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. 2022 Jul 9;31:101944. doi: 10.1016/j.jcot.2022.101944

Enhanced recovery after surgery (ERAS) protocol in spine surgery

Tungish Bansal, Alok D Sharan, Bhavuk Garg ∗
PMCID: PMC9293758  PMID: 35865326

Abstract

Enhanced recovery after surgery (ERAS) protocols are a set of interventions which are carried out in the preoperative and perioperative period. They are aimed to decrease the harmful effects of surgery on the body and help the patient recover better post-surgery. The effectiveness of ERAS has been well established in various other surgical specialities. Earlier spine surgery was thought to be very complex for application of ERAS protocols. However, this has changed over the last decade with (ERAS) protocols gaining widespread popularity in spine surgery. Initial studies involving ERAS in spine surgery were limited to lumbar spine. However, over the years the horizon of ERAS has expanded to include anterior cervical surgeries, spine deformity, spinal tumors and spine surgery in the elderly. ERAS has been shown to reduce the length of hospital stay, overall hospital costs, opioid consumption in perioperative and postoperative period and to lower complication rates in spine surgery. In this narrative review, we discuss various aspects of ERAS in spine surgery including the benefits of ERAS in spine surgery, the various components of preoperative, intraoperative and postoperative measures of ERAS protocol.

Keywords: ERAS, Spine surgery, Fast track surgery, Enhanced Recovery after surgery, Multimodal analgesia

1. Introduction

Enhanced recovery after surgery (ERAS) or fast track surgery has gained widespread popularity across surgical specialties.1 The concept behind ERAS is the amalgamation of a set of evidence based measures in the perioperative and postoperative period that can reduce the surgery related stress on the body, help the patient recover faster and better without increasing complications.1,2 It often involves multiple modalities and many disciplines to achieve the same. The concepts of ERAS were first defined around three decades ago in colorectal surgery and over the years has gained wide spread popularity after showing enormous benefit in terms of decreased hospital stay and costs.1 While other surgical specialities like gynaecology, urology, head and neck surgery, and pancreatic surgery etc3, 4, 5, 6 were quick to adopt and embrace the principles of ERAS, the same was not the case with spine surgery. However, the last decade has seen a change in this regard and adoption of ERAS in spine surgery has been growing leaps and bounds.7,8 While initially the lumbar spine formed the main area for application of ERAS,8 over the years the span of surgeries incorporating ERAS have expanded to include cervical spine surgery, deformity surgery, spinal tumors, and even elderly patients undergoing spine surgery.9, 10, 11, 12 In this narrative review we discuss the various benefits of ERAS protocols in spine surgery, the major components of ERAS, and the potential challenges in implementation of ERAS in spine surgery.

2. Why ERAS protocols in spine surgery?

The most commonly noticed benefit of ERAS protocols in spine surgery include decreased length of stay in hospital. Multiple systematic reviews have shown that ERAS protocols result in significant reduction in length of hospital stay and facilitate fast track discharge.8,13,14 Adoption of ERAS protocols or fact track discharge has not been shown to increase the complication rates. In fact multiple studies have reported lower complication rates in ERAS groups.8,14 Many ERAS protocols have also shown lower postoperative pain scores in the ERAS group compared to conventional treatment group.8,14,15

Continued opioid use after spine surgery is a growing challenge for spine surgeons across the world. A large number of patients continue to use opioids in the long term after spine surgery especially if they were on opioids preoperatively.16 ERAS protocols have proven to be effective in this regard. Multiple studies have shown significant reduction in perioperative consumption of opioids in patients on ERAS protocol compared to control group.13,17 Flanders et al. in their prospective cohort study highlighted the post-surgical benefits of ERAS on opioid use where they found a significant reduction of opioid use at 1, 3 and 6 months postoperatively. At 6 months followup nearly 24% patients were on opioids in the ERAS group compared to 52% in the non-ERAS group.18

ERAS has been shown to be effective across an array of different spine surgeries. A recent systematic review relating to the use of ERAS in paediatric deformity correction surgeries noted that a significant reduction of length of hospital stay (LOS) and postoperative complications were seen in the ERAS group. They also noted lower pain scores on day 0 and day 2 without any significant increase in 30 day readmission rates.19 A meta-analysis relating to Adolescent idiopathic scoliosis (AIS) also found a reduced LOS in the ERAS group.10 Liu et al. in their RCT on 94 patients with intraspinal tumors noted a significant reduction in LOS, lower postoperative pain scores, decreased patient controlled analgesia use and opioid use, early removal of urinary catheter and higher satisfaction rates in the ERAS group. However, the complication rates were not different between the two groups.11 A case matched study related to applicability of ERAS in the elderly population (>65 years) undergoing short lumbar fusion found that a significant reduction in LOS was seen in the ERAS group without an increase in complication rates.20 A multivariate regression analysis revealed that comorbidities and implementation of ERAS protocols were the only two factors that correlated with length of hospital stay.20 ERAS pathways have also been shown to reduce the postoperative use of opioids at one and three months in the elderly population.21 ERAS pathways are of benefit even in frail elderly patients, improving physiological function return and LOS. The results approximated outcomes of non-frail patients.12 The applicability of ERAS has also been established for anterior cervical surgery. A retrospective case matched study in patients undergoing anterior cervical surgery on an ERAS pathway resulted in a significant decrease in LOS. There was no difference in the complication rate and readmission rates at one and 3 months.22 Leng et al. in their patients undergoing anterior cervical surgery noted a lower cost, higher patient satisfaction, and shorter LOS in hospital stay. The applicability of ERAS in multilevel disease (n ≥ 3) was also established.9

The cost benefit of application of ERAS protocol has been noted by multiple authors across various types of spine surgeries.9,23 It leads to significant savings in hospital days and reduction in cost.24 However, the initial cost of implementation and further maintenance of ERAS programs can be a costly affair.25 The training of personnel and intraoperative costs account for the major expenses associated with the ERAS protocols.25 Despite these higher initial costs ERAS has been found to be cost effective overall.26 However this is likely to be affected by the volume of patients being operated in a centre.

