Surgery: A Systematic Review
Enhanced Recovery After Surgery Trends in Adult Spine
YIXUAN TONG, LAVIEL FERNANDEZ, JOHN A. BENDO and JEFFREY M. SPIVAK
https://www.ijssurgery.com/content/14/4/623
https://doi.org/10.14444/7083doi:
2020, 14 (4) 623-640Int J Spine Surg
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https://doi.org/10.14444/7083
ÓInternational Society for the Advancement of Spine Surgery
Enhanced Recovery After Surgery Trends in Adult Spine
Surgery: A Systematic Review
YIXUAN TONG, BA,
1
LAVIEL FERNANDEZ, MD,
2
JOHN A. BENDO, MD,
2
JEFFREY M. SPIVAK, MD
2
1
New York University Grossman School of Medicine, New York, New York,
2
Spine Division, New York University Langone Orthopedic Hospital, New York, New
York
ABSTRACT
Background: Enhanced Recovery After Surgery (ERAS) is a multimodal, multidisciplinary approach to
optimizing the postsurgical recovery process through preoperative, perioperative, and postoperative interventions.
ERAS protocols are emerging quickly within orthopedic spine surgery, yet there is a lack of consensus on optimal
ERAS practices.
Objective: The aim of this systematic review is to identify and discuss the trends in spine ERAS protocols and the
associated outcomes.
Methods: A literature search on PubMed was conducted to identify clinical studies that implemented ER AS
protocols for various spine procedures in the adult population. The search included English-language literature
published t hrough December 2019. Additional sources were r etrieved from the r eference lists of key studies. Studies
that met inclusion criteria were identified manually. Data regarding the study population, study design, spine
proced ures, ERAS interventio ns, and associated outcom e metrics were extracted from eac h s tudy that met inclusion
criteria.
Results: Of the 106 studies identified from the literature search, 22 studies met inclusion criteria. From the
ERAS protocols in these studies, common preoperative elements include patient education and modified preoperative
nutrition regim ens. Perioperative elements include multimodal analgesia and minimally invasive surgery.
Postoperative elements include multimodal pain management and early mobilization/rehabilitation/nutrition
regimens. Outcomes from ERAS implementation include significant reductions in length of stay, cost, and opioid
consumption. Although these trends were observed, there remained great variability among the ERAS pr otocols, as
well as in the reported outcomes.
Conclusions: ERAS may improve cost-effectiveness to varying degrees for spinal procedures. Specifically, the
use of multimodal analgesia may reduce overall opioid consumption. However, the benefits of ERAS likely will vary
based on the specific procedure.
Clinical Relevance: This review contributes to the assessment of ERAS protocol implementation in the field of
adult spine surgery.
Other and Speci al Categories
Keywords: Enhanced Recovery After Surgery, ERAS, fast-track surgery, rapid recovery program, spine surgery,
orthopedics, multimodal analgesia
INTRODUCTION
Enhanced Recovery After Surgery (ERAS; also
known as enhanced or rapid recovery program, fast-
track surgery, enhanced perioperative care/EPOC)
refers to a multimodal care pathway to accelerate
patient recovery after surgery. The goal of ERAS is
to mitigate the surgical stress response while also
enhancing the recovery of bodily functions, ulti-
mately increasing cost-effectiveness without com-
promising the quality of care.
1
An ERAS protocol
typically contains preoperative, perioperative, and/
or postoperative elements that are standardized
across all patients undergoing a certain procedure.
1
The implementation of such a protocol i s a
multidisciplinary effort involving surgery, anesthe-
sia, nursing, and other disciplines. This concept was
first introduced by Kehlet
1
and adapted for colonic
resection and colorectal procedures.
2
Since then,
ERAS care pathways have been developed for a
variety of other surgical specialties.
3
As evidence for
and adoption o f ERAS have grown, multiple
societies also have been established (see the global
society http://erassociety.org, the UK society http://
www.erasuk.net/, and the American society http://
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enhancedrecovery.org/) to curate ERAS guidelines
worldwide.
The stress response to surgical insult can be
particularly devastating for a patient, resulting in a
proinflammatory, procatabolic state that can drive
metabolic changes and insulin resistance.
4–6
Such
changes in turn may significantly impact postoper-
ative m orbidity and mortality.
5,6
Additionally,
blood loss and fluid homeostasis are major factors
that can affect surgical outcomes.
2
To address these concerns, ERAS pathways are
being implemented with increasing frequency. Com-
pared with traditional care pathways, which are
often unstandardized and according to surgeon
preference, ERAS pathways have been associated
with improved outcomes within various surgical
fields
2
; for example, ERAS protocols developed for
high-volume total knee and hip replacements have
been associated with reductions in length of stay
(LOS) and hospital costs, as well as in readmission,
complication, and mortality rates to varying de-
grees.
7–11
ERAS implementation may become a mainstay
for orthopedic spine surgery. The volume of patients
undergoing elective spine surgery is increasing, as is
the population of aging patients who may become
surgical candidates.
3,12
Moreover, some spine pro-
cedures are associated with significant postoperative
pain, LOS, and complications.
3
Thus, there is room
to grow in terms of optimizing clinical and
economic outcomes.
Research on spine ERAS protocols is still in the
early stages, but it has been gaining traction.
12
Recent reviews by Dietz et al,
13
Elsarrag et al,
14
and
Corniola et al
15
highlight the various spine proce-
dures for which E RAS pathw ays have been
designed and implemented. However, there remains
a l ack of consensus on which specific ERAS
elements may be relatively more effective. Indeed,
there are no official ERAS guidelines for spine
surgery, although many spine ERAS proto cols
contain elements that are present in the guidelines
for other surgical specialties (see http://erassociety.
org.loopiadns.com/guidelines/list-of-guidelines).
