection of Guideline Topics

We invited Chinese authoritative clinicians (including traditional Chinese medicine), anesthesiologists, and nurses in spinal metastatic tumor surgery. They were considered quite influential in the surgery or care of spinal metastatic tumors. The group could receive timely support from anesthesiologists and paramedics with ERAS expertise [20]. The appraised group was consulted to advise on the appropriate items to be included in the guidelines, and the final decision was made by the author. Guidelines items were admeasured to authors for literature summary and grading based on individuals' expertise. The final content was obtained with the unanimous agreement of all the authors.

2.2. Literature Search Strategy

The literature was systematically reviewed adhering to the Preferred Items for Systematic Evaluation and Meta‐Analysis (PRISMA) statement guidelines [21, 22]. Key words included “spinal metastasis” or “metastasis” and “enhanced recovery after surgery”. Reference lists of all eligible articles were checked for other relevant studies. Due to the sample size of relevant literature being small, authors did not limit the literature by language or the date of publication.

2.3. Quality Assessment

After Literature search, the expert panel conducted a quality assessment of the literature. Conduct a bias risk assessment of the included systematic reviews using a tool for evaluating the risk of bias. The quality levels for systematic reviews are categorized into “high, moderate, low, and very low” quality grades. Methodological quality of randomized controlled trials (RCTs) is evaluated using a bias risk assessment tool. The assessment includes seven items based on the type of bias, namely, the generation of random sequences, concealment of allocation, blinding of participants and personnel, blinding of outcome assessment, completeness of outcome data, publication bias, and other biases. The grading system is classified into “low risk, unclear, high risk” three levels.

2.4. Data Analyses

After Quality assessment, the evidence bodies included are summarized and quality assessed using the GRADE system. Although the evidence derived from RCTs initially receives a high‐quality rating, our confidence in this type of evidence might decrease due to the following five factors: limitations of the study, inconsistent results, indirect evidence, imprecise results, and biased reporting. We divided the outcome indicators into Critical (LOS, pain score, time to ambulation, postoperative complications, patient satisfaction score), Importance (oral morphine equivalent daily, duration of urinary catheterization, time to resumption of regular diet, estimated blood loss, operation time, anxiety/depression), Not importance (total intraoperative fluid intake, overall cost). The specific process included: clarifying the initial quality level of evidence, clarifying the factors, grading the quality of evidence, considering other factors (such as patient values and preferences, the applicability of clinicians or policymakers), and making recommendations (Tables 1 and 2). Differences in judgment shall be resolved by the author and the members of the working group during committee meetings or the Delphi process. Based on the preliminary summary, valuable items from the ERAS project were selected through the Delphi process, resulting in an initial set of ERAS items with a relatively high level of clinical evidence. Of course, through the Delphi process, some lower‐level evidence also received strong recommendations.

TABLE 1.

GRADE system for rating strength of recommendations.

Recommendation Strength	Definition
Strong	When desirable effects of intervention clearly outweigh the undesirable effects, or clearly do not
Weak	When trade‐offs are less certain‐either because of low‐quality evidence or because evidence suggests desirable and undesirable effects are closely balanced

TABLE 2.

GRADE system for rating quality of evidence.

Evidence level	Definition
High quality	Further research unlikely to change confidence in estimate of effect
Moderate quality	Further research likely to have important impact on confidence estimate of effect and may change the estimate
Low quality	Further research very likely to have important impact on confidence in estimate of effect and likely to change the estimate
Very low quality	Any estimate of effect is very uncertain

3. Result

After searching existing relevant studies and removing duplicates, 5 relevant projects were screened out and included in our study [23, 24, 25, 26, 27] (Figure 1). There was no disagreement among the authors in their assessment of the quality and grading of the evidence. Therefore, a second round Delphi process was not needed. Table 3 summarized the recommendations, evidence, and recommendation levels. Table 4 summarized the positive outcomes of these studies.

FIGURE 1.

PRISMA flow diagram of study inclusion.

TABLE 3.

Summary of recommended interventions for the ERAS of surgical treatment of patients with SM.

No	Item	Recommendation	Evidence level	Grade
1	Preoperative education and counseling	Receive consultation from patients and inform them of the relevant ERAS process	Moderate	Strong
2	Patient evaluation	Assess the patient's preoperative status using a series of scales, and evaluation 30 days after discharge	Moderate	Strong
3	Smoking and alcohol abstinence	Abstinence smoking and alcohol for 2 weeks	High	Strong
4	Nutritional intervention	Treat or improve malnutrition	High	Strong
5	Antithrombotic prophylaxis	Physical or pharmacological thrombus prophylaxis before surgery	High	Strong
		Patients should undergo physical prevention of DVT after surgery, and anticoagulants should be used if necessary	Moderate	Strong
6	Preoperative intestinal intervention	Treatment of constipation and oral carbohydrate loading: 400 mL of oral carbohydrate loading 2 h before surgery	High	Weak
		Preop fasting: Clear liquids permissible up to 2 h before surgery except for high risk of aspiration	Moderate	Strong
7	Pain management	Routine use of multimodal analgesic regimens to improve pain control and reduce opioid consumption, make standardization and personalization of perioperative analgesia protocols	Moderate	Strong
8	General anesthesia	General anesthesia: Combined IV‐inhalation anesthesia	High	Strong
9	Surgical consideration	Minimally invasive spine surgery when applicable	Moderate	Strong
10	Hemostasis and prevent bleeding	Prevent bleeding before surgery and using Tranexamic acid for Hemostasis	Moderate	Strong
11	Temperature management	Constant body temperature monitoring throughout the surgery and actively attempt to keep temperature above 36°C	Moderate	Strong
12	Goal‐directed fluid balance	Individualized goal‐directed fluid therapy based on surgical and patient risk factors	Moderate	Strong
13	Wound suture	Absorbable suture for dura, muscle and subcutaneous tissue, intradermal suture for skin incision	High	Strong
14	Surgical site drains	Restrict placement of surgical site drains unless deemed necessary or clinically indicated	High	Strong
15	Urinary catheter	Early discontinuation of urinary catheters(within 24 h after surgery)	Moderate	Strong
16	Ambulation	Early ambulation and independent ambulation or ambulation with minimal assistance by discharge	Moderate	Strong
17	Postoperative Diet	Early oral intake and postoperative reduction of IV fluids	Moderate	Strong
18	PONV management	PONV prophylaxis	High	Weak
19	Systemic audit	Routinely auditing and feedback is necessary for implementation of ERAS protocols, maintaining high compliance to ERAS protocols and realizing quality improvement	Moderate	Strong

