Evidence-based practice of enhanced recovery after surgery in spinal surgery: Comprehensive insights into perioperative care and outcome improvement

Abstract

Enhanced recovery after surgery protocols, first proposed in the late 1990s, represent a multimodal and interdisciplinary framework for surgical management and perioperative care, with nursing involvement as a pivotal component. The application of enhanced recovery after surgery in cranial and spinal neurosurgery has advanced rapidly, with 89.01% of relevant publications emerging in the past 5 years. However, research on its implementation in this subfield remains immature. This narrative review focuses on the development of fast-track surgery, refinement of enhanced recovery after surgery protocols in spinal surgery, and the roles of nursing within enhanced recovery after surgery. Key perioperative interventions include preoperative personalized education, smoking cessation (≥4 weeks), nutritional support, prehabilitation, and preemptive analgesia; intraoperative tranexamic acid use, rational antibiotic administration, standardized or minimally invasive surgery, and goal-directed fluid therapy; and postoperative multimodal analgesia and early mobilization. Clinical evidence confirms that these interventions collectively reduce postoperative complication rates, shorten hospital stay, alleviate pain, and improve prognosis, with nurses playing a central role in enhanced recovery after surgery implementation across all phases. In conclusion, successful enhanced recovery after surgery adoption in spinal surgery relies on multidisciplinary collaboration, and evidence-based individualized care is critical for optimizing recovery. Future studies should focus on refining guidelines to promote enhanced recovery after surgery standardization and broader application.

Introduction

Enhanced recovery after surgery (ERAS) protocols were first proposed by Kehlet in the late 1990s. ¹ This framework advocates a multimodal and interdisciplinary approach to surgical management and perioperative care, incorporating continuous nursing involvement, particularly in patient education and nutritional support.^2,3 Since its introduction, the field of cranial and spinal neurosurgery has rapidly developed, with the number of academic publications showing a consistent upward trend. It maintained steady growth from 2008 to 2018, entered an exponential growth phase after 2019, and publications in the past 5 years account for 89.01% of the total. However, existing evidence indicates that research on the application of ERAS in this neurosurgical subfield remains far from mature. ⁴ This narrative review synthesizes evidence on core perioperative ERAS interventions in spinal surgery, clarifies key implementation priorities of nursing roles, and provides a standardized reference for clinical practice.

Methods

This narrative review was guided by the Scale for the Assessment of Narrative Review Articles (SANRA). ⁵ To synthesize relevant evidence, a systematic literature search was conducted in PubMed and Embase in August 2025, focusing on three core themes: the development and implementation of fast-track surgery, the refinement of ERAS protocols in spinal surgery, and the evolving role of nursing within ERAS frameworks. The following search terms were used: “Nursing*” AND/OR “enhanced recovery after surgery” AND/OR “fast-track” AND/OR “spine” AND/OR “spinal” AND/OR “implementation” AND/OR “prehabilitation” AND/OR “rehabilitation.” Articles were considered eligible when they addressed the historical context of fast-track surgery, the establishment of ERAS protocols, key requirements for ERAS implementation, or the multifaceted roles of nursing in ERAS pathways. Additionally, the impact of ERAS integration within enhanced recovery (ER) pathways on the primary outcome of interest was evaluated.

Pre-operation

Preoperative education

Preoperative education, a core component of the ERAS pathway, plays a critical role in reducing preoperative anxiety, improving treatment compliance, and optimizing postoperative outcomes in patients undergoing spinal surgery through systematic health education and tailored psychological interventions. Given the inherent high surgical risk, prolonged recovery period, and uncertainty in therapeutic efficacy associated with spinal surgery, clinical data indicate that up to 52% of patients undergoing lumbar fusion experience fear due to inadequate preoperative pain-related information, whereas an additional 40% report postoperative pain exceeding expectations. ⁶ In response to these clinical challenges, preoperative education should focus on “diversified formats + personalized adaptation,” which are key factors for successful implementation. For example, short-term, concentrated education programs (e.g. 2-h preoperative simulated demonstrations of surgical processes and hands-on demonstrations of analgesic techniques) have been shown to improve patient satisfaction by 30%. ⁷ As primary facilitators of preoperative education, nurses tailor interventions according to patients’ age, educational level, and cognitive capacity. For example, illustrated brochures and concise videos may be used for older patients. Nurses also evaluate knowledge retention through post-education questionnaires or verbal assessment to identify and address unmet informational needs. Furthermore, Lee et al. ⁸ confirmed that standardized preoperative education for patients undergoing spinal surgery not only effectively alleviates preoperative anxiety but also significantly reduces postoperative anxiety levels, thereby providing evidence-based support for the clinical implementation of nurse-led preoperative education.