Moreover, existing ERAS spine protocols vary sig-
nificantly in their preoperative, perioperative, and
postoperative elements, rendering it difficult to as-
sess their individual effectiveness. Thus, the aim of
this review is to discuss the trends in spine ERAS
protocols—the commonly adopted interventions
and prior evidence for their implementation in other
surgical specialties—as well as the associated out-
come metrics.
METHODS
Electronic Literature Search
A literature review of PubMed was conducted as
per the Preferred Reporting Items for Systematic
Reviews and Meta -Analyse s (PRISMA ) guide-
lines.
16
Keywords were combined with Boolean
operators to generate the following search term:
[‘‘ERAS’’] OR [‘‘enhanced recovery after surgery’’]
OR [‘‘rapid recovery’’] OR [‘‘accelerated pathway’’]
OR [‘‘fast-track surgery’’] OR [‘‘ same-day dis-
charge’’] AND [‘‘spine surgery’’], in order to retrieve
relevant English-language literature published
through December 2019. The literature search was
performed independently by 2 reviewers, and a
consensus was reached for wh ich articles met
inclusion criteria. The last search was performed
on December 30, 2019. Later, additional articles
were i dentified from the reference lists of key
articles.
Inclusion and Exclusion Criteria
Titles, abstracts, and fu ll-text articles were
screened by 2 independent reviewers. Inclusion
criteria included: (1) adult patients undergoing (2)
any type of elective spine surgery, and (3) random-
ized, nonrandomized, con troll ed, noncontrolled,
retrospective, and prospective study designs. Exclu-
sion criteria included: (1) pediatric patients, (2)
articles not available in English, (3) hypothetical
ERAS designs, (4) studies that introduced only a
single ERAS element (eg, not in full protocol), and
(5) revie w articles and case reports. D uplicate
articles were accounted for. Data from the articles
that fit our criteria were extracted and assessed. This
review does not incorporate the pediatric popula-
tion because of the variability in protocols, param-
eters, and discharge criteria that significantly differ
from those for adult populations.
Data Extraction and Quality Assessment
Where available, the following data were extract-
ed from each study that met criteria: sample size,
study design, spine procedure(s), quantity and types
of ERAS inter ventions per p rotocol, and all
associated outcome s t hat were reported—which
commonly included LOS, cost, method(s) of pain
control, and complication and readmission rates. If
ERAS Trends in Adult Spine Surgery
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the number of ERAS interventions in a study was
not itemized explicitly (eg, in a data table), the
information was extracted from the article text.
Assessment of quality and risk bias was performed
according to the Centre for Evidence-Based Medi-
cine guidelines for therapeutic studies,
17
as well as
the Newcastle-Ottawa Scale,
18
which is a 9-point
scale designed to assess nonrandomized and case-
control studies for sample selection, comparability,
and outcome/exposure. A higher score on the scale
indicates a higher-quality study.
18
Data Analyses
There was great heterogeneity among the studies;
for example, there was a wide range of study
designs, and several studies did not provide a
comparative analysis of pre- and post-ERAS data.
A meta-analysis would have been limited by the
nature of this source data. As such, data points of
interest wer e reported when available i n the
literature, but statistical analyses were not per-
formed for this review.
RESULTS
Study Selection
A total of 106 articles were identified from the
initial literature search. The 85 nonduplicate articles
underwent abstract and title review for inclusion, of
which 36 were excluded based on our exclusion
criteria and nonapplicability. A total of 49 articles
underwent full-text review, and 27 of those articles
were excluded because of a lack of evidence
pertaining to ERAS protocols. The remaining 22
articles met inclusion criteria.
19–40
Of the 22 ERAS studies that met criteria, 12 were
controlled ‘‘before-and-after’’ studies,
22,25–30,32–36
8
were prospective noncontrolled trials,
19,21,23,24,31,3 7,39,40
1 was a r etrospective ma tched coho rt study,
38
and 1 was
a retrospective noncontrolled study.
20
Publication
dates ranged from 2004 to 2019.
The literature search process is presented in the
PRISMA flow diagram (Figure). Table 1 presents
an overview of the 22 studies and their associated
outcomes.
Assessment of Quality and Risk of Bias
As per the Centre f or Evidence-Based Medicine
guidelines for therapeutic studies,
17
the 12 con-
trolled ‘‘before-and-after ’’ s tudie s
22,25–30,32– 36
and
the retrospective c ontroll ed stud y
38
are graded a s
level of evidence 2B.
17
The remaining noncon-
trolled retrospective study
20
is graded as level of
evidence 4. The 8 p rospective noncontrolled
trials
19,21,23,24,31,37,39,40
are graded as l evel of
evidence 4.
According to the Newcastle-Ottawa Scale,
18
12 of
the nonrandomized, controlled cohort stud-
ies
22,25–30,32,34–36
received 8 stars out of 9 (4 for
selection, 1 for comparability, and 3 for outcome),
and 1 study
39
received 9 stars out of 9.
Types of Spine Surgery
Associated spine procedures included minor,
major, and complex spi ne surgeries, such as
laminectomy/laminotomy, (micro)discectomy, open
and minimally invasive posterior lumbar interbody
fusion (PLIF), transforaminal lumbar interbody
fusion (TLIF), anterior lumbar interbody fusion
(ALIF), anterior cervical discectomy and fusion
(ACDF), anterior cervical disc arthroplasty (AC-
DA), and metastatic tumor resection (Table 1).
Most spine ERAS protocols were implemented for
lumbar spine procedures. Because reporting of the
type(s) of spine surgery was not standardized across
the 22 studies, quantifying the prevalence of any
single type of spine procedure among the ERAS
protocols was difficult to perform.