3. Components of the protocol

ERAS pathway is a set of evidence based interventions that are carried out in the perioperative period that leads to a faster recovery of patients. There are many protocols described in the literature and these can vary to great extent in their components.27,28 Despite these variations, the goal of ERAS remains to improve patient outcomes by preoperative optimization, pre-emptive analgesia, opioid sparing multimodal anesthesia, early mobilization and nutrition etc. in an attempt to prevent catabolism and immune dysfunction. The interventions can be divided into preoperative, intraoperative and postoperative measures. The major components in each of periods are described below. The list is non-exhaustive and components can vary across protocols.

3.1. Preoperative measures

3.1.1. Preoperative education and counselling

The ERAS pathway begins right at the start when the patient is counselled for surgery. It has been seen that patients with adequate preoperative information regarding the surgery and expected outcomes have higher satisfaction scores post-surgery than those with inadequate information.29 A recent systematic review based on seven RCT's related to preoperative education and counselling in spine surgery noted that it not only improved postoperative pain and reduced length of hospital stay (LOS)but also improved psychological and economic outcomes.30

3.1.2. Preoperative optimization of patient

Malnutrition has been shown to be an independent risk factor for the risk of perioperative complications, increased length of hospital stay and 30 day readmission rates in various studies across lumbar and cervical spine.31,32 Serum albumin levels have been shown to be an effective marker for gauging the nutritional status of the patients.31,32 The serum albumin level greater than 3.5 gm/dl are considered optimal before surgery. Patients with poor nutritional status benefit greatly from optimization before surgery. Xu et al. in an RCT noted that multimodal nutritional management involving protein carbohydrates and nutritional supplements in the preoperative and perioperative period in patients with poor nutritional status reduced LOS, decreased incidence of electrolyte disturbances, and resulted in higher postoperative albumin levels compared to controls.33

Preoperative anaemia is another modifiable risk factor that has a huge bearing on surgical outcomes. A study based on a National surgical quality improvement program database noted that preoperative anaemia of all levels (mild, moderate and severe) is associated with increased LOS, risk of perioperative complications and higher 30 day mortality rate than nonanemic patients. It was also worth noting that this association was not affected by the intra and postoperative transfusions.34 Preoperative screening in outpatient departments, use of iron (oral or intravenous), erythropoietin injections and cell saver techniques can be used as effective techniques to reduce the need for allogeneic blood transfusions across various spine surgeries including paediatric deformity correction.35,36

3.1.3. Cessation of smoking and alcohol

Preoperative smokers have been shown to be at higher risk of postoperative complications including increased risk of wound issues, surgical site infections, respiratory complications, delirium and pseudoarthrosis and need for intensive care.37,38 A systematic review noted that cessation of smoking resulted in a decrease of total complication rates and decreased the wound healing and pulmonary complications. It was also seen that each week of cessation resulted in a 19% increase in magnitude effect. The cessation time of at least 4 weeks resulted in more benefit than shorter trials.39 Counselling of patient and nicotine replacement therapy are effective strategies which for smoking cessation that should be implemented with the help of deaddiction clinic referrals.40

Alcohol consumption has been related to increased risk of post-operative complications like infection, pseudarthrosis, cardiac and respiratory complications, delirium, ileus and deep vein thrombosis.41 It has also been suggested that daily consumption of more than two alcohol units increases the risk of complications in spine surgery with effects being less obvious for lesser quantities.41 A recent Cochrane review suggested that cessation of alcohol for 4–8 weeks before surgery was effective in decreasing the risk of postoperative complications.42

3.1.4. Pre-emptive analgesia

Pre-emptive analgesia is a single or a group of medications that are given before surgery in an attempt to reduce the effects of upcoming painful stimuli. The drugs used in various protocols are varied.43 However, the commonly used drugs mostly in combination of two or more in this regard include acetaminophen, non-steroidal anti-inflammatory drugs and gabapentinoids (gabapentin or pregabalin). Low dose local anaesthetics like ropivacaine and bupivacaine and opioids like oxycodone and tramadol have also been used.28,43 It has been shown that pre-emptive analgesia is effective in improving postoperative pain scores, decreasing total morphine equivalent consumption, and reducing LOS without increasing the risk of complications.43 Another meta-analysis assessing the use of gabapentin as pre-emptive analgesia in spine surgery noted significantly lower total morphine consumption and better VAS scores in the first 24 h postoperatively. They also noted a significant decrease in postoperative complications like vomiting, pruritus and urinary retention (opioid related complications) with the use of gabapentin.44

3.2. Intraoperative measures

3.2.1. Prophylactic antibiotics and surgical preparation

Multiple RCT's have demonstrated that prophylactic administration of antibiotics leads to decreased rates of surgical site infections in patients undergoing instrumented spinal fusion.45 Both chlorohexidine or iodine preparations have been shown to be effective for adequate skin preparation before surgery.41