TABLE 4.

Quality analysis of included literature.

	Publication Time	Sample size	Study limitations	Inconsistency of results	Indirectness of evidence	Imprecision	Reporting bias
Bolin Liu	2020	94	0	0	0	0	0
Roxana M. Grasu, MD	2018	97	−2	−1	0	0	0
Vikram B. Chakravarthy MD	2022	390	−1	0	0	0	0
Feng Baojuan	2021	60	0	0	0	0	0
Mingxing Lei	2023	184	−2		0	0	0

3.1. Preoperative Education and Counseling

Many ERAS programs advocated preoperative patient counseling and education [28, 29, 30, 31]. As the important treatment plans for SM, the surgical risks and postoperative complications are difficult for patients to bear [32]. However, simply making multidisciplinary consultation or strictly implementing the ERAS process did not perfectly avoid the complications and sequelae of surgery. Study showed that the use of opioids could be significantly reduced by improving preoperative counseling. It was also a very important indicator in the postoperative rehabilitation process of SM. Preoperative consultation seemed to reduce the anxiety, which made the patients better cooperate with the implementation of the ERAS program. The preoperative consultation could also affect the surgical outcome and satisfaction, which was also reflected in previous research [33, 34]. Unfortunately, the existing study did not recommend conducting preoperative education as an independent intervention prior to elective spine surgery. But our team still recommended it as the first one to present it here, because we believed that the preoperative consultation was not only purely to improve the clinical prognosis, but also a part of the right to informed consent. Of course, we considered that preoperative consultation could be beneficial for the ERAS regimen, but it may need further research to clarify the timing and method of preoperative consultation which could make benefit.

Summary/recommendation:

Receive consultation from patients and inform them of the relevant ERAS process.

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.2. Patient Evaluation

Patients with SM have variable preoperative physical conditions. It was recommended using a series of scales to assess the physical status and for perioperative preparation. The evaluation of pain severity is recommended to be conducted using the VAS. The assessment of spinal stability is advised to utilize the Spinal Instability SINS, while neurological impairment should be evaluated according to the ASIA. Clinically, patients with spinal metastases often experience pain and frequently present with vertebral collapse and kyphotic or scoliotic deformities. The assessment of spinal instability necessitates a comprehensive evaluation combining imaging findings with clinical manifestations to inform decision‐making. The SINS scoring system exhibits high sensitivity and specificity for detecting potential or existing spinal instability, thereby aiding clinicians in identifying patients at high risk of vertebral instability or deformity.

In addition, in 2006, Bilsky et al. proposed the NOMS decision framework. This system encompasses four components: neurological status; tumor characteristics; spinal stability; and systemic disease. The NOMS system emphasizes the urgency of treating ESCC symptoms. Based on the ESCC grading standard, grades 2 and 3 represent severe spinal cord compression requiring urgent surgical intervention. In 2011, Paton et al. introduced the LMNOP treatment decision system, which emphasizes the impact of tumor invasion sites, systemic therapy effects, and responses. Unlike the NOMS system, LMNOP incorporates a broader application of minimally invasive procedures, such as percutaneous vertebral augmentation, which are simple to perform, effectively alleviate pain, and facilitate subsequent radiotherapy and systemic treatments. This system assesses factors including the patient's overall condition, nutritional and hematological status, and the efficacy of chemotherapy or radiotherapy, thereby supporting accurate prognosis estimation and optimization of treatment strategies.

Spratt had proposed a clinical decision plan, which guided the treatment of spinal tumors by evaluating the functional status (KPS) of the patients. Symptomatic support or external radiation was selected for patients with KPS score less than 40, heavy tumor burden, continuous progression and no clinical systemic therapy [35]. It was recommend implementing patient evaluation throughout the ERAS process. Evaluation at discharge help us to understand the surgical efficacy as well as predict patient outcomes, such as Tomita score and Tokuhashi score [36].

In 2023, the Liu Yao Sheng team proposed the SENO framework, which includes systemic disease status, efficacy of systemic treatments, neurological and oncological characteristics, and explores its clinical effectiveness through multicenter analyses. Compared to the non‐SENO group, patients in the SENO group demonstrated significantly improved survival outcomes. Three months post‐discharge, the SENO group also showed greater improvements in quality of life.

And we recommended continuous follow‐up throughout the treatment cycle. Generally, we could have a more comprehensive understanding of the impact of ERAS on the long‐term survival of patients.

Summary/recommendation:

Assess the patient's preoperative status using a series of scales, and evaluation 30 days after discharge.