Associated Outcomes
A total of 13 of the 22 studies
22,25–30,32–36,38
conducted controlled trials that compared ERAS
versus traditional care pathways. The outcomes are
variable and are summarized in Table 1. Common
outcome metrics reported were LOS, cost, opioid
consumption, pos tope rati ve pain, int raop erat ive
time, patient satisfaction, complication rate, and
readmission rate. The most commonly reported
outcomes were reductions in LOS, cost, and opioid
consumption. Importantly, no ERAS study was
associated with worse patient outcomes compared
with traditional pathways.
A total of 10 studies reported significantly
reduced hospital and/or intensive care unit
LOS
22,26,28–30,32–35,38
; however, some studies found
no sign ificant change in LO S com pared with
control.
25,27,36
Additionally, there was large varia-
tion in mean/median LOS, ranging from several
hours to several days.
Four studies reported a reduction in hospital
costs.
26,30,32,34
Wang et al
26
calculated a mean acute
care cost reduction of $3,444 (15.2%) for ERAS
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Table 1. Overview of spine Enhanced Recovery After Surgery (ERAS) studies.
ERAS Study Surgical Procedure Study Type Sample Size(s)
No. of ERAS
Interventions/
Protocol
Scanlon and
Richards,
19
2004
Lumbar laminectomy 6 discectomy Prospective, noncontrolled n ¼ 27 13
Chin et al,
20
2015 Single-level instrumented PLIF Retrospective, noncontrolled n ¼ 16 8
Bednar,
21
2017 Unilateral and bilateral lumbar decompression
and interbody fusion, ACDF, ACDA,
miscellaneous
Prospective, noncontrolled n ¼ 124 11
Bradywood et al,
22
2017
Lumbar spinal fusion Controlled before-and-after study ERAS protocol, n ¼ 244
Control, n ¼ 214
38
Debono et al,
23
2017 Lumbar microdiscectomy Prospective, noncontrolled n ¼ 201 13
Wang et al,
24
2017 Lumbar spinal fusion Prospective, noncontrolled n ¼ 42 17
Grasu et al,
25
2018 Metastatic tumor resection Controlled before-and-after study ERAS protocol, n ¼ 41
Control, n ¼ 56
15
Wang et al,
26
2018 MIS TLIF Controlled before-and-after study ERAS protocol, n ¼ 38
Control, n ¼ 15
6
Ali et al,
27
2019 Elective spine or peripheral nerve surgery Controlled before-and-after study ERAS protocol, n ¼ 201
Control, n ¼ 74
16
Angus et al,
28
2019 Complex spine surgery Controlled before-and-after study ERAS protocol, n ¼ 214
Control, n ¼ 412
19
Brusko et al,
29
2019 Posterior lumbar fusion (open and MIS, 1–3
levels)
Controlled before-and- after study ERAS protocol, n ¼ 57
Control, n ¼ 40
3
Carr et al,
30
2019 Arthrodesis for spinal deformity, anterior or
posterior fusion, corpectomy, pelvic fixation
Controlled before-and-after study ERAS protocol, n ¼ 620
Traditional, n ¼ 183
Control, n ¼ 129
15
Chakravarthy et al,
31
2019
ACDF/PCDF, decompression,
microdiscectomy, ALIF, TLIF, XLIF,
anterior/posterior fusion 6 instrumentation,
pedicle subtraction osteotomy, tumor
corpectomy/debulking
Prospective, noncontrolled n ¼ 1770 14
Dagal et al,
32
2019 Elective major spine surgery Controlled before-and-after study ERAS protocol, n ¼ 267
Traditional pathway, n ¼ 183
No intervention, n ¼ 108
36
Debono et al,
33
2019 ACDF, ALIF, PLIF Controlled before-and-after study ERAS protocol, n ¼ 1920
Control, n ¼ 1563
23
Feng et al,
34
2019 MIS-TLIF Controlled before-and-after study ERAS protocol, n ¼ 30
Control, n ¼ 44
12
Sivaganesan et al,
35
2019
Elective degenerative spine disease Controlled before-and-after study ERAS protocol, n ¼ 151
Control, n ¼ 1596
9
Smith et al,
36
2019 1- to 2-level primary open lumbar fusion Controlled before-and-after study ERAS protoc ol, n ¼ 123
Control, n ¼ 230
40
Soffin et al,
37
2019 ACDF and CDA Prospective, noncontrolled n ¼ 33 (25 ACDF, 8 CDA) 18
Soffin et al,
38
2019 Lumbar decompression (laminectomy,
laminotomy, microdiscectomy)
Retrospective, matched cohort ERAS protocol, n ¼ 18
Control, n ¼ 18
30
Soffin et al,
39
2019 MIS lumbar decompression Prospective, noncontrolled n ¼ 61 15
Staartjes et al,
40
2019 Elective tubular microdiscectomy, mini-open
decompression, MIS, ALIF, and PLIF
Prospective, noncontrolled n ¼ 2592 22
Abbreviations: ACDA, anterior cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion; ALIF, anterior lumbar interbody fusion; CDA, cervical disc
arthroplasty; ICU, intensive care unit; LOS, length of stay; MIS, minimally invasive surgery; N/A, not applicable; PCA, patient-controlled analgesia; PCDF, posterior
cervical discectomy and fusion; PLIF, posterior lumbar interbody fusion; POD, postoperative day; PONV, postoperative nausea and vomiting; TLIF, transforaminal
lumbar interbody fusion; XLIF, extreme lateral interbody fusion.
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Table 1. Extended.