3.2.2. Standardized anesthesia protocol and multimodal analgesia

Anesthesia protocols can vary widely in spine surgery. However, ERAS pathways through multimodal analgesia (MMA) use a variety of interventions to decrease the use of opioids intraoperatively and postoperatively, decrease postoperative complications associated with anesthesia and achieve better perioperative pain control. A number of modifications and interventions have been described in this regard to enhance postoperative recovery. Soffin et al. in their study described the feasibility an opioid free anesthesia protocol which included the use of total intravenous anesthesia with MAC for inhalational agents maintained below 0.5. They noted that the perioperative requirement of opioids was significantly less compared to the traditional group with similar pain scores in both the groups.46 Such protocols have been supported by other studies as well.7

Regional and local anaesthetic techniques like regional blocks, infiltration of wound, spinal and epidural analgesia can not only improve postoperative pain but also decrease the opioid requirement. Intrathecal morphine has been evaluated for use in lumbar spine surgery. Its use has been shown to effectively decrease pain scores and opioid consumption in the post-operative period.47 Some respiratory depression is associated with its use, but it did not require any intervention or treatement.47 The combination of naloxone and morphine for intrathecal use has been shown to further increase efficacy and reduce complications compared to intrathecal morphine alone.48 Besides morphine the intrathecal use of fentanyl has also been shown to be effective in decreasing pain and opioid requirements with minimal respiratory depression requiring no intervention.49 Epidural analgesia (EA) using long acting local anaesthetics with or without opioids have also been shown to be effective in reducing postoperative pain and decreasing opioid requirement.50 It is recommended to start EA early in the procedure to for optimal results.51

Regional plane blocks like erector spinae (ESP) block, thoracolumbar interfacial plane block [TLIP] block, and quadratus lumborum block have gained popularity over the years as effective and safe strategies for postoperative pain management. A recent meta-analysis of 9 RCT's of the use of TLIP block in lumbar spine surgery noted lower VAS cores at all time points on first postoperative day. The frequency and overall use of patient controlled analgesia was also lower in the TLIP group.52 Goel et al. in their prospective study utilizing ultrasound guided ESP in single level lumbar fusion noted a lower opioid consumption, muscle relaxant requirement, operative blood loss, better pain scores and higher satisfaction rates than the control group.53

Infiltration of long acting local anaesthetics like ropivacaine and bupivacaine at the local wound site at the time of closure have been very effective in decreasing postoperative pain scores and opioid requirement.54 Recently the addition of alpha-2 agonists like dexmedetomidine and clonidine have been shown to improve the efficacy of long acting anaesthetics compared to when they are used alone.55

Spinal anesthesia (SA) instead of general anesthesia (GA) has also been proposed by some for use in lumbar discectomies and lumbar spine fusion.56,57 Sekerak et al. in their retrospective comparative study between SA and GA in 1 and 2 level lumbar TLIF surgeries noted that SA significantly reduced the time in operating room, postoperative recovery room time, and time under anesthesia. Postoperative pain scores and opioid requirement was also less in the SA group. The complications and operative cost were not different between the two groups. Spinal and regional anesthesia protocols combined with ERAS principles has led to awake spinal fusion gaining popularity in the last few years.58 The evidence for this new concept at present is limited and further large scale studies are needed in this field.

3.2.3. Maintenance of normothermia and euvolemia

Hypothermia during surgery increases the risk of blood loss, cardiac complications, long LOS and even surgical site infections.59 Strategies such as warmed intravenous fluids, prewarming of patient and warming blankets along with continuous monitoring can effectively prevent hypothermia and its adverse effects.60 Maintenance of euvolemia is an important component of ERAS as both hypo and hypervolemia have been associated with compromised cellular oxygen supply, especially in patients with poor cardiac and renal reserve.41 Goal directed fluid therapy has been shown to result in less crystalloid administration, fewer blood transfusions, and improved diuresis when applied to scoliosis surgery.61 Debeono et al. in their evidence based ERAS guidelines recommended goal directed fluid therapy for patients with comorbidities undergoing lumbar fusion.41

3.2.4. Use of MIS techniques

ERAS pathways often employ the use of minimally invasive surgery (MIS) techniques where possible, though the former works well in traditional open surgeries as well.62 The use of MIS techniques along with ERAS has been a natural progression, as MIS surgery also aims at minimizing tissue trauma, blood loss, faster rehabilitation and reduction of postoperative pain which are in line with the goals of ERAS.62 The effectiveness of minimally invasive techniques in terms of decreasing blood loss and length of stay has been seen in lumbar fusions.63,64 However steep learning curve and more radiation exposure during surgery for patient and surgeon and still major concerns.62

3.2.5. Urinary catheters and wound drains

Urinary catheters are often used during surgery as they help in monitoring urine output, a marker of hemodynamic stability and prevent bladder distension.65 However, delayed removal of urinary catheters is associated with increased risk of not only urinary tract and surgical site infections but also postoperative urinary retention (POUR) which in turn increases the risk of sepsis, hospital cost and LOS.66 It also acts as a deterrent to early mobilization in the postoperative period. ERAS pathway recommends limited use urinary catheters to avoid complications. It has been shown that short elective spinal surgeries including lumbar spinal fusions can be managed without the use of urinary catheters.7 However, if they are used early removal within few hours of surgery with monitoring for POUR should be the goal.

The use of wound drains in spine surgery is a common practice which has been promoted by advantages such as low cost and belief that they lead to decreased risk of surgical site infection (SSI) and epidural hematoma formation. However, the rates of SSI, epidural hematoma formation and other complications have been found to be same irrespective of whether or not drain is used in various cervical and lumbar surgeries.67,68 The use of wound drains should be limited and if used, used should be removed early to facilitate mobilization.