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.3. Smoking and Alcohol Abstinence

Substantial evidence suggested that smoking would increase the morbidity of perioperative and postoperative complications. If patients scheduled for surgery did not stop smoking during the perioperative period, the risk of in‐hospital death increases by 20% and has a 40% increased risk of major postoperative complications [37]. Smoking had a significant impact on the postoperative course and might cause many consequences such as difficult wound healing, surgical site infection, anastomotic fistula, and cardiovascular and respiratory complications [38]. Preoperative smoking cessation and perioperative smoking cessation were beneficial to reduce operative site infection. Compared with smoking patients, patients who had quit or never smoked had a significantly lower probability of site wound infection, and even smoking cessation in the perioperative period could significantly reduce the infection rate of surgical site infection [39].

Alcohol was also an important cause for increasing the complications of spinal surgery. Alcohol abuse might lead to an increased rate of total endoscopic spinal surgery for lumbar disc herniation within ten decades and a potential risk of infection after spinal surgery [40]. A study of 3,132,192 samples about alcohol abuse and alcohol withdrawal within spine fusion surgery noted that alcohol consumption was associated with multi‐organ complications and significantly increased venous thromboembolism, wound‐related complications, and hospital mortality. Moreover, it increased treatment costs and LOS [41]. Studies concerning the relationship between preoperative abstinence and elective orthopedic surgery revealed that brief behavioral interventions were shown to be effective in reducing alcohol consumption among increased risk and risky drinkers in other health‐care settings and improving the surgical outcome [42]. Except for alcohol abstinence for 4–8 weeks before surgery, it may also include first‐line therapy of alcohol withdrawal symptoms, benzodiazepines, and barbiturates (if refractory to benzodiazepines) [43].

Summary/recommendation:

Abstinence from smoking and alcohol for 2 weeks.

Quality of evidence: High.

Recommendation grade: Strong.

3.4. Nutritional Intervention

Malnutrition is common in cancer patients, with an estimated prevalence of 40% [44]. It was always overlooked by clinicians and could affect a patient's tolerance to chemotherapy, radiotherapy, and surgery. It is also associated with LOS and increased morbidity after spinal tumor surgery. Recommendations for nutritional interventions were gradually emerging in studies on spine surgery [25, 45]. Previously study on the relationship between preoperative nutritional interventions and postoperative complications stated that, nutritional intervention with guidance and supplements reduced postoperative medical complications in malnourished patients.

Summary/recommendation:

Treat or improve malnutrition.

Quality of evidence: High.

Recommendation grade: Strong.

3.5. Antithrombotic Prophylaxis

Patients undergoing orthopedic surgery were at increased risk of thromboembolism, which might include pulmonary embolism and deep vein thrombosis (VTE). Acute thromboembolic disease can lead to severe morbidity, poor quality of life, and even death. The main risk factors for thrombotic events include age, gender, higher BMI, surgical method, passive intraoperative blood loss, underlying diseases, and abnormal preoperative coagulation function [46, 47].

Antithrombotic prophylaxis should continue throughout the course of treatment. The simplest VTE prevention was early ambulation [48, 49]. In addition to physiotherapy, there were multiple studies that showed that enoxaparin, fragmin, and fondaparinux are effective in preventing screen detected VTE, and prophylactic anticoagulation with low molecular weight heparin in surgically treated patients reduced the risk of DVT. Guidelines also recommend thromboprophylaxis with oral anticoagulants (including apixaban, rivaroxaban) or low molecular weight heparin in selected high‐risk populations as an effective measure [50].

Summary/recommendation:

Physical or pharmacological thrombus prophylaxis before surgery.

Quality of evidence: High.

Recommendation grade: Strong.

Summary/recommendation:

Patients should undergo physical prevention of DVT after surgery, and anticoagulants should be used if necessary.

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.6. Preoperative Intestinal Intervention

Constipation has a high prevalence in the general population, and patients' quality of life is significantly impaired. Particularly, patients with SM appeared to be more prone to constipation due to their limited mobility. The clinical presentation of patients with constipation is varied; even reports showed that constipation could lead to sexual dysfunction, urinary retention, and dyspareunia. Early treatment of constipation, including prevention and treatment, can reduce symptoms and improve quality of life. But unfortunately, we did not find any studies that directly demonstrated that constipation treatment or preoperative intestinal intervention could benefit patients undergoing spinal tumor surgery.

Fasting before surgery is a standardized procedure before surgery. It can avoid the possibility of lung aspiration of the gastric contents during surgery [51]. However, fasting potentially increases blood loss during surgery, may lead to dehydration, and increase fluid supplementation during anesthesia. According to the guidelines, low‐risk patients were advised to fast solid food 6–8 h before surgery and encouraged consumption of clear fluid 2 h before surgery [52].

Preoperative oral carbohydrate loading had been mentioned in several ERAS protocols, and there was such RCT research about preoperatively oral carbohydrate loading. But the results did not appear to be consistent. Some gynecologic procedures did not show clinical benefit or just alleviate patient's anxiety [53, 54]. In some gastrointestinal surgeries, it appeared to improve surgical outcomes, reduce complications, and reduce LOS [55, 56]. Similar results occurred in a study about the effect of pre‐operative carbohydrate loading in femur fracture [57]. As regards oral carbohydrate loading 2 h before surgery, some studies showed that no significantly increase the risk of lung aspiration and hyperglycemia [58]. Furthermore, it had been shown that preoperative oral administration of carbohydrate‐rich beverages did not affect the hemodynamic parameters in healthy volunteers. However, we still did not recommend it as our recommended items until there was conclusive evidence that oral carbohydrates 2 h before surgery do not affect the safety of spinal tumor surgery.