LOS/Time to Discharge
for ERAS
‘‘Changed’’ Outcomes Compared
With Traditional Pathway
‘‘No Change’’ Outcomes Compared
With Traditional Pathway
4–6 hr in PACU (mean 3.95 hr) No control group No control group
Same-day discharge No control group No control group
Same-day discharge No control group No control group
Mean 3.4 days Reduced LOS
Improved discharge disposition/readiness
No significant difference in patient satisfaction
Mean total inpatient time 10 hr 12 min No control group No control group
Mean 1.29 6 0.9 nights No control group No control group
Mean 1.5 6 1.9 days Reduced postoperative opioid consumption No significant difference in LOS
No significant difference in complication rate
No significant difference in readmission rate
No significant difference in postoperative pain scores
Mean 1.23 6 0.8 days Reduced LOS
Reduced intraoperative time
Reduced complication rate (12% ERAS vs 21%
control)
Reduced acute care cost, mean $3444 in savings
~15.2% reduction
N/A
Mean 3.6 6 2.4 days Reduced opioid use at 1 mo postoperatively
Increased administration of postoperative ketorolac
and gabapentin
Reduction of PCA (0.5% ERAS vs 54.1% control)
Increased administration of nonopioid analgesic agents
No significant difference in LOS
No significant difference in complication rate
No significant difference in readmission rate
No significant difference in postoperative pain scores
Mean 8 days for scoliosis; mean 5.2 days
for complex fixation
Reduced LOS; 100% patient satisfaction (vs 84%
control)
Statistically nonsignificant reduction in readmission rate
(2.1% to 1.9%)
2.9 days Reduced LOS
Reduced opioid/analgesia consumption on PODs 0, 1,
and 3
Reduced narcotics consumption
Reduced PONV medication consumption
Reduced postoperative pain scores on POD1
Increased distance of ambulation on POD1
N/A
1.8 days for intensive care LOS; 5.4 days
for hospital LOS
Reduced ICU and overall hospital LOS
Reduced total costs ($19,344 reduction)
N/A
N/A No control group
Estimated $827 cost savings per patient
No control group
Mean hospital LOS 6.1 days
Mean ICU stay 1.9 days
Reduced ICU and hospital LOS
Reduced cost ($53,355 ERAS vs $62,429 control)
No significant difference in complication rate
No significant difference in readmission rate
ALIF mean 3.33 days; ACDF mean 1.3
days; PLIF mean 4.8 days
Reduced LOS for ACDF, ALIF, and PLIF
Reduced complication rate for PLIF, but NOT for
ALIF or ACDF
86.5% of patients satisfied/very satisfied regarding
mobile e-health app
82.3% of patients satisfied/very satisfied with perceived
optimization of care management
N/A
Median 5 days Reduced LOS
Reduced cost (mean $70,467 ERAS vs mean $71,426
control)
No significant difference in intraoperative time
No significant difference in complication rate
N/A Reduced LOS for lumbar procedures
Reduced complication rate for lumbar procedures
No significant difference in readmission rate
No significant difference in patient satisfaction
Mean 92 hr (3.83 days) Reduced long-acting opioid use (5.2% ERAS vs 14%
control)
Reduced PCA use (0% ERAS vs 7% control)
No significant difference in intraoperative time
Clinically (not statistically) significantly reduced LOS
Median PACU LOS 416 min (6 hr 56
min)
No control group No control group
Median PACU LOS 237 min (3.95 hr) Reduced LOS
Reduced total perioperative opioid consumption
No significant difference in postoperative pain scores
No significant difference in postoperative opioid
consumption
Median PACU LOS 279 min (4.65 hr),
298 min (4.67 hr) for lumbar
decompression, 285 min (4.75 hr) for
microdiscectomy
No control group No control group
Mean 1.1 6 1.2 days No control group No control group
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minimally invasive TLIF (MIS TLIF) procedures;
Carr et al
30
reports a $19,344 reduction in cost.
Dagal et al
32
calculated a mean cost reduction of
$62,429 (control) to $53,355 (ERAS) for several
types of major spine surgery; and Feng et al
34
found
a mean cost decrease from $71,426 to $70,467, also
for MIS TLIF. Although the study was not a
controlled trial, Chakravarthy et al
31
also estimated
a per-patient decrease of $827 in hospital costs.
A reduction in intraoperative time has also been
noted,
26
but conversely no change in intraoperative
time has been reported as well.
34,36
Here, a decrease
in LOS and/or intraoperative time may translate to
decreased cost; in fact, Wang et al
26
reported
reductions in LOS and intraoperative time, as well
as cost.
For postoperative opioid consumption, the bulk
of evidence suggests a reduction in opioid use after
ERAS implementation,
25,27,29,36,38
with no reports
of increased opioid use. Interestingly, Soffin et al
38
reported both reduced and no change in opioid
consumption at different time points, with reduced
perioperative opioid consumption but no difference
in postoperative opioid consumption.
Common ERAS Elements
Preoperative ERAS elements are defined here as
interventions that occur any time before the day of
surgery (postoperative day 0 [POD0]). They are
Figure. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for systematic review of Enhanced Recovery After Surgery
(ERAS) protocols in adult spine surgery.
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designed to optimize the patient’s condition prior to
surgery. The mos t comm on int erv en tio ns wer e
patient education (72.7% of studies), assessment of
patient health and comorbidities (45.5%), carbohy-
drate loading (40.9%), and a modified preoperative
fasting regimen (31.8%). Perioperative ERAS ele-
ments refer to interventions that occur from POD0
until patient extubation and transfer to the postan-
esthesia care unit (PACU). Common interventions
were perioperative multimodal analgesia (MMA)
(68.2%), infection prophylaxis (54.5%), ‘‘preemp-
tive’’ analgesia (50%), catheter and surgical drain
sparing (50%), and minimally invasive sur gery
(MIS; 40.9%). Postoperative ERAS elements are
defined as interventions that occur during and after
admission to the recovery area (eg, PACU).