3.3. Postoperative measures

3.3.1. Postoperative analgesia

Postoperative pain is one of the major concerns in spin surgery. Adequate pain control is not only helpful in improving functional outcomes and facilitating early mobilization and discharge but also prevents development of chronic pain.69 It has been estimated that over half of the patients undergoing spine surgery experience poor pain control especially in the first 24 h post-surgery.70 ERAS pathways improve postoperative pain with anticipation of pain, early intervention and multimodal analgesic strategies as discussed earlier being the key.71 Acetaminophen, NSAID's and selective COX-2 inhibitors alone or in combination have been shown to very effectively reduce postoperative pain and are the pillars of opioid sparing multimodal analgesia followed in ERAS pathways.71,72 Opioids should be used sparingly as rescue analgesics only.

3.3.2. Post-operative nausea and vomiting care

Post-operative nausea and vomiting (PONV) is a common concern post-surgery and affects nearly one third of all surgical patients.73 Risk factors for PONV include females, non-smokers, and patients with history of motion sickness or PONV.74,75 Opioid and nitrous oxide use perioperatively also increase the risk of PONV.74 It results in dehydration, delay in nutrition, increased LOS and hospital charges.73 Preoperative risk assessment and adequate prophylaxis is an important part of ERAS. First line drugs for prophylaxis and treatment include serotonin (5HT3) antagonists, dopamine (D2) antagonists and steroids.73

3.3.3. Early mobilization

Prolonged recumbency is associated with multiple issues like insulin resistance, atrophy of muscles, decreased pulmonary function and tissue oxygenation and risk of deep vein and pulmonary thromboembolism.76 Hence, early mobilization is an important component of ERAS pathways. There are multiple studies that have shown that early mobilization is associated with reduced LOS and decreased morbidity.77,78 The mobilization should be goal directed with progressive goals on each postoperative day. Goals like independent transfer in and out of bed and the ability to climb the stairs should be aimed at before discharge.78 The importance of team work and early involvement of physiotherapist to achieve these goals especially in geriatric population cannot be overstated.

3.4. Periodic audit and improvement

Designing of ERAS protocols may sound easy, but its implementation in actual practice can be a challenging task. Studies from gastrointestinal surgery in this regard have shown that compliance with the ERAS protocol components can be highly variable with very poor to excellent compliance rates being reported.79,80 It is important to appreciate that ERAS pathways often require multidisciplinary teams including surgeons, anaesthetics, nurses, physiotherapist and other speciality personal for successful implementation of a protocol.81 It has been seen that hospital personnel though positive about ERAS pathway, often find the process difficult.81 It requires effort and constant reinforcement to switch practices being followed earlier and change over to evidence based ERAS guidelines to improve the standard of healthcare.82 All the stakeholders should be involved early during the planning phase of a protocol, so as to enhance compliance. Regular meetings and audits for appraisal of practical challenges faced and incorporation of suggestions is equally important. Periodic monitoring, feedback of processes and measuring outcomes are essential so that successful implementation of ERAS protocols can be done.83

4. Conclusion

ERAS protocols have gained prominence over the last decade in spine surgery. They have been shown to reduce length of hospital stay, decrease hospital costs and lower opioid requirement as compared to traditional protocols. Their applicability and reproducibility of results across various types of surgeries in the spine including lumbar, anterior cervical, deformity correction and spinal tumors reinstates the fact that they are here to stay. It is important to appreciate that the protocols can vary between different centres. They can often be dictated by hospital setups and resource constraint. However, preoperative optimization of patient, use of multimodal analgesia, and minimizing surgical trauma and early mobilization remain the cornerstones of nearly all ERAS protocols.