Summary/recommendation:

Treatment of constipation and oral carbohydrate loading: 400 mL of oral carbohydrate loading 2 h before surgery.

Quality of evidence: High.

Recommendation grade: Weak.

Summary/recommendation:

Preop fasting: Clear liquids permissible up to 2 h before surgery except for high risk of aspiration.

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.7. Pain Management

The main clinical manifestation of SM is pain. How to relieve the pain and reduce the pain after surgery is one of the important contents of the ERAS program for spinal tumor surgery. Opioid analgesics are often used in clinical practice to control intraoperative and postoperative pain. However, they also bring many undesirable side effects [59, 60]. The opioid analgesic dosage is an important outcome of the ERAS regimen. Each ERAS regimen was slightly different about pain management and reducing opioid analgesic dosage, but all involve the use of multimodal analgesia.

Patients receiving the ERAS regimen showed better postoperative pain score, reducing use of patient‐controlled analgesia, and fewer oral opioids. Dose reduction was considered if the patient was up to 65 years old. With postoperative gabapentin 300 mg every 8 h, celecoxib 200 mg every 12 h, tramadol 200 mg every 12 h, and acetaminophen 1 g every 6 h. Patients received PCA and progressive transition to oral analgesics as needed. Ultimately, the ERAS group showed a trend towards better pain score and reduced opioid consumption [24]. In the study of Chakravarthy, patients took preoperative oral neuropathic painkillers (300 mg gabapentin) and 1000 mg acetaminophen/200 mg celecoxib. Muscle relaxants (10 mg baclofen every 8 h or 5 mg diazepam every 8 h) and PCA were used. Less opioid consumption was finally obtained than in the control group [23]. Multiple studies on the application of NSAID and COX‐2 specific inhibitors had also demonstrated their role in pain management. A meta‐study by Zhang et al. included 408 patients after lumbar spine surgery from eight studies, which showed the mean difference in pain scores between the NSAID and placebo groups within the first 24 h [61]. In conclusion, reducing opioid consumption facilitates the implementation of the ERAS protocol in patients. While reducing opioid consumption, the ERAS protocol also includes topical use of anesthetics to strengthen pain management.

Besides local infiltration, the use of interfacial plane blocks or an erector spinae plane block could also work. A study about comparison of the ultrasound‐guided modified‐thoracolumbar interfacial plane block and wound infiltration showed that opioid consumption and the use of rescue analgesia were significantly lower in all the postoperative periods, and the VAS scores for pain during mobility and while at rest were significantly lower 8 h after the surgery [62]. Although some of the above multimodal analgesic regimens were not mentioned in this recommendation, we believe that pain management in ERAS protocol should be more individualized and multimodal.

Summary/recommendation:

Routine use of multimodal analgesic regimens improves pain control and reduces opioid consumption, making standardization and personalization of perioperative analgesia protocols.

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.8. General Anesthesia

In most cases that the anesthesia of choice for spinal tumor surgery is combined IV‐inhalation anesthesia, which includes propofol, sufentanil, rocuronium, propofol, fentanyl, sevoflurane, dexmedetomidine, and ketamine, lidocaine. Some of these anesthetic drugs may require more caution by the anesthesiologist. Nielsen found the intraoperative use of intravenous S‐ketamine on analgesics consumed 1 year after surgery in patients undergoing spinal fusion surgery could reduce the use of analgesics and improve labor market attachment 1 year after spine surgery in an opioid‐dependent population [63]. A study on the combination of methadone and ketamine also showed that the combination of methadone and ketamine enhanced postoperative analgesia and had fewer oral opioids on the first postoperative day [64]. Although it has been shown that adjunctive therapy with intravenous ketamine reduces opioid consumption and pain, Brinck investigated the efficacy of intraoperative intravenous S‐ketamine in 198 patients undergoing lumbar fusion surgery. It showed that intraoperative intravenous infusion of 0.12 mg/kg/h S‐ketamine did not reduce oxycodone consumption at 48 h after lumbar fusion surgery in an RCT experiment [65]. However, current opioid‐free anesthesia (OFA) was a multimodal strategy using multiple combinations of drugs that may include ketamine, dexmedetomidine, and lidocaine infusion seems to have become the primary anesthetic option for major spinal surgery [66]. A study evaluating the OFA regimen in the lumbar decompression surgery ERAS showed a significant reduction in total perioperative opioid consumption when receiving OFA [67].

Of course, other anesthesia options were still needed for patients at high risk of general anesthesia for severe comorbidities. A study retrospectively evaluated 14 patients with spinal tumors who underwent spinal anesthesia surgery for severe comorbidities, showing that spinal anesthesia was a feasible and useful procedure for older patients with American Society of Anesthesiologists (ASA) 3 or 4 points and at high risk of general anesthesia [68]. This view was also supported by another study containing 343 complex lumbar spine surgeries [69]. Meanwhile, 424 lower thoracic and lumbar spine surgeries performed under spinal anesthesia were collected in a prospective database; the results of the study showed that the extreme elderly cohort had increased ASA scores, levels of surgery, and LOS. Similar rates occurred for surgical complications. Spinal anesthesia showed its safety and feasibility in the elderly population [70].

Summary/recommendation:

General anesthesia: Combined IV‐inhalation anesthesia.

Quality of evidence: High.

Recommendation grade: Strong.