Common postoperative elements include postoper-
ative MMA (81.8%), early mobilization/rehabilita-
tion (77.3%), and early nutrition (54.5%).
The number of ERAS elements per protocol
ranged from 3 to 40 items (Table 1); however, it is
important to note that there was great variability
across studies in how the ERAS elements were
itemized and the degree of detail to which the
protocols were presented.
Tables 2, 3, and 4 summarize the percentage
prevalence of preoperative, perioperative, and post-
operative ERAS elements that were common among
the 22 studies, respectively. Table 5 details the
postoperative discharge criteria reported by several
spine ERAS protocols. Other studies did not report
discharge criteria.
DISCUSSION
The most commonly implemented preoperative,
perioperative, and postoperative spine ERAS ele-
ments are discussed here, both with regard to how
they were implemented in the ERAS studies and in
the context of prior evidence from other surgical
specialties or non-ERAS spine studies. ERAS
elements that were not popular among the reviewed
studies are not discussed.
Table 2. Common preoperative Enhanced Recovery After Surgery (ERAS) interventions implemented in spine surgery procedures.
ERAS Study Surgical Procedure
Patient
Education
Comorbidity
Assessment
and Health
Optimization
Modified
Preoperative
Fasting
Carbohydrate
Loading
Scanlon and Richards,
19
2004 Lumbar laminectomy 6 discectomy X
Chin et al,
20
2015 Single-level instrumented PLIF X
Bednar,
21
2017 Unilateral and bilateral lumbar decompression and
interbody fusion, ACDF, ACDA, miscellaneous
XX
Bradywood et al,
22
2017 Lumbar spinal fusion X X
Debono et al,
23
2017 Lumbar microdiscectomy X X
Wang et al,
24
2017 Lumbar spinal fusion X X X
Grasu et al,
25
2018 Metastatic tumor resection X X X
Wang et al,
26
2018 MIS TLIF
Ali et al,
27
2019 Elective spine or peripheral nerve surgery X X X
Angus et al,
28
2019 Complex spine surgery X X X
Brusko et al,
29
2019 Posterior lumbar fusion (open and MIS, 1–3 levels)
Carr et al,
30
2019 Arthrodesis for spinal deformity, anterior or
posterior fusion, corpectomy, pelvic fixation
XX
Chakravarthy et al,
31
2019 ACDF/PCDF, decompression, microdiscectomy,
ALIF, TLIF, XLIF, anterior/posterior fusion 6
instrumentation, pedicle subtraction osteotomy,
tumor corpectomy/debulking
X
Dagal et al,
32
2019 Elective major spine surgery X X X
Debono et al,
33
2019 ACDF, ALIF, PLIF X X
Feng et al,
34
2019 MIS TLIF X X X
Sivaganesan et al,
35
2019 Elective degenerative spine disease
Smith et al,
36
2019 1- to 2-level primary open lumbar fusion X X
Soffin et al,
37
2019 ACDF and CDA X X X
Soffin et al,
38
2019 Lumbar decompression (laminectomy, laminotomy,
microdiscectomy)
X
Soffin et al,
39
2019 MIS lumbar decompression X X X
Staartjes et al,
40
2019 Elective tubular microdiscectomy, mini-open
decompression, MIS, ALIF, and PLIF
XX
Percentage (n/total) 72.7 (16/22) 45.5 (10/22) 31.8 (7/22) 40.9 (9/22)
Abbreviations: ACDA, anterior cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion; ALIF, anterior lumbar interbody fusion; CDA, cervical disc
arthroplasty; MIS, minimally invasive surgery; PCDF, posterior cervical discectomy and fusion; PLIF, posterior lumbar interbody fusion; TLIF, transforaminal lumbar
interbody fusion; XLIF, extreme lateral interbody fusion.
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Table 3. Common perioperative Enhanced Recovery After Surgery (ERAS) interventions implemented in spine surgery procedures.
ERAS Study Surgical Procedure
Preemptive
Analgesia
Intraoperative
MMA/
Analgesia MIS
Blood Loss
Management
Fluid
Management
Temperature
Management
DVT
Prophylaxis
Infection
Prophylaxis
PONV
Prophylaxis
Catheter
and Surgical
Drain
Sparing
Scanlon and
Richards,
19
2004
Lumbar laminectomy 6
discectomy
X
Chin et al,
20
2015 Single-level instrumented PLIF X
Bednar,
21
2017 Unilateral and bilateral lumbar
decompression and interbody
fusion, ACDF, ACDA,
miscellaneous
XXX
Bradywood et al,
22
2017
Lumbar spinal fusion X XX
Debono et al,
23
2017
Lumbar microdiscectomy X
Wang et al,
24
2017 Lumbar spinal fusion X X X X X X X
Grasu et al,
25
2018 Metastatic tumor resection X X X X X X
Wang et al,
26
2018 MIS TLIF X X
Ali et al,
27
2019 Elective spine or peripheral nerve
surgery
XX X
Angus et al,
28
2019 Complex spine surgery X X
Brusko et al,
29
2019 Posterior lumbar fusion (open &
MIS, 1–3 levels)
XX
Carr et al,
30
2019 Arthrodesis for spinal deformity,
anterior or posterior fusion,
corpectomy, pelvic fixation
XX XXX XX
Chakravarthy et
al,
31
2019
ACDF/PCDF, decompression,
microdiscectomy, ALIF, TLIF,
XLIF, anterior/posterior fusion
6 instrumentation, pedicle
subtraction osteotomy, tumor
corpectomy/debulking
XXXXXX
Dagal et al,
32
2019 Elective major spine surgery X X X X X X X
Debono et al,
33
2019
ACDF, ALIF, PLIF X X X X
Feng et al,
34
2019 MIS TLIF X X X X X X X
Sivaganesan et al,
35
2019
Elective degenerative spine disease XX
Smith et al,
36
2019 1- to 2-level primary open lumbar
fusion
XX XXX
Soffin et al,
37
2019 ACDF and CDA X X X X X
Soffin et al,
38
2019 Lumbar decompression
(laminectomy, laminotomy,
microdiscectomy)
XX X X
Soffin et al,
39
2019 MIS lumbar decompression X X X X X X X
Staartjes et al,
40
2019
Elective tubular microdiscectomy,
mini-open decompression, MIS,
ALIF, and PLIF
XXXXXXX X
Percentage (n/total) 50% (11/22) 68.2% (15/22) 40.9% (9/22) 31.8 (7/22) 40.9 (9/22) 36.4 (8/22) 22.7 (5/22) 54.5 (12/22) 22.7 (5/22) 50 (11/22)
Abbreviations: ACDA, anterior cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion; ALIF, anterior lumbar interbody fusion; CDA, cervical disc arthroplasty; DVT, deep venous thrombosis; MIS,
minimally invasive surgery; MMA, multimodal analgesia; PCDF, posterior cervical discectomy and fusion; PLIF, posterior lumbar interbody fusion; PONV, postoperative nausea and vomiting; TLIF, transforaminal lumbar
interbody fusion; XLIF, extreme lateral interbody fusion.