Smoking cessation

As a key preoperative management intervention in the ERAS pathway for spinal surgery, smoking cessation has well-established clinical significance supported by numerous studies. Evidence indicates that smoking not only decreases bone mineral density (BMD), thereby impairing tissue healing capacity, ⁹ but also increases the incidence of postoperative complications by 41% compared with those in nonsmokers. ⁹ Specifically, patients with persistent preoperative smoking habit are at an elevated risk of postoperative adverse events, including surgical site infection, systemic infection, pulmonary complications, neurological complications, and a notably higher likelihood of intensive care unit (ICU) admission. ¹⁰ In view of these risks, clinical evidence suggests that smoking cessation for more than 4 weeks before surgery can effectively reduce the incidence of postoperative respiratory complications and decrease adverse outcomes such as delayed wound healing.^9,11

Nutrition

Perioperative nutritional status is a critical factor influencing postoperative recovery in patients undergoing spinal surgery. Studies have shown that malnutrition is an independent risk factor for adverse surgical outcomes. Particularly, low albumin levels, low transferrin levels, and low lymphocyte counts are significantly associated with a higher risk of spinal surgical site infection (SSI), increased incidence of postoperative complications, prolonged hospital stay, higher 30-day readmission rate, and increased postoperative mortality. ¹² To accurately identify such risks, clinical evaluation of malnutrition can be performed using serological tests (e.g. albumin, prealbumin, and transferrin levels), anthropometric measurements, and standardized nutritional scoring scales (e.g. Nutritional Risk Screening (NRS) 2002 and Malnutrition Universal Screening Tool (MUST)). ¹³ Preoperative anemia, an important nutrition-related risk factor, also adversely affects patient outcomes. One study indicates that preoperative anemia significantly increases postoperative morbidity, mortality, and the requirement for allogeneic blood transfusion ¹⁴ compared with patients undergoing joint replacement without preoperative anemia. Patients with preoperative anemia exhibit significantly higher risk of postoperative infection risk, increased blood transfusion rate, a higher incidence of lower extremity deep vein thrombosis (DVT), prolonged hospital stay, higher 3-month readmission rates, and increased mortality. To address these nutrition-related risks, proactive nutritional intervention can improve outcomes. Oe et al. ¹⁵ demonstrated that standardized nutritional guidance and supplementation for malnourished patients significantly reduce postoperative complication rates (25% in the ERAS intervention group vs. 53.6% in the conventional care group, P = 0.015). Additionally, a meta-analysis by Zhong et al. ¹⁶ incorporating 15 randomized controlled trials (RCTs), confirmed that perioperative systematic nutritional support effectively lowers the incidence of postoperative complications and shortens hospital stay.

Prehabilitation (prehab)

Prehab, a new rehabilitation intervention strategy within the ERAS framework, comprises core components including exercise intervention, psychological intervention, and nutritional support. By systematically enhancing patients’ organ function reserve and metabolic capacity prior to surgery, it can effectively accelerate the postoperative recovery process. Given the high incidence of frailty in older patients undergoing spinal surgery, a multimodal prehab program, encompassing physical function training, nutritional status adjustment, pain management, and cognitive intervention, should be developed and implemented. Nurses, as central facilitators in the design and delivery of these programs, instruct patients on targeted exercises (e.g. breathing training and core muscle strengthening), monitor exercise intensity and adherence, alleviate psychological distress via cognitive-behavioral interventions, and integrate nutritional guidance to ensure a holistic prehab approach. The clinical significance of this intervention has been confirmed in previous studies. Oe et al. ¹⁵ reported that preoperative nutritional prehab for malnourished patients significantly reduced the postoperative complication rates from 53.6% to 25% (P = 0.015).