3.9. Surgical Consideration

Spinal surgery has evolved from open techniques to more minimally invasive techniques. MISS has been utilized in spinal tumor operations, particularly for metastatic tumors. Notably, regarding radiotherapy, when employing MISS techniques, the interval between surgery and radiotherapy can be as short as 1 week post‐operation. Existing research has demonstrated that the minimally invasive approach for treating intradural‐extramedullary tumors of the thoracolumbar spine is both safe and effective. Furthermore, endoscopic spinal surgery has been introduced to advance minimally invasive spinal surgical techniques, aimed at reducing tissue trauma and improving clinical outcomes. It has been established as a feasible and effective option for managing specific spinal metastases and intradural‐extramedullary tumors. This technique offers a minimally invasive pathway for tumor access, with a low incidence of complications and significant clinical benefits, particularly for frail patients requiring palliative care.

We also recommend that the MIS technology should incorporate it into the ERAS protocol. It significantly reduced blood loss and shortened the average time to start radiotherapy after surgery. In a meta‐study on the effect of minimally invasive surgery versus conventional open surgery for spinal metastases, it also concluded that MIS was associated with lower complications, blood loss, transfusion rate, and shorter hospital stay [71]. Furthermore, there was a study on the successful treatment of metastatic thoracic tumors through the minimally invasive retractor lateral approach [72].

In addition to the completion with the help of the retractor and microscope, the resection of the spinal tumor could also be performed with the assistance of the endoscope. A retrospective study of endoscopic‐assisted global lobectomy and spinal resection for non‐small cell lung cancer showed that it was feasible and safe to achieve En‐bloc resection of spinal non‐small cell lung cancer through endoscopic assistance [73]. Similarly, a study on a posterior total endoscopic approach to resection of metastatic cervical tumors suggested that the posterior full endoscopic decompression of cervical metastases causing unilateral radiculopathy seemed feasible [74].

Summary/recommendation:

Minimally invasive spine surgery when applicable.

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.10. Perioperative Prevention of Bleeding and Intraoperative Hemostasis

Bleeding can become very fatal in patients undergoing spinal tumor surgery. In addition to compression and hemostasis, allogeneic blood transfusion has also become an important means of clinical treatment, but blood transfusion may cause many complications [75, 76]. In a retrospective study, transfusion patients had 2.27 times higher odds of any postoperative complication and 1.24 times higher odds of any postoperative complication per unit of transfusion. Transfusion exposure also increased the odds of overall postoperative infection, with 1.24 times per unit increase in transfusion. This suggests that we need to take some means to reduce the bleeding [77].

The first is the preoperative withdrawal of some drugs to reduce the bleeding. Decision making for perioperative anticoagulation must balance the risk of thromboembolism and surgical bleeding [78]. The next was preoperative treatment of anemia and maintenance of platelet count. For adult patients undergoing spinal surgery, transfusion of red blood cells should be avoided if the Hb values are maintained at 9 and 8 g/dL during the intraoperative and immediate postoperative periods respectively [79]. A retrospective study of 921 patients found that blood transfusion rate was significantly higher in patients with preoperative thrombocytopenia and severe thrombocytopenia than in those with non‐thrombocytopenia. Preoperative platelet count was the most important factor for blood transfusion [80]. Of course, some studies disagree about this result. Studies showed that the invasive nature of the procedure was the only variable that affects blood loss. Intraoperative application of hemostatic drugs is also a common method. Tranexamic acid was effective in reducing blood loss when used locally during surgery [81]. An RCT containing 60 patients indicated that the intraoperative blood loss in the tranexamic acid oral group during major spinal surgery was significantly lower than that in the control group [82]. Additionally, preoperative vascular embolization is considered a feasible approach for highly vascularized spinal metastatic tumors. Its associated complications include severe hypertension, transient visual field deficits, cerebral embolism, and spinal cord ischemia. Studies indicate that the primary complications of embolization may occur within 1 day post‐procedure [83]. Furthermore, research has shown that for highly vascular spinal tumors such as invasive hemangiomas, multiple myeloma, plasmacytoma, and renal cell carcinoma metastases, there is no significant difference in intraoperative blood loss between palliative decompression performed after preoperative tumor embolization and surgery using intraoperative local hemostatic agents. However, for patients undergoing total vertebrectomy, preoperative embolization can effectively reduce intraoperative bleeding [84]. In conclusion, we recommend keeping the preoperative precursor with anticoagulants to maintain the platelet count at 50 × 10⁹/L and if not necessary, embolization was not chosen. Intravenous tranexamic acid can be continuously pumped according to the situation.

Summary/recommendation:

Prevent bleeding before surgery and using Tranexamic acid for Hemostasis.

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.11. Temperature Management

Most patients with general anesthesia lasting over 30 min or lasting more than 1 h should monitor their body temperature and maintain temperature, especially for large surgery. A study divided 130 patients scheduled for elective surgery under general anesthesia into two groups. Patients in the heating group were heated with a forced air heater set to 47°C during anesthesia induction, while the control group were passively covered with a cotton blanket. All patients were heated with a forced air heater during the procedure. The incidence of intraoperative and postoperative hypothermia was lower in the last warming group than in the control group [85]. Moreover, a study compared the outcome of upper and lower body forced air blanket in patients which underwent spinal surgery in prone position [86]. Hypothermia in the perioperative environment may have many negative effects on physiological conditions and is associated with postoperative complications. In general, anesthesiologists should continuously monitor the temperature throughout the operation.

Summary/recommendation:

Constant body temperature monitoring throughout the surgery and actively attempt to keep temperature above 36°C.