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Preoperative ERAS Elements
Patient Education
Educating the patient prior to surgery is a common
component of the ERAS preoperative pathway.
Although traditional care pathways may include
patient education, they are less structured and
standardized i n implementation. ERAS patient
education for spine surgery includes setting realistic
goals and expecta tion s for surge ry and re cov-
ery,
21–25,28,30,32–34,36,37,39,40
recommending preoper-
ative nutrition and exercise regimens,
25
educating
about the ERAS components,
23,34,39
and educating
about pain management (perioperative and postop-
erative MMA, how to grade pain, how pain scores
translate to analgesia selection, etc.).
25,33,34,37–39
In
addition to providing videos, handouts, and oral
presentations to educate patients, some research
groups also implemented a helpline and enlisted 24-
hour on-call nurses to aid in preoperative patient
education.
23,28,33
Many of the ERAS patient edu-
cation guidelines share similar features but differed
in their degree of detail and implementation.
Despite the frequent inclusion of patient educa-
tion in ERAS protocols, there is a lack of evidence
regarding its impact on patient outcomes. Previous-
ly, patient education was not found to significantly
improve surgical outcomes or reduce patient anxi-
ety; in a review of preoperative education for hip
and knee replacement procedures, McDonald et al
41
concluded that patient education may only benefit
patients with preexisting depression, anxiety, or
unrealistic expectations. It is thus unclear whether
standardized patient education guidelines are nec-
essary in most cases. However, some research
groups
34,39
have based their rationale for including
ERAS patient education on the McDonald et al
41
review article, claiming that educating patients can
enhance postoperative and recovery outcomes.
Table 4. Common postoperative Enhanced Recovery After Surgery (ERAS) interventions implemented in spine surgery procedures.
ERAS Study Surgical Procedure
Postoperative
MMA/Analgesia
Early Mobilization
and Physical
Rehabilitation
Early
Nutrition
Early
Discharge
Criteria
Scanlon and Richards,
19
2004 Lumbar laminectomy 6 discectomy X X
Chin et al,
20
2015 Single-level instrumented PLIF X X
Bednar,
21
2017 Unilateral and bilateral lumbar
decompression and interbody fusion,
ACDF, ACDA, misc.
Bradywood et al,
22
2017 Lumbar spinal fusion X X X X
Debono et al,
23
2017 Lumbar microdiscectomy X X X
Wang et al,
24
2017 Lumbar spinal fusion X X X
Grasu et al,
25
2018 Metastatic tumor resection X X X
Wang et al,
26
2018 MIS TLIF
Ali et al,
27
2019 Elective spine or peripheral nerve surgery X X
Angus et al,
28
2019 Complex spine surgery X X
Brusko et al,
29
2019 Posterior lumbar fusion (open and MIS, 1–3
levels)
X
Carr et al,
30
2019 Arthrodesis for spinal deformity, anterior or
posterior fusion, corpectomy, pelvic
fixation
XX
Chakravarthy et al,
31
2019 ACDF/PCDF, decompression,
microdiscectomy, ALIF, TLIF, XLIF,
anterior/posterior fusion 6
instrumentation, pedicle subtraction
osteotomy, tumor corpectomy/debulking
XX
Dagal et al,
32
2019 Elective major spine surgery X X X
Debono et al,
33
2019 ACDF, ALIF, PLIF X X X
Feng et al,
34
2019 MIS-TLIF X X X
Sivaganesan et al,
35
2019 Elective degenerative spine disease X X
Smith et al,
36
2019 1- to 2-level primary open lumbar fusion X X X
Soffin et al,
37
2019 ACDF and CDA X X X X
Soffin et al,
38
2019 Lumbar decompression (laminectomy,
laminotomy, microdiscectomy)
XXXX
Soffin et al,
39
2019 MIS lumbar decompression X X X
Staartjes et al,
40
2019 Elective tubular microdiscectomy, mini-open
decompression, MIS, ALIF, and PLIF
XXX
Percentage (n/total) 81.8 (18/22) 77.3 (17/22) 54.5 (12/22) 27.3 (6/22)
Abbreviations: ACDA, anterior cervical disc arthroplasty; ACDF, anterior cervical discectomy and fusion; ALIF, anterior lumbar interbody fusion; CDA, cervical disc
arthroplasty; MIS, minimally invasive surgery ; MMA, multimodal analgesia; PCDF, posterior cervical discectomy and fusion; PLIF, posterior lumbar interbody fusion;
TLIF, transforaminal lumbar interbody fusion; XLIF, extreme lateral interbody fusion.