Conceptually, prehab prepares patients cognitively and physically for upcoming surgical procedures. ¹⁷ It optimizes functional capacity, thereby enabling patients to better tolerate stressors associated with postoperative inactivity.^17,18 An ideal prehab program integrates both cognitive and physical components, specifically including warm-up exercises, cardiovascular training, functional task practice, and resistance training. ¹⁷ As primary facilitators of prehab programs, nurses tailor CBT and exercise content to individual patient capabilities, provide ongoing motivation and feedback, and ensure program adherence.

In addition to CBT, patients educated about radicular pain before lumbar spine surgery used fewer healthcare resources, such as imaging studies and physical therapy, at 1 year postoperatively compared with those receiving conventional preoperative education. Implementation of prehab was also associated with shorter recovery times, reduced hospital stays, and lower postoperative pain intensity.^17,19

Preemptive analgesia

In the pain management of spinal surgery, conventional analgesic strategies primarily focus on the intraoperative and postoperative periods, using opioid analgesics as the main drugs. However, conventional opioids can cause adverse effects such as respiratory depression and paralytic ileus. Preoperative administration of these drugs may also prolong hospital stay, increase medical expenses, and, according to some studies, raise the risk of postoperative infection and the likelihood of reoperation. ²⁰ By comparison, preemptive analgesia, a more targeted approach (e.g. preoperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs)), can notably reduce opioid consumption, such as morphine, during 24–48 h postoperatively by minimizing the development of pain memory and can effectively reduce morphine-associated adverse effects, including nausea, vomiting, pruritus, and urinary retention.^12,21 As key implementers of analgesic protocols, nurses ensure the timely and accurate administration of preemptive analgesics according to clinical guidelines, assess baseline pain intensity using standardized scales (e.g. Visual Analog Scale (VAS)), and document therapeutic efficacy and adverse events to guide intraoperative and postoperative analgesic regimen adjustments. The clinical value of preemptive analgesia extends beyond pain control: it diminishes pain memory, reduces the stress response induced by surgical trauma, relieves acute postoperative pain, and accelerates functional recovery in patients undergoing spinal surgery. It also lowers the incidence of chronic postoperative pain and the risk of opioid dependence, thereby enhancing patients’ postoperative quality of life. ²¹

Intraoperation

Tranexamic acid (TXA)

The clinical significance of TXA, a commonly used antifibrinolytic agent in the perioperative period of spinal surgery, has been validated by multiple studies. In a systematic review, Alboog et al. ²² analyzed three core clinical outcome measures following spinal surgery: intraoperative and postoperative blood loss, pain management efficacy, and the incidence of position-associated complications. This study included three antifibrinolytic drugs, namely TXA, ε-aminocaproic acid (EACA), and aprotinin, for comparative analysis to identify differences in their effects on reducing blood loss and decreasing subsequent complications.

The findings suggested that TXA demonstrates clear advantages in reducing intraoperative, postoperative, and total blood loss. Furthermore, TXA dosage demonstrated no significant effect on blood loss reduction. No statistical difference in blood loss control efficacy was observed between the low-dose protocol (10 mg/kg intravenous push, followed by continuous infusion at a rate of ≤10 mg/kg/h) and the high-dose protocol (10–100 mg/kg intravenous push, followed by continuous infusion at a rate of >10 mg/kg/h).By comparison, EACA fails to demonstrate a significant effect in blood loss reduction. In contrast, aprotinin reduced intraoperative blood loss; however, it demonstrated no notable effect on improving total blood loss. ²² Additionally, Qureshi et al. ²³ affirmed the application value of TXA in perioperative blood loss management for spinal surgery. Studies have demonstrated that patients receiving TXA during spinal surgery experience not only significantly reduced intraoperative and postoperative blood loss but also a corresponding decrease in the required volume of allogeneic blood transfusions as well as a notable reduction in orthopedic surgery-associated complications. Clinically, TXA is both cost-effective and safe, with a low rate of adverse reactions. Studies have demonstrated that a TXA administration protocol of “2 g loading dose intravenous push + subsequent continuous infusion at 100 mg/h” effectively reduces blood loss during spinal surgery. ²³ However, no unified standard for the clinical dosage of TXA has been developed, and adjustments in practice primarily depend on the personal experience and preference of clinicians. ²³ Nurses play a key role in safe TXA implementation by verifying preoperative drug dosages, monitoring for signs of adverse reactions, and documenting intraoperative blood loss in real-time to support timely adjustments by the surgical team.