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.12. Goal‐Directed Fluid Balance

Hemodynamic management during anesthesia is essential to prevent fluid overload and insufficient blood volume [87]. It showed that individualized hemodynamic management based on extended continuous non‐invasive hemodynamic monitoring was associated with more hemodynamic interventions and a more aggressive fluid balance. Goal‐directed fluid management (GDFM), a different approach, was based on tailored fluid management with the use of static and dynamic factors. GDFM is a focus of recent clinical research, a protocol to guide individualized fluid therapy based on specific physiological indicators reflecting patient volume status and show clear advantages in improving patient outcomes. The substance of GDFM was to monitor volume‐related hemodynamic parameters, using the obtained parameters, administering intravenous fluid infusion and (or) the use of vasoactive drugs [88, 89]. Too much or too little volume was associated with a higher rate of complications in postoperative patients. Such as plethysmography variability index, perfusion index, mean arterial pressure, heart rate are important detection indicators of GDFM. Although different GDFM clinical trials had different clinical outcomes in promoting early postoperative rehabilitation [90, 91]. In the ERAS protocol, patients could improve their outcomes by monitoring individual pathophysiological changes and establishing a clearer course of fluid therapy [92].

Summary/recommendation:

Individualized goal‐directed fluid therapy based on surgical and patient risk factors.

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.13. Wound Suture

Suturing as the foundation of surgery is very easily overlooked by surgeons. A study showed that the incidence of wound infection after spinal surgery with triclosan‐coated sutures and non‐coated suture material varied significantly, and the use of triclosan sutures could reduce the number of wound infections after spinal surgery [93].

Barbed suture is a knotless surgical suture containing barbed or angled spikes that can clamp the tissue with a barb. The barbed suture may facilitate a safer operative closure of the wound layer. Some studies have indicated that the closure time of the incision was significantly shortened when using the barbed suture; incidence of wound complications was reduced [94]. Using staples to close the skin could reduce the operation time compared to barbed suture. A study had reported the application effect of skin staples after neck dissection. Compared with sutures, it had better aesthetic results, fewer complications, faster closure, minimal pain, and faster healing on removal. The closure time was the slowest. However, the disadvantage may be the cost [95]. In contrast, another systematic review showed that the risk of superficial wound infection after suture closure was more than three times higher [96]. In our recommendation, it was supported that absorbable suture for dura, muscle, and subcutaneous tissue, intradermal suture for skin incision, because this protocol not only achieves satisfactory suture effect, but also fits the purpose of ERAS protocol to reduce LOS. But this does not mean that there is only one choice of suture or suture technique.

Summary/recommendation:

Absorbable suture for dura, muscle, and subcutaneous tissue; intradermal suture for skin incision.

Quality of evidence: High.

Recommendation grade: Strong.

3.14. Surgical Site Drains

The drain is a foreign matter for the patient, which can induce an infection of the wound site. Drainage after a surgical procedure causes a local inflammatory response and spreads the inflammation. But it had some effect on the prevalence of postoperative fever [97]. However, it was also shown that drainage time and drainage volume were not independent predictors of readmission, postoperative blood transfusion, or postoperative anemia [98]. A review indicated that the use of a drain did not affect wound healing, and an incision vacuum dressing was recommended [99]. A multicenter randomized prospective controlled clinical trial analyzed the impact of wound drains on clinical outcomes. A multicenter study of postoperative drain uses for posterior cervical surgery demonstrated no difference in reoperation rates, surgical site infection, and hematoma incidence between the drainage and non‐drainage group [100]. In an RCT study with multiple‐stage posterior spinal surgery, total perioperative blood loss was significantly higher in the drainage group, the incidence of postoperative hematoma was higher in the no drainage group, and the transfusion requirement was significantly higher in the drainage group. Risks must be carefully weighed in their clinical application188. For minimally invasive lumbar surgery, such as transforaminal lumbar intervertebral body fusion, the study concluded that drains caused postoperative pain, anxiety, and discomfort. Patients without a drain early ambulation [101].

Summary/recommendation:

Restrict placement of surgical site drains unless deemed necessary or clinically indicated.

Quality of evidence: High.

Recommendation grade: Strong.

3.15. Urinary Catheter

Catheter is often used during or after spinal surgery. If postoperative urinary retention occurred, temporary catheter carrying was certainly beneficial, but routine catheter use was not beneficial [102]. In fact, conventional preoperative catheter insertion did not seem to reduce postoperative bladder problems compared to no catheter treatment [103]. However, the use of a urinary catheter carried a risk of causing symptomatic urinary tract infections. The use of perioperative catheters might also lead to more surgical site infections. A study had evaluated the potential association between perioperative catheter carriage and surgical site infection after spinal surgery. Gram‐negative surgical site infection after spinal surgery was associated with perioperative urethral catheter carriage [104]. In ERAS regimens, early urinary catheter removal was recommended (within 24 h after surgery) [105].

Summary/recommendation:

Early discontinuation of urinary catheters (within 24 h after surgery).

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.16. Ambulation

Early ambulation after spinal surgery was generally encouraged, and several studies had shown a reduction of perioperative complications, readmissions, and LOS [106]. Ambulation within 4 h after surgery was found to improve postoperative functional status, reduce the incidence of complications, and shorten LOS in elderly patients with lumbar decompression and fusion surgery [107]. Ambulation less than 8 h after spinal surgery was found to be associated with discharge, shortening LOS, 90‐day readmission, and urinary retention [108]. A total of 23,295 patients with lumbar spine surgery were analyzed. As ambulation on postoperative day 0 was a modifiable factor in the postoperative care of any patient after most spine surgery, its inclusion in the enhanced postoperative recovery plans associated with the spine should be encouraged [109]. Besides, a study showed that awake spinal fusion under spinal anesthesia was related to early ambulation in patients [110]. Early ambulation and independent ambulation were recommended by ERAS protocol for all included studies. Despite the different ambulation protocols, each acknowledged that early ambulation was considered a key element of the accelerated postoperative recovery protocol after spinal surgery.