References

  • 1.Ljungqvist O., Scott M., Fearon K.C. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292–298. doi: 10.1001/jamasurg.2016.4952. [DOI] [PubMed] [Google Scholar]
  • 2.Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78(5):606–617. doi: 10.1093/bja/78.5.606. [DOI] [PubMed] [Google Scholar]
  • 3.Bannister M., Ah-See K.W. Enhanced recovery programmes in head and neck surgery: systematic review. J Laryngol Otol. 2015;129(5):416–420. doi: 10.1017/S0022215115000936. [DOI] [PubMed] [Google Scholar]
  • 4.Barton J.G. Enhanced recovery pathways in pancreatic surgery. Surg Clin. 2016;96(6):1301–1312. doi: 10.1016/j.suc.2016.07.003. [DOI] [PubMed] [Google Scholar]
  • 5.Smith H.J., Leath C.A., Straughn J.M. Enhanced recovery after surgery in surgical specialties: gynecologic oncology. Surg Clin. 2018;98(6):1275–1285. doi: 10.1016/j.suc.2018.07.013. [DOI] [PubMed] [Google Scholar]
  • 6.Saidian A., Nix J.W. Enhanced recovery after surgery: urology. Surg Clin. 2018;98(6):1265–1274. doi: 10.1016/j.suc.2018.07.012. [DOI] [PubMed] [Google Scholar]
  • 7.Garg B., Mehta N., Bansal T., Shekhar S., Khanna P., Baidya D.K. Design and implementation of an enhanced recovery after surgery protocol in elective lumbar spine fusion by posterior approach: a retrospective, comparative study. Spine. 2021;46(12):E679–E687. doi: 10.1097/BRS.0000000000003869. [DOI] [PubMed] [Google Scholar]
  • 8.Pennington Z., Cottrill E., Lubelski D., Ehresman J., Theodore N., Sciubba D.M. Systematic review and meta-analysis of the clinical utility of Enhanced Recovery after Surgery pathways in adult spine surgery. J Neurosurg Spine. Published online November. 2020;6:1–23. doi: 10.3171/2020.6.SPINE20795. [DOI] [PubMed] [Google Scholar]
  • 9.Leng X., Zhang Y., Wang G., et al. An enhanced recovery after surgery pathway: LOS reduction, rapid discharge and minimal complications after anterior cervical spine surgery. BMC Muscoskel Disord. 2022;23(1):252. doi: 10.1186/s12891-022-05185-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Gadiya A.D., Koch J.E.J., Patel M.S., Shafafy M., Grevitt M.P., Quraishi N.A. Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review. Spine Deform. 2021;9(4):893–904. doi: 10.1007/s43390-021-00310-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Liu B., Liu S., Wang Y., et al. Enhanced recovery after intraspinal tumor surgery: a single-institutional randomized controlled study. World Neurosurg. 2020;136:e542–e552. doi: 10.1016/j.wneu.2020.01.067. [DOI] [PubMed] [Google Scholar]
  • 12.Porche K, Yan S, Mohamed B, et al. Enhanced recovery after surgery (ERAS) improves return of physiological function in frail patients undergoing 1-2 level TLIFs: an observational retrospective cohort study. Spine J Off J North Am Spine Soc. Published online April 18, 2022:S1529-9430(22)00148-6. doi:10.1016/j.spinee.2022.04.007. [DOI] [PMC free article] [PubMed]
  • 13.Tong Y., Fernandez L., Bendo J.A., Spivak J.M. Enhanced recovery after surgery trends in adult spine surgery: a systematic review. Internet J Spine Surg. 2020;14(4):623–640. doi: 10.14444/7083. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Zaed I., Bossi B., Ganau M., Tinterri B., Giordano M., Chibbaro S. Current state of benefits of Enhanced Recovery after Surgery (ERAS) in spinal surgeries: a systematic review of the literature. Neurochirurgie. 2022;68(1):61–68. doi: 10.1016/j.neuchi.2021.04.007. [DOI] [PubMed] [Google Scholar]
  • 15.Dietz N., Sharma M., Adams S., et al. Enhanced recovery after surgery (ERAS) for spine surgery: a systematic review. World Neurosurg. 2019;130:415–426. doi: 10.1016/j.wneu.2019.06.181. [DOI] [PubMed] [Google Scholar]
  • 16.Uhrbrand P., Helmig P., Haroutounian S., Vistisen S.T., Nikolajsen L. Persistent opioid use after spine surgery: a prospective cohort study. Spine. 2021;46(20):1428–1435. doi: 10.1097/BRS.0000000000004039. [DOI] [PubMed] [Google Scholar]
  • 17.Chang H.K., Huang M., Wu J.C., Huang W.C., Wang M.Y. Less opioid consumption with enhanced recovery after surgery transforaminal lumbar interbody fusion (TLIF): a comparison to standard minimally-invasive TLIF. Neurospine. 2020;17(1):228–236. doi: 10.14245/ns.1938422.211. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Flanders T.M., Ifrach J., Sinha S., et al. Reduction of postoperative opioid use after elective spine and peripheral nerve surgery using an enhanced recovery after surgery program. Pain Med. 2020;21(12):3283–3291. doi: 10.1093/pm/pnaa233. [DOI] [PubMed] [Google Scholar]
  • 19.Pennington Z., Cottrill E., Lubelski D., et al. Clinical utility of enhanced recovery after surgery pathways in pediatric spinal deformity surgery: systematic review of the literature. J Neurosurg Pediatr. 2020;27(2):225–238. doi: 10.3171/2020.7.PEDS20444. [DOI] [PubMed] [Google Scholar]
  • 20.Wang P., Wang Q., Kong C., et al. Enhanced recovery after surgery (ERAS) program for elderly patients with short-level lumbar fusion. J Orthop Surg. 2020;15:299. doi: 10.1186/s13018-020-01814-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Ifrach J., Basu R., Joshi D.S., et al. Efficacy of an enhanced recovery after surgery (ERAS) pathway in elderly patients undergoing spine and peripheral nerve surgery. Clin Neurol Neurosurg. 2020;197 doi: 10.1016/j.clineuro.2020.106115. [DOI] [PubMed] [Google Scholar]