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Comorbidity Assessment and Health Optimization
Patients who undergo elective spine surgery often
have other comorb iditi es, suc h as dia betes or
cardiovascular disease, especially as the population
of elderly patients desiring spine surgery continues
to increase. Cons iderin g the physiol ogic str ess
placed on the body by surgery, several institutions
opted to evaluate and address patient comorbidities
as part of their preoperative ERAS protocol (Table
2). In th is way , the patient’ s heal th may be
optimized prior to surgery to reduce the risk of
postoperative complications.
40
Several ERAS spine protocols required screening
for risk factors like diabetes, cardiovascular disease,
obesity (body mass index), smoking status, narcotic/
alcohol use, anemia, nutritional status, and obstruc-
tive sleep apnea. The American Society of Anesthe-
siologists classification, which indicates the severity
of a patient’s comorbidities, was also calculated in
some protocols.
20,21,36,40
For patients who presented
with comorbidities or who did not meet the health
criteria, one of several forms of intervention were
taken. Some studies built in exclusion criteria for
surgery, such as cutoff body mass in dex and
American Society of Anesthesiologists classification
values
20,31
; some delayed the pro cedure and/o r
offered counseling and medical services for diabetes,
weight loss/nutrition, exercise, smoking cessation,
obstru ctive slee p apn ea, and n arcot ics/a lco hol
use
21,22,28,31,37,40
; and some developed their own
‘‘pre-habilitation’’ exercise regimens for patients to
follow.
22,27
Although it is unclear how health assessment and
optimization independently contributed to patient
outcomes, previous studies in other surgical special-
ties have shown a link between preoperative comor-
bidities and postoperative outcomes. In a study of
geriatric patients undergoing noncardiac surgery,
Leung and Dzankic
42
showed that patients with
neurologic or cardiovascular comorbidities were at
higher risk of adverse postoperative events. Oresanya
et al
43
similarly reported a correlation between
cognitive impairment, malnutrition, and frailty with
adverse outcomes in geriatric surgical patients.
43
Modified Preoperative Fasting With Carbohydrate
Loading
Traditionally, patients are instructed to begin
fasting the night prior to surgery. But this practice
not only lacks scientific backing but also can
Table 5. Summary of early discharge criteria from spine Enhanced Recovery After Surgery (ERAS) protocols.
ERAS Study Surgical Procedure Discharge Criteria
Scanlon and Richards,
19
2004 Lumbar laminectomy for
discectomy
PACU stay of at least 4 hr
Respiratory, energy, alertness, circulation, and temperature (REACT) score
Controlled nausea and/or vomiting
Controlled pain managed with oral medications
Has ambulated and is steady on feet
Stable neurologic status
Stable hemodynamic status
Has voided
Ride is available to take patient home
Discharge instruction provided to patient and caregiver
Neurosurgeon and anesthesiologist each approve discharge
Bradywood et al,
22
2017 Lumbar spinal fusion Has had x-rays
Has passed gas
Understands medications
Understands activity limitations and use of the brace
Understands where to go next
Understands f/u plan
Has had all questions and concerns addressed
Debono et al,
23
2017 Lumbar microdiscectomy Patients discharged upon reaching a score of 9 on the Chung Post-Anesthetic
Discharge Scoring System
Debono et al,
33
2019 ACDF, ALIF, PLIF Patients discharged upon reaching a score of 9 on the Chung Post-Anesthetic
Discharge Scoring System
Soffin et al,
37
2019 ACDF and CDA 5 hr of observation in PACU, after which patient evaluated for discharged by
anesthesia using Aldrete criteria (tolerating regular diet, ambulating without
assistance, adequate pain control on oral analgesics, clear understanding of
f/u plan, contact details in case of event/questions/complications)
Soffin et al,
38
2019 Lumbar decompression
(laminectomy, laminotomy,
microdiscectomy)
Discharge from PACU when patients achieved a modified Aldrete score 9
Abbreviations: ACDF, anterior cervical discectomy and fusion; ALIF, anterior lumbar interbody fusion; CDA, cervical disc arthroplasty; f/u, follow-up; PACU,
postanesthesia care unit; PLIF, posterior lumbar interbody fusion.
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exacerbate the surgical stress response and the
development of postsurgical insulin resistance.
2
As
such, several spine ERAS protocols modified their
preoperative fasting guidelines, instead permitting
consumption of solid foods up to 6 to 12 hours prior
to surgery and liquids up to 2 to 8 hours prior to
surgery.
24,25,33,34,37,39
There is evidence that clear
fluids are safe to ingest up to 2 hours prior to
surgery, and so fasting guidelines have been
changing accordingly since the mid-1990s.
2
Additionally, carbohydrate loading—which in-
volves the oral (PO) or intravenous (IV) adminis-
tration of a carbohydrate fluid (eg, Nutricia
preOp)—usually 2 hours prior to surgery—was
incorporated in to many spine ERAS protocols
(Table 2). The carbohydrate fluid was often but
not always administered in conjunction with the
shortened preoperative fasting regimen. Carbohy-
drate loading has become a staple practice in ERAS
surgery protocols and is thought to help mitigate
postsurgical insulin resistance.
44
A review by Smith
et al
44
of preoperative carbohydrate loading treat-
ments from ERAS surgery protocols found an
association with reduced LOS, b ut not wi th
postoperative complications. Similarly, spine ERAS
protocols that featured carbohydrate loading have
not yielded significant changes in postoperative
complication and/or readmission rates.
25,27,30,32
However, some protocols that included carbohy-
drate loading did report reduced LOS,
28,30,32,34
whereas others denied any significant change in
outcomes.