Summary/recommendation:

Early ambulation and independent ambulation or ambulation with minimal assistance by discharge.

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.17. Postoperative Diet

Study showed that postoperative dietary restriction time was an independent risk factor for ileus in patients with posterior thoracolumbar fusion. While a prospective cohort study including 109 patients demonstrated that starting diet 24 h after surgery was a risk factor for prolonged ICU stay in cancer patients undergoing major surgery. A multicenter survey of 988 patients on guidance and actual postoperative fasting showed that half of the patients reported thirst and hunger after surgery. Patients started oral intake before the first postoperative discharge (16.5 h) or the first postoperative defecation (41 h) without increasing serious complications. Study recommended oral intake about 4 h after total hip replacement, and there was no difference in nausea, recovery of bowel function and length of stay. In addition, investigations suggested that Ultra‐early postoperative feeding (oral liquid diet offered in the post‐anesthetic recovery room) was associated with reduced postoperative infusion [111, 112, 113, 114]. In summary, early oral intake and postoperative reduction of IV fluids were encouraged.

Summary/recommendation:

Early oral intake and postoperative reduction of IV fluids.

Quality of evidence: Moderate.

Recommendation grade: Strong.

3.18. PONV Management

Postoperative nausea and vomiting (PONV) are the two most common adverse events during the postoperative period [115]. It was deemed to use multimodal systemic analgesia, reduce perioperative opioids, use dexmedetomidine, and use epidural and regional anesthesia [116]. A reference to the ERAS components which decrease baseline PONV risk was proposed including minimize preoperative fasting, preoperative carbohydrate loading, minimally invasive surgical techniques, standardized anesthetic protocol, multimodal analgesia, maintain euvolemia, avoid routine nasogastric intubation, and prevent postoperative ileus with caffeine, chewing gum, and laxatives [117].

Summary/recommendation:

PONV prophylaxis.

Quality of evidence: High.

Recommendation grade: Weak.

3.19. Systemic Audit

RCT studies of ERAS regimens for spinal tumors are very scarce nowadays. Routinely auditing and feedback are necessary for implementation of ERAS protocols, maintaining high compliance to ERAS protocols and realizing quality improvement.

Summary/recommendation:

Routinely auditing and feedback are necessary for the implementation of ERAS protocols, maintaining high compliance with ERAS protocols and realizing quality improvement.

Quality of evidence: Moderate.

Recommendation grade: Strong.

4. Discussion

4.1. Advantages Of ERAS Regimen

We had put forward a total of 19 consensus opinions, including preoperative, anesthetic, intraoperative, postoperative, and follow‐up periods. Compared with the routine treatment process, the ERAS regimen of spinal SM surgery showed its advantages, which could significantly reduce LOS and the use of perioperative opioids. The implementation of ERAS could significantly reduce time to ambulation. Each project occupied the same important position as surgical technology.

4.2. Integration of Previous ERAS Protocols

Comparison with previous relevant studies and guidelines, the ERAS protocol was similar in many ways. This study incorporated core components based on existing ERAS guidelines. These components encompassed patient education, smoking cessation, nutritional management, preoperative fasting and fluid rehydration, antibiotic administration and skin preparation, as well as anesthesia and analgesia strategies. Additionally, the study emphasized the management of intraoperative bleeding and blood transfusion, along with the prevention of perioperative thrombosis. Studies and guidelines had confirmed that surgery was an effective treatment for metastatic spinal tumors. Patients with spinal metastases should undergo a multidisciplinary evaluation before surgery, and detailed scoring before surgery helps the implementation of the surgery and provides data support for subsequent related research. It was recommended that treating physicians involve patients and relatives when considering treatment options in the Dutch national guideline of clinical management of spinal metastases. This was consistent with our recommendations about preoperative education and counseling. Studies and guidelines had confirmed that surgery was an effective treatment for metastatic spinal tumors [118]. Patients with spinal metastases should undergo a multidisciplinary evaluation before surgery, and detailed scoring before surgery helps the implementation of the surgery and provides data support for subsequent related research [119]. This was consistent with our recommendations about preoperative education and counseling. Research indicates that the choice of surgical method and prognosis for patients undergoing MISS is associated with reduced surgical time, decreased blood loss, shorter hospital stays, fewer infections, and a lower dependence on blood transfusions and postoperative intensive care unit admissions. For spinal metastatic patients whose neurological status remains unchanged, minimally invasive techniques should undoubtedly be the preferred option. Furthermore, this study employed various scoring systems to assess the necessity for surgical intervention, which aligns with our summarized ERAS item [120]. Most of the existing guidelines for spinal metastases focus on the choice of surgery or radiotherapy. The establishment of the ERAS program can enrich the missing details of guidelines. The development of the ERAS protocol for surgical treatment of patients with SM is still addressed in its infancy. Unlike other well‐established ERAS protocols, many of these recommendations may be of low quality. In fact, most of the recommendations require higher quality RCT studies. The consensus statement also points to parts that still need to be experimentally explored and encourages further research.