  • 22.Debono B., Sabatier P., Boniface G., et al. Implementation of enhanced recovery after surgery (ERAS) protocol for anterior cervical discectomy and fusion: a propensity score-matched analysis. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2021;30(2):560–567. doi: 10.1007/s00586-020-06445-0. [DOI] [PubMed] [Google Scholar]
  • 23.Tarıkçı Kılıç E., Demirbilek T., Naderi S. Does an enhanced recovery after surgery protocol change costs and outcomes of single-level lumbar microdiscectomy? Neurosurg Focus. 2019;46(4):E10. doi: 10.3171/2019.1.FOCUS18665. [DOI] [PubMed] [Google Scholar]
  • 24.Heathcote S., Duggan K., Rosbrugh J., et al. Enhanced recovery after surgery (ERAS) protocols expanded over multiple service lines improves patient care and hospital cost. Am Surg. 2019;85(9):1044–1050. [PubMed] [Google Scholar]
  • 25.Naik BI, Dunn LK, Wanchek TN. Incremental cost-effectiveness analysis on length of stay of an enhanced recovery after spine surgery program: a single-center, retrospective cohort study. J Neurosurg Anesthesiol. Published online December 15, 2021. doi:10.1097/ANA.0000000000000827. [DOI] [PubMed]
  • 26.Wang M.Y., Chang H.K., Grossman J. Reduced acute care costs with the ERAS® minimally invasive transforaminal lumbar interbody fusion compared with conventional minimally invasive transforaminal lumbar interbody fusion. Neurosurgery. 2018;83(4):827–834. doi: 10.1093/neuros/nyx400. [DOI] [PubMed] [Google Scholar]
  • 27.Echt M., Poeran J., Zubizarreta N., et al. Enhanced recovery components for posterior lumbar spine fusion: harnessing national data to compare protocols. Clin Spine Surg. 2022;35(1):E194–E201. doi: 10.1097/BSD.0000000000001242. [DOI] [PubMed] [Google Scholar]
  • 28.Naftalovich R., Singal A., Iskander A.J. Enhanced Recovery after Surgery (ERAS) protocols for spine surgery - review of literature. Anaesthesiol Intensive Ther. 2022;54(1):71–79. doi: 10.5114/ait.2022.113961. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Kong C.B., Jeon D.W., Chang B.S., Lee J.H., Suk K.S., Park J.B. Outcome of spinal fusion for lumbar degenerative disease: a cross-sectional study in Korea. Spine. 2010;35(15):1489–1494. doi: 10.1097/BRS.0b013e3181c49fd0. [DOI] [PubMed] [Google Scholar]
  • 30.Burgess L.C., Arundel J., Wainwright T.W. The effect of preoperative education on psychological, clinical and economic outcomes in elective spinal surgery: a systematic review. Healthc Basel Switz. 2019;7(1):E48. doi: 10.3390/healthcare7010048. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Adogwa O., Elsamadicy A.A., Mehta A.I., Cheng J., Bagley C.A., Karikari I.O. Preoperative nutritional status is an independent predictor of 30-day hospital readmission after elective spine surgery. Spine. 2016;41(17):1400–1404. doi: 10.1097/BRS.0000000000001551. [DOI] [PubMed] [Google Scholar]
  • 32.Somani S., Kim J.H., Kim J., et al. Hypoalbuminemia as a risk factor following anterior cervical discectomy and fusion (ACDF) Spine J. 2016;16(10):S152. doi: 10.1016/j.spinee.2016.07.048. [DOI] [Google Scholar]
  • 33.Xu B., Xu W.X., Lao Y.J., Ding W.G., Lu D., Sheng H.F. Multimodal nutritional management in primary lumbar spine surgery: a randomized controlled trial. Spine. 2019;44(14):967–974. doi: 10.1097/BRS.0000000000002992. [DOI] [PubMed] [Google Scholar]
  • 34.Seicean A., Seicean S., Alan N., et al. Preoperative anemia and perioperative outcomes in patients who undergo elective spine surgery. Spine. 2013;38(15):1331–1341. doi: 10.1097/BRS.0b013e3182912c6b. [DOI] [PubMed] [Google Scholar]
  • 35.Muñoz M., Acheson A.G., Auerbach M., et al. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia. 2017;72(2):233–247. doi: 10.1111/anae.13773. [DOI] [PubMed] [Google Scholar]
  • 36.Dick A.G., Pinder R.J., Lyle S.A., Ember T., Mallinson C., Lucas J. Reducing allogenic blood transfusion in pediatric scoliosis surgery: reporting 15 Years of a multidisciplinary, evidence-based quality improvement project. Global Spine J. 2019;9(8):843–849. doi: 10.1177/2192568219837488. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Grønkjær M., Eliasen M., Skov-Ettrup L.S., et al. Preoperative smoking status and postoperative complications: a systematic review and meta-analysis. Ann Surg. 2014;259(1):52–71. doi: 10.1097/SLA.0b013e3182911913. [DOI] [PubMed] [Google Scholar]
  • 38.Hermann P.C., Webler M., Bornemann R., et al. Influence of smoking on spinal fusion after spondylodesis surgery: a comparative clinical study. Technol Health Care Off J Eur Soc Eng Med. 2016;24(5):737–744. doi: 10.3233/THC-161164. [DOI] [PubMed] [Google Scholar]
  • 39.Mills E., Eyawo O., Lockhart I., Kelly S., Wu P., Ebbert J.O. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med. 2011;124(2):144–154. doi: 10.1016/j.amjmed.2010.09.013. e8. [DOI] [PubMed] [Google Scholar]
  • 40.Thomsen T., Villebro N., Møller A.M. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014;(3) doi: 10.1002/14651858.CD002294.pub4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Debono B., Wainwright T.W., Wang M.Y., et al. Consensus statement for perioperative care in lumbar spinal fusion: enhanced Recovery after Surgery (ERAS®) Society recommendations. Spine J Off J North Am Spine Soc. 2021;21(5):729–752. doi: 10.1016/j.spinee.2021.01.001. [DOI] [PubMed] [Google Scholar]