Perioperative antibiotics

Perioperative antibiotic administration is a critical component of infection prevention and control in spinal surgery, focusing on the prevention of SSI. SSI is defined as an infection that develops at the surgical incision, organ, or body cavity space postoperatively and is a common cause of postoperative illness in surgical patients. ²⁴

SSI is the third most common postoperative complication in spinal surgery.^25,26 Published literature reports that the incidence of SSI following spinal surgery ranges from 0.2% to 16.1%. ²⁷ SSI not only results in higher patient readmission rates and poorer prognosis but also increases additional medical costs. ²⁸ A limited number of studies have identified risk factors for SSI following spinal surgery, including diabetes mellitus, obesity, hypertension, intraoperative blood transfusion, preoperative urinary tract infection, cerebrospinal fluid leakage, and extended surgical time.^28–30

Currently, considerable debate exists regarding the perioperative administration of prophylactic antibiotics in spinal surgery. Their advantages include high drug concentration at the target site, low rate of systemic adverse reactions, and good patient adherence. However, due to potential adverse consequences, such as triggering allergic reactions, gastrointestinal discomfort, and the development of antibiotic-resistant microorganisms following antibiotic exposure, the rationality of the clinical use of prophylactic antibiotics remains controversial. ³¹ Although the preventive effect of prophylactic antibiotics on SSI in specific surgical procedures was established years ago, ³² their clinical value has been increasingly challenged due to the global issue of antibiotic resistance. Studies have indicated that prophylactic antibiotics are unnecessary in some clean and clean-contaminated surgeries.^33,34 However, an alternative strategy suggested by a meta-analysis demonstrates that topical administration of vancomycin powder (VP) can notably decrease the incidence of SSI in spinal deformity surgery. ³⁵

Standardized surgical procedures

Within the ERAS framework for spinal surgery, reducing surgical duration through standardized surgical procedures is a critical intervention to lower intraoperative risks and improve outcomes. Clinical data indicate that standardized work processes used by surgeons and their supporting teams with expertise in complex spinal surgery can reproducibly decrease operating room time.^36,37 Additional studies have demonstrated that integrating an intraoperative standardized operation protocol with the “operating room dual-attending surgeon collaboration model” and preoperative patient clearance by a multidisciplinary team can notably reduce intraoperative estimated blood loss (EBL), the incidence of major complications, and the reoperation rate.^38–40 As integral members of the surgical team, nurses facilitate standardized workflows through preoperative preparation of surgical instruments and patient positioning aids, intraoperative assistance to maintain stable patient positioning (minimizing position-related complications), and postoperative documentation of surgical duration and instrument utilization. These measures support quality improvement initiatives for standardized procedures.

Recent evidence suggests that different surgical modalities, such as tubular minimally invasive discectomy, endoscopic discectomy, and open microdiscectomy, exhibit comparable safety profiles; however, they differ in their impact on rehabilitation-related outcomes. ⁴¹ Furthermore, for spinal trauma and complex cases, minimally invasive surgery (MIS) achieves significantly reduced blood loss, shorter hospital stays, and lower postoperative pain scores compared with traditional open surgery. ⁴²

Goal-directed fluid therapy (GDFT)