4.3. Attention to the Assessment and Adjustment of Psychological Status

Based on existing research, we found that most ERAS protocol had ignored the assessment and adjustment of patients' psychological status. Preoperative education and counseling, which included in our recommendations, showed it could reduce patient anxiety and preoperative anxiety and depression. We speculated that assessing and adjusting psychological status could also improve outcomes in surgical treatment. Commonly used clinical assessment and screening tools for psychological anxiety in cancer patients include State–Trait Anxiety Inventory, Self‐Rating Anxiety/Depression Scale, Hospital Anxiety and Depression Scale, Hamilton Anxiety Scale, Symptom Checklist, and self‐made scales. In spinal degenerative disease surgery, the relationship between psychological states such as anxiety and depression and prognosis had been noted by researchers. The Hospital Anxiety and Depression Scale was used to assess the impact of depression/anxiety on symptoms and function after lumbar spinal stenosis surgery. The results showed that depression was associated with more symptoms and worse functioning at 12 and 24 months after surgery. Anxiety and depressive disorders are common among cancer patients. The prevalence of cancer is higher in patients than in the general population but is often underrecognized. Therefore, assessing and adjusting the patient's psychological state is valuable for research on the prognosis of patients who undergo spine SM surgery. Interventions for anxiety and depression in cancer patients include medications, physical and non‐traditional interventions such as exercise, yoga, meditation, psychological intervention, and so on. It is necessary to conduct research on the impact of anxiety/depression/assessment tools and intervention measures on the surgical prognosis of patients with SM and incorporate it into the ERAS program. Through the evaluation, a scheme suitable for perioperative mental state assessment and adjustment of spinal SM patients was obtained.

4.4. Establishing Regionally Tailored ERAS Protocols

The Delphi study has inherent limitations. The consensus process, based on expert opinions, integrates existing evidence, with summaries of the current literature included as a part of the preliminary investigation. However, the outcome was primarily grounded in the cumulative experience of the group. The recommendations derived from the study lack empirical clinical support, necessitating further clinical research to assess their efficacy and adherence.

The heterogeneity of spinal tumors, both in terms of histology and location, poses a significant challenge in the standardization of ERAS protocols. For instance, tumors involving the spinal cord may require more intensive perioperative monitoring and management than those located extramedullary. Furthermore, the complexity of spinal tumor surgeries, which often require multidisciplinary teams and specialized equipment, may complicate the consistent application of ERAS principles across institutions. This is particularly true in resource‐limited settings, where access to specialized care may be constrained. The conclusions drawn from the study might only be applicable to specific regions. We recommend that different centers customize their ERAS protocols according to the unique circumstances. Based on the regional characteristics of China, we adopted a two‐round modified Delphi method. According to the findings of this manuscript, a set of 37 consensus‐driven best practice recommendations has been established, integrating research on both Traditional Chinese Medicine and Western Medicine treatment approaches, thus laying the foundation for the development of an enhanced recovery program for SM surgical interventions [121].

4.5. Limitations and Strengths

The main limitation is the few published studies on ERAS protocol for spinal tumor surgery. Too little samples may have an impact on our quality control. Due to there were few literatures about spinal SM surgery that could be searched. This might lead to a downgrade of the evidence recommended by some of the consensus. In addition, the five included studies included prospective studies as well as retrospective studies, which may reduce the credibility of the overall recommendation. Among the five studies included, there were still some projects that had not been recommended as consensus. Such as Minimize ICU admissions; start incentive spirometry in PACU; Management and treatment of delirium. We did not consider these items can be routine postoperative situations.

We expect more RCT studies on spinal tumor surgery ERAS to help us continue to refine this consensus and improve the quality of evidence. We also hope to establish a systematic framework, which will be easier to compare ERAS studies and summarize future systematic reviews and meta‐analyses.

5. Conclusion

The perioperative risk and postoperative complications of SM are high. With the increasing amount of spinal SM surgery, the proposal and implementation of ERAS become very important. We presented this comprehensive consensus review for spinal SM surgery. Based on this consensus, physicians can select relevant recommendations in accordance with actual conditions and appropriately adjust the details of the ERAS program based on the patient's compliance or completion. This comprehensive consensus covers a wide range of areas and the items can significantly improve patient outcomes, which can significantly reduce LOS, VAS scores, and the use of opioids. Although the evidence level of some consensus recommendations is low, it is still a relatively reliable spinal tumor surgery ERAS nowadays. We hope that this consensus could guide patients undergoing SM surgery to achieve early recovery.

Author Contributions

Fanjie Li, Wenlong Yu, and Changchang Shen initiated the collaborative project. Jinxin Luo and Zhibin Li participated in the conceptualization. Qiang Gao, Tao Li, and Chengchun Jin participated in manuscript preparation and review of the manuscript in several stages. Quan Huang and Shuqiang Wang approved the final version of the manuscript and the revisions as needed. The guarantors of the study were Peilin Chu and Mengchen Yin. Mengchen Yin accepts full responsibility for the finished work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

Funding

The study was supported by Project of Shanghai Municipal Health Commission (20204Y0165, 20224Y0165), National Natural Science Foundation of China (82205145), Shanghai “Rising Stars of Medical Talents”‐Youth Development Program‐Youth Medical Talents‐Specialist Program SHWSRS (2023‐062), Project of Chinese Society of Traditional Chinese Medicine youth talent lifting (2023‐QNRC2‐A03), Project of Shanghai University of Traditional Chinese Medicine “Visit famous schools and worship famous teachers” (079).

Conflicts of Interest

The authors declare no conflicts of interest.