  • 42.Egholm J.W., Pedersen B., Møller A.M., Adami J., Juhl C.B., Tønnesen H. Perioperative alcohol cessation intervention for postoperative complications. Cochrane Database Syst Rev. 2018;(11) doi: 10.1002/14651858.CD008343.pub3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Zhang L kai, Li Q., Quan R.F., Liu J.S. Is preemptive analgesia a good choice for postoperative pain relief in lumbar spine surgeries?: a meta-analysis of randomized controlled trials. Medicine (Baltim) 2021;100(13) doi: 10.1097/MD.0000000000025319. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Han C., Kuang M.J., Ma J.X., Ma X.L. The efficacy of preoperative gabapentin in spinal surgery: a meta-analysis of randomized controlled trials. Pain Physician. 2017;20(7):649–661. [PubMed] [Google Scholar]
  • 45.Barker F.G. Efficacy of prophylactic antibiotic therapy in spinal surgery: a meta-analysis. Neurosurgery. 2002;51(2):391–400. discussion 400-401. [PubMed] [Google Scholar]
  • 46.Soffin E.M., Wetmore D.S., Beckman J.D., et al. Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study. Neurosurg Focus. 2019;46(4):E8. doi: 10.3171/2019.1.FOCUS18645. [DOI] [PubMed] [Google Scholar]
  • 47.Ziegeler S., Fritsch E., Bauer C., et al. Therapeutic effect of intrathecal morphine after posterior lumbar interbody fusion surgery: a prospective, double-blind, randomized study. Spine. 2008;33(22):2379–2386. doi: 10.1097/BRS.0b013e3181844ef2. [DOI] [PubMed] [Google Scholar]
  • 48.Firouzian A., Gholipour Baradari A., Ehteshami S., et al. The effect of ultra-low-dose intrathecal naloxone on pain intensity after lumbar laminectomy with spinal fusion: a randomized controlled trial. J Neurosurg Anesthesiol. 2020;32(1):70–76. doi: 10.1097/ANA.0000000000000537. [DOI] [PubMed] [Google Scholar]
  • 49.Chan J.H.H., Heilpern G.N.A., Packham I., Trehan R.K., Marsh G.D.J., Knibb A.A. A prospective randomized double-blind trial of the use of intrathecal fentanyl in patients undergoing lumbar spinal surgery. Spine. 2006;31(22):2529–2533. doi: 10.1097/01.brs.0000241135.79983.52. [DOI] [PubMed] [Google Scholar]
  • 50.Park S.Y., An H.S., Lee S.H., Suh S.W., Kim J.L., Yoon S.J. A prospective randomized comparative study of postoperative pain control using an epidural catheter in patients undergoing posterior lumbar interbody fusion. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2016;25(5):1601–1607. doi: 10.1007/s00586-016-4385-8. [DOI] [PubMed] [Google Scholar]
  • 51.Wenk M., Liljenqvist U., Kaulingfrecks T., et al. Intra- versus postoperative initiation of pain control via a thoracic epidural catheter for lumbar spinal fusion surgery. Minerva Anestesiol. 2018;84(7):796–802. doi: 10.23736/S0375-9393.17.12136-X. [DOI] [PubMed] [Google Scholar]
  • 52.Hu Z., Han J., Jiao B., et al. Efficacy of thoracolumbar interfascial plane block for postoperative analgesia in lumbar spine surgery: a meta-analysis of randomized clinical trials. Pain Physician. 2021;24(7):E1085–E1097. [PubMed] [Google Scholar]
  • 53.Goel V.K., Chandramohan M., Murugan C., et al. Clinical efficacy of ultrasound guided bilateral erector spinae block for single-level lumbar fusion surgery: a prospective, randomized, case-control study. Spine J Off J North Am Spine Soc. 2021;21(11):1873–1880. doi: 10.1016/j.spinee.2021.06.015. [DOI] [PubMed] [Google Scholar]
  • 54.Jirarattanaphochai K., Jung S., Thienthong S., Krisanaprakornkit W., Sumananont C. Peridural methylprednisolone and wound infiltration with bupivacaine for postoperative pain control after posterior lumbar spine surgery: a randomized double-blinded placebo-controlled trial. Spine. 2007;32(6):609–616. doi: 10.1097/01.brs.0000257541.91728.a1. ; discussion 617. [DOI] [PubMed] [Google Scholar]
  • 55.Li J., Yang J.S., Dong B.H., Ye J.M. The effect of dexmedetomidine added to preemptive ropivacaine infiltration on postoperative pain after lumbar fusion surgery: a randomized controlled trial. Spine. 2019;44(19):1333–1338. doi: 10.1097/BRS.0000000000003096. [DOI] [PubMed] [Google Scholar]
  • 56.Attari M.A., Mirhosseini S.A., Honarmand A., Safavi M.R. Spinal anesthesia versus general anesthesia for elective lumbar spine surgery: a randomized clinical trial. J Res Med Sci Off J Isfahan Univ Med Sci. 2011;16(4):524–529. [PMC free article] [PubMed] [Google Scholar]
  • 57.Sekerak R., Mostafa E., Morris M.T., Nessim A., Vira A., Sharan A. Comparative outcome analysis of spinal anesthesia versus general anesthesia in lumbar fusion surgery. J Clin Orthop Trauma. 2021;13:122–126. doi: 10.1016/j.jcot.2020.11.017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Garg B., Ahuja K., Sharan A.D. Awake spinal fusion. J Clin Orthop Trauma. 2020;11(5):749–752. doi: 10.1016/j.jcot.2020.06.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.Kurz A. Thermal care in the perioperative period. Best Pract Res Clin Anaesthesiol. 2008;22(1):39–62. doi: 10.1016/j.bpa.2007.10.004. [DOI] [PubMed] [Google Scholar]
  • 60.Simegn G.D., Bayable S.D., Fetene M.B. Prevention and management of perioperative hypothermia in adult elective surgical patients: a systematic review. Ann Med Surg. 2021;72 doi: 10.1016/j.amsu.2021.103059. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Koraki E., Stachtari C., Stergiouda Z., et al. Blood and fluid management during scoliosis surgery: a single-center retrospective analysis. Eur J Orthop Surg Traumatol Orthop Traumatol. 2020;30(5):809–814. doi: 10.1007/s00590-020-02637-y. [DOI] [PubMed] [Google Scholar]