In the perioperative management of spinal surgery, GDFT is a core intervention to optimize patients’ fluid balance and improve postoperative outcomes. In conventional fluid management, patients often exhibit significant variations in postoperative fluid balance. Some patients need additional fluid resuscitation, whereas others require maintenance of endotracheal intubation due to postoperative oropharyngeal edema. The GDFT protocol recommends early combined administration of colloids following an initial infusion of 2 L crystalloids, guided by monitoring central blood volume and arterial blood pressure. Compared with crystalloids alone, colloids can reduce fluid shift to the interstitial space, thereby minimizing the occurrence of soft tissue edema. ⁴³ Although no consensus exists on the clinical use of colloids, literature indicates that colloid infusion can notably lower the incidence of postoperative complications compared with crystalloids alone. ⁴⁴ Similarly, combined infusion of crystalloids and colloids guided by hemodynamic parameters (e.g. stroke volume, mean arterial pressure, and cardiac output) can reduce the incidence of postoperative pulmonary edema, acute kidney injury, acute respiratory distress syndrome, and SSI as well as shorten ICU stay. ⁴⁵ Mechanistically, optimizing tissue perfusion can reduce the inflammatory response associated with surgical trauma, whereas maintaining a physiological euvolemic state prevents tissue ischemia from dehydration or endothelial glycocalyx injury and interstitial edema caused by fluid overload. ⁴⁵ In orthopedic research, Peng et al. ⁴³ further demonstrates that targeted bolus administration of colloids can prevent excessive fluid infusion, thereby reducing ischemic damage associated with tissue edema. This intervention not only decreases the incidence of gastrointestinal intramural acidosis but also suggests improved tissue perfusion in patients, with a faster intestinal function recovery rate compared with traditional intraoperative fluid management.

Notably, other institutions implementing the ERAS pathway for spinal surgery have observed similar trends, reinforcing that the ERAS protocol is a critical factor in lowering ICU admission rates.^46,47 Studies confirm that blood transfusion therapy and fluid balance disturbances are independent risk factors for adverse outcomes following high-risk spinal surgery. Consequently, mitigating fluid imbalance and reducing blood transfusion requirements through GDFT has emerged as a key strategy to lower ICU admissions. Nurses play a pivotal role in successful GDFT implementation by accurately recording intraoperative fluid intake (e.g. crystalloids and colloids) and output (e.g. blood loss and urine output), conveying real-time data to the anesthesia team to guide infusion adjustments, and thereby preventing fluid overload or dehydration.

Post-operation

Multimodal analgesia

Given the significant side effects of opioid analgesics (e.g. nausea and drowsiness) and their potential for addiction, nonopioid analgesics have been progressively integrated into postoperative pain management protocols to minimize opioid dependence and associated adverse events. Among these, the Opioid-Free Analgesia Protocol (OFAP) has been developed and implemented. This protocol improves postoperative outcomes by combining NSAIDs, acetaminophen, ketamine, and regional anesthesia techniques.^48–50

Several clinical studies have verified the efficacy of such pain management regimens. Dietz et al. ⁵¹ reported that implementing the ERAS analgesic protocol in patients undergoing spinal surgery results in significant reductions in pain scores, notable decreases in opioid consumption, and lower hospital costs. Furthermore, Rajpal et al. ⁵² demonstrated that a multimodal analgesic protocol after spinal surgery not only reduces opioid consumption but also significantly lowers minimum pain scores. Compared with patients receiving intravenous patient-controlled analgesia (IV-PCA), those in the multimodal group experienced a lower incidence of postoperative nausea and drowsiness, fewer limitations in walking ability, and fewer disturbances in coughing and deep breathing. Mathiesen et al. ⁵³ compared two cohorts of patients undergoing spinal surgery: those who had previously undergone multilevel instrumented fusion and those who received a new broad-spectrum multimodal analgesia (MMA) protocol. The latter group had lower opioid consumption on postoperative days (PODs) 1 and 2 (POD 1–2); earlier initiation of independent mobility (with or without a walker); and significantly reduced intensity of nausea, sedation, and dizziness during POD 1–6. A recent meta-analysis confirmed that thoracic paravertebral block (TPVB) effectively lowers postoperative pain scores, particularly during nonresting states, and reduces the need for rescue analgesia, which is critical for promoting early mobilization. ⁵⁴

Nurses play a pivotal role in optimizing multimodal analgesia by conducting regular pain assessments using standardized scales (e.g. VAS and NRS), administering nonopioid analgesics according to clinical protocols, managing regional anesthesia catheters if utilized, monitoring for adverse events (e.g. nausea and urinary retention), and adjusting analgesic strategies based on patient feedback to achieve optimal pain control.

Early mobilization/ambulation

During the postoperative rehabilitation phase of spinal surgery, prolonged bed rest can lead to multisystem adverse effects, including cardiovascular dysfunction, impaired respiratory function, musculoskeletal deterioration, and neuropsychological disturbances. Additionally, it significantly increases the risk of lower extremity DVT and pulmonary embolism (PE). ⁵⁵ In contrast, implementing early postoperative mobilization protocols in patients undergoing spinal surgery has been shown to notably reduce the incidence of complications, including respiratory decompensation, pneumonia, DVT, PE, urinary tract infection, urinary retention, sepsis, and surgical incision infection, and effectively shorten average hospital stay. ⁵⁶ Additional studies have demonstrated that patients who initiate ambulation between the day of spinal surgery (POD 0) and POD 1 experience lower complication rates and shorter hospital stays compared with patients on continuous postoperative bed rest. ⁵⁷

Based on this evidence, early postoperative ambulation is clinically recommended for patients undergoing elective spinal surgery when their physical status permits. A randomized clinical trial by Zakaria et al. ⁵⁸ indicates that early postoperative mobilization reduces hospital stay; increases the rehabilitation discharge rate; and lowers the incidence of complications, including urinary tract infection, intestinal obstruction, and urinary retention, within 90 days postoperatively.

Additionally, a clear association exists between postoperative walking distance and reduced hospital stay. Macki et al. ⁵⁹ found that for every additional 15.24 m (50 feet) walked, the risk of prolonged hospital stay decreased by 39% (P = 0.002), providing evidence-based support for quantitatively guided early mobilization.

Nurses play a key role in facilitating mobilization interventions. They develop individualized mobilization plans based on the type of spinal surgery and patient tolerance, guide patients through progressive activities (from bed turning and sitting upright to ambulation with or without assistive devices), assess for signs of intolerance (e.g. dizziness, incisional pain, and limb numbness) during mobilization, and document daily ambulation distance and duration to track progress and adjust plans accordingly.

Venous thromboembolism (VTE) prophylaxis

Among patients with prolonged immobilization following spinal surgery, the incidence of VTEs, including DVTs and pulmonary emboli (PE), may be as high as 2% to 4%. ⁶⁰ In addition to early ambulation, mechanoprophylaxis also functions as a cornerstone of postoperative VTE prevention. This includes interventions such as elastic compression stockings (ECSs) and intermittent pneumatic compression (IPC) devices, which are widely recommended because of their low cost, minimal complication rates, and proven efficacy in mitigating VTE risk.^61,62 Identifying the optimal thromboprophylaxis strategies remains challenging, primarily attributable to the paucity of high-quality RCTs and substantial variations in clinical practice patterns.

Nurses play a key role in implementing VTE prophylaxis by educating patients on the importance of early ambulation, ensuring proper fit and adherence to ECSs, administering IPC devices per clinical protocols, and performing daily lower extremity assessments for signs of DVT (e.g. swelling, warmth, and tenderness) to allow early detection and timely intervention.

Surgical drains

Surgical drains have long been considered a conventional prophylactic intervention in spinal surgery, particularly in posterior thoracolumbar procedures, with the primary objective of mitigating postoperative epidural hematomas (PEHs) and SSIs. ⁶³ A recent study demonstrated that single-segment procedures (e.g. single-level discectomy) benefit from drain placement through a reduced incidence of PEHs (odds ratio (OR), 0.09; 95% confidence interval (CI): 0.02–0.36), lower fever rates (OR, 0.62; 95% CI: 0.39–0.97), and fewer dressing changes (OR, 0.33; 95% CI: 0.13–0.79), findings consistent with ERAS objectives. ⁶³ In contrast, multisegment surgeries (e.g. scoliosis correction) do not derive PEH prevention benefits from drains and are associated with an increased transfusion risk (OR, 2.88; 95% CI: 1.13–7.32), which may impede postoperative recovery. ⁶⁴

In the context of ERAS implementation, these findings support a selective, patient-centered approach to drain utilization rather than routine placement. For single-segment procedures, drain use may be justified to reduce PEH-related neurological risks and optimize wound management. For multisegment surgeries, drains should be avoided unless specific risk factors (e.g. excessive intraoperative bleeding and coagulopathy) are present. This strategy is consistent with the core principles of ERAS, which emphasize minimizing unnecessary interventions, individualizing patient care, and prioritizing evidence-based practices to expedite recovery. Future studies should further investigate the impact of drain-specific characteristics (e.g. indwelling duration and catheter type) and patient-specific factors (e.g. traumatic vs. degenerative spinal pathology) to refine guidelines for drain utilization in spinal ERAS protocols.