  • 62.Corniola M.V., Debono B., Joswig H., Lemée J.M., Tessitore E. Enhanced recovery after spine surgery: review of the literature. Neurosurg Focus. 2019;46(4):E2. doi: 10.3171/2019.1.FOCUS18657. [DOI] [PubMed] [Google Scholar]
  • 63.Kim C.H., Easley K., Lee J.S., et al. Comparison of minimally invasive versus open transforaminal interbody lumbar fusion. Global Spine J. 2020;10(2 Suppl):143S–150S. doi: 10.1177/2192568219882344. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 64.Hammad A., Wirries A., Ardeshiri A., Nikiforov O., Geiger F. Open versus minimally invasive TLIF: literature review and meta-analysis. J Orthop Surg. 2019;14(1):229. doi: 10.1186/s13018-019-1266-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 65.Baldini G., Bagry H., Aprikian A., Carli F. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology. 2009;110(5):1139–1157. doi: 10.1097/ALN.0b013e31819f7aea. [DOI] [PubMed] [Google Scholar]
  • 66.Golubovsky J.L., Ilyas H., Chen J., Tanenbaum J.E., Mroz T.E., Steinmetz M.P. Risk factors and associated complications for postoperative urinary retention after lumbar surgery for lumbar spinal stenosis. Spine J Off J North Am Spine Soc. 2018;18(9):1533–1539. doi: 10.1016/j.spinee.2018.01.022. [DOI] [PubMed] [Google Scholar]
  • 67.Kanayama M., Oha F., Togawa D., Shigenobu K., Hashimoto T. Is closed-suction drainage necessary for single-level lumbar decompression?: review of 560 cases. Clin Orthop. 2010;468(10):2690–2694. doi: 10.1007/s11999-010-1235-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Patel S.B., Griffiths-Jones W., Jones C.S., et al. The current state of the evidence for the use of drains in spinal surgery: systematic review. Eur Spine J. 2017;26(11):2729–2738. doi: 10.1007/s00586-017-4983-0. [DOI] [PubMed] [Google Scholar]
  • 69.Bajwa S.J.S., Haldar R. Pain management following spinal surgeries: an appraisal of the available options. J Craniovertebral Junction Spine. 2015;6(3):105–110. doi: 10.4103/0974-8237.161589. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 70.Yang M.M.H., Riva-Cambrin J., Cunningham J., et al. Development and validation of a clinical prediction score for poor postoperative pain control following elective spine surgery. J Neurosurg Spine. Published online September. 2020;15:1–10. doi: 10.3171/2020.5.SPINE20347. [DOI] [PubMed] [Google Scholar]
  • 71.Feldheiser A., Aziz O., Baldini G., et al. Enhanced Recovery after Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand. 2016;60(3):289–334. doi: 10.1111/aas.12651. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 72.Walker C.T., Gullotti D.M., Prendergast V., et al. Implementation of a standardized multimodal postoperative analgesia protocol improves pain control, reduces opioid consumption, and shortens length of hospital stay after posterior lumbar spinal fusion. Neurosurgery. 2020;87(1):130–136. doi: 10.1093/neuros/nyz312. [DOI] [PubMed] [Google Scholar]
  • 73.Gan T.J., Diemunsch P., Habib A.S., et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118(1):85–113. doi: 10.1213/ANE.0000000000000002. [DOI] [PubMed] [Google Scholar]
  • 74.Apfel C.C., Philip B.K., Cakmakkaya O.S., et al. Who is at risk for postdischarge nausea and vomiting after ambulatory surgery? Anesthesiology. 2012;117(3):475–486. doi: 10.1097/ALN.0b013e318267ef31. [DOI] [PubMed] [Google Scholar]
  • 75.Sarin P., Urman R.D., Ohno-Machado L. An improved model for predicting postoperative nausea and vomiting in ambulatory surgery patients using physician-modifiable risk factors. J Am Med Inform Assoc JAMIA. 2012;19(6):995–1002. doi: 10.1136/amiajnl-2012-000872. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 76.Harper C.M., Lyles Y.M. Physiology and complications of bed rest. J Am Geriatr Soc. 1988;36(11):1047–1054. doi: 10.1111/j.1532-5415.1988.tb04375.x. [DOI] [PubMed] [Google Scholar]
  • 77.Burgess L.C., Wainwright T.W. What is the evidence for early mobilisation in elective spine surgery? A narrative review. Healthcare. 2019;7(3):92. doi: 10.3390/healthcare7030092. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 78.Tazreean R., Nelson G., Twomey R. Early mobilization in enhanced recovery after surgery pathways: current evidence and recent advancements. J Comp Eff Res. 2022;11(2):121–129. doi: 10.2217/cer-2021-0258. [DOI] [PubMed] [Google Scholar]
  • 79.Maessen J., Dejong C.H.C., Hausel J., et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007;94(2):224–231. doi: 10.1002/bjs.5468. [DOI] [PubMed] [Google Scholar]
  • 80.Polle S.W., Wind J., Fuhring J.W., Hofland J., Gouma D.J., Bemelman W.A. Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg. 2007;24(6):441–449. doi: 10.1159/000108327. [DOI] [PubMed] [Google Scholar]
  • 81.Cohen R., Gooberman-Hill R. Staff experiences of enhanced recovery after surgery: systematic review of qualitative studies. BMJ Open. 2019;9(2) doi: 10.1136/bmjopen-2018-022259. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 82.Cunningham B.P., Bakker C.J., Parikh H.R., Johal H., Swiontkowski M.F. Physician behavior change: a systematic review. J Orthop Trauma. 2019;33(Suppl 7):S62–S72. doi: 10.1097/BOT.0000000000001616. [DOI] [PubMed] [Google Scholar]
  • 83.Hu Q.L., Liu J.Y., Hobson D.B., et al. Best practices in data use for achieving successful implementation of enhanced recovery pathway. J Am Coll Surg. 2019;229(6):626–632. doi: 10.1016/j.jamcollsurg.2019.08.1448. e1. [DOI] [PubMed] [Google Scholar]

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