Early postoperative nutritional management

Spinal surgery typically involves long operative times, considerable surgical trauma, and an extended period of preoperative fasting and water deprivation. Based on these factors, early postoperative nutritional management should be a key focus of clinical care. Studies have shown that providing perioperative nutritional support combined with early rehabilitation interventions can effectively reduce the incidence of postoperative complications.^65,66

Postoperative nausea and vomiting (PONV)

PONV is a common complication following general anesthesia. It not only significantly increases patients’ subjective discomfort but may also trigger adverse events, including dehydration, electrolyte disturbance, worsening of pre-existing pain, and surgical incision dehiscence, thereby serving as a key factor restricting early patient discharge. Intraoperative administration of volatile anesthetics and postoperative use of opioid analgesics are two critical factors that notably elevate the incidence of PONV. ⁶⁷ The Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting recommend administering pharmacological prophylaxis for adult patients who present with one or two of the following risk factors: female sex, young age, history of PONV, prolonged surgical duration, and postoperative opioid use. ⁶⁸

Regarding the selection of specific drugs, ondansetron has been verified as an effective agent for the treatment and prevention of PONV. ⁶⁹ Clinical guidelines recommend a common dosing protocol of 4 mg intravenous injection or 8 mg oral disintegrating tablet. ⁷⁰ Based on these guideline recommendations and pharmaceutical evidence, spinal surgeons should perform preoperative PONV risk stratification and routinely select prophylactic medications according to the assessment results to lower the risk of PONV.

Nurses play a key role in PONV management by assisting in preoperative risk stratification, administering prophylactic medications per provider orders, monitoring patients postoperatively for signs of nausea and vomiting, documenting the frequency and severity of episodes, providing supportive care (e.g. positional adjustment to prevent aspiration and fluid replacement), and administering rescue antiemetics as needed to alleviate symptoms and facilitate early recovery.

Conclusions

ERAS represents a paradigm-shifting, multimodal framework that has transformed perioperative care in spinal surgery, with growing evidence supporting its efficacy in reducing postoperative complications, shortening hospital stays, alleviating acute and chronic pain, and optimizing long-term outcomes. This narrative review, guided by the SANRA, synthesizes findings from PubMed and Embase to highlight that the success of ERAS in spinal surgery depends on interdisciplinary collaboration, integrating surgical, anesthetic, nursing, and rehabilitative expertise, with nurses playing an essential role across preoperative, intraoperative, and postoperative phases. From providing personalized preoperative education and prehabilitation programs to ensuring accurate implementation of analgesic protocols, fluid therapy, and early mobilization strategies, nursing involvement is critical for translating ERAS principles into tangible patient benefits.

ERAS has established itself as an evidence-based cornerstone of modern spinal surgical care, with its value rooted in minimizing iatrogenic harm, optimizing physiological reserve, and promoting patient-centered recovery. As the field progresses, bridging the gap between clinical evidence and standardized practice through interdisciplinary collaboration and iterative guideline refinement will be pivotal to realizing the full potential of ERAS, enabling more consistent, equitable, and effective perioperative care for all patients undergoing spinal surgery.

This review focuses on nursing interventions and does not elaborate on surgical or anesthetic technical details, thereby precluding the development of a comprehensive interdisciplinary perspective. Additionally, although it synthesizes generalized ERAS principles across various spinal surgery subtypes (degenerative, traumatic, and deformity-related conditions), it lacks subtype-specific analyses, which may restrict its applicability to specific clinical scenarios.

Data availability statement

Not applicable (narrative review; no new datasets were generated).

Declaration of conflicting interests

The authors declare that there are no relevant conflicts of interest.

Source of funding

None