25,27
Perioperative ERAS Elements
‘‘Preemptive’’ Analgesia
The consumption of nonopioid analgesics prior to
induction has been correlated independently with
decreased pain levels and reduced opioid consump-
tion (known as an opioid sparing effect) after spine
surgery.
45,46
Notably, Kim et al
46
administered a
cocktail of 200 mg of celecoxib, 75 mg of
pregabalin, 500 mg of acetaminophen, and 10 mg
of extended-release oxycodone—as opposed to
conventional morphine for the control group—at
least 1 hour prior to surgery. Patients who received
this preemptive cocktail demonstrated lower visual
analog scale (VAS) and Oswestry Disability Index
values at nearly all POD time points measured.
Furthermore, there were no significant differences in
postoperative complication rates.
46
For spine ERAS protocols, the combination of
acetaminophen PO (usually 1000 mg) and gabapen-
tin PO (usually 300 mg) was commonly administered
to patients on the morning of surgery,
25,30,32,36–39
and
also the night before surgery.
30,32
Other oral analge-
sics, like 200 mg of celecoxib
34
and 150 or 75 mg of
pregabalin,
25,34
were also administered. These anal-
gesic options have been shown to effectively reduce
pain
45–47
and opioid consumption
45
following spine
surgery. For the acetaminophen and gabapentin
combination specifically, Syal et al
48
previously
reported improved postoperative pain scores in
patients who underwent open cholecystectomy,
which suggests that this combination of premedica-
tion may be effective for other types of surgeries.
Indeed, some spine ERAS studies that imple-
mented preemptive analgesia showed decreased use
of postoperative patient-controlled analgesia (PCA)
and/or opioid consumption, even as their associated
surgical procedures varied greatly.
25,27,36,38
These
studies did no t indicate reduced pain s cores,
however.
25,27
In fact, Soffin et al
38
implemented
the a cetaminophen-gabapentin combination yet
found neither reduced pain scores nor reduced
opioid consum ption postoperatively—even wi th
the contribution of other ERAS elements. It seems
that more research regarding the effects of preemp-
tive analgesia on postoperative outcomes in spine
surgery is required.
Intraoperative MMA
The use of intraoperative medications to minimize
postoperative pain is another integral component of
optimizing patient outcomes. A variety of intraop-
erative MMA regimens have been implemented in
the spine ERAS protocols (Table 3). For example,
for spinal metastatic tumor resection surgerie s,
Grasu et al
25
implemented infusions of propofol,
dexmedetomidine, ketamine, and lidocaine, along
with a single upfront IV dose of methadone (0.1–0.2
mg/kg) in opioid-tolerant patients. In contrast, Ali
et al
27
administrated intraoperative NSAIDs, dexa-
methasone, and local bupivacaine in addition to
conventional opioids for various elective spine
procedures.
27
Other common analgesic medications
were used intraoperatively, like acetaminophen
30,32
and other local analge sics.
24,31,34,39,40
Particular
attention was given to modulating the choice of
anesthetics; several studies avoided using general
anesthesia and long-acting agents. When general
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anesthesia was used, propofol appeared to be
preferred among the ERAS studies.
25,30,32,38–40
Moreover , n um er ous non-ERAS studies h ave
investigated whether a multimodal approach to
pain management can limit postoperative pain and
opioid use in spi ne surge ry.
49–52
Loftus et al
49
studied the effe ct of intraoperative keta mine (initial
bolus of 0. 5 mg/kg, fol low ed by infusi on at 10 lg/
kg/min). In th is study, the t reatment g roup
received a loading dose of ketamine prior to
induction and a continuous drip during s urgery.
49
Patients i n this tre atme nt group r equir ed 24% le ss
intraoperative opiate medication; these patients
also consumed 37% less morphine in the 48 hours
following sur gery compared with the control
group.
49
Moreover, at the 6-week follow-up, the
treatment group patien ts reported the same reduc-
tion in pain despite a 71% reduction in opio id
consumption.
49
Tunali et al
50
similarly studied the
efficacy of IV paracetamol (1 g) and dexketoprofen
(50 mg) on postopera tive pain and mor phine
consumpti on f ol l owing lumbar disc sur ger y. Here,
Tunali and colleagues
50
measured VAS scores an d
total morphine consumption in the first 24 hours
after surgery, respecti vely. The authors re ported
that pain scores wer e signi ficantly reduced wit h
dexketoprofen administration but not with para-
cetamol.
50
However, there was no difference in
morphine co nsumpt ion with ei ther medi catio n
when c ompare d to placebo.
50
Later, in a random-
ized controlled s tudy, Ni elsen et al
51
investigated
the administration of preoperative dexamethasone
(16 mg) c om bi ned with intrao per at ive paraceta-
mol, re port i ng t ha t although pain sco res were
significantly r educed in the first 24 hours following
surgery, this diffe rence d issip ated at th e 3-mont h
follow-up. Not ably, there was a 6.5% inci dence of
postoperative infection in the dexamethasone
treatment group, which limi ts the benefi t that this
medicati on can hav e on patie nt s.
51
Finally, Gar g et
al
52
administered ketamine (bolus 0.25 mg/kg
followed by 10 mg/kg/hr infusion) or de xmedeto-
midine (0.5 mg/kg followed by 0.3 mg/kg/hr
infusion) to patients during induction for various
elective s pine procedures.
52
The auth or s reporte d
that patients who received ketamine and dexmede-
tomidine experienced greater pain-f ree periods
during the first 48 hours after surgery, as well as
reduced co ns umpt i on o f r esc ue pain medic at io n,
compared wi th the c ontr ol gr ou p.
52
Minimally Invasive Surgery
The MIS technique is being adopted rapidly in
spine surge ry and involves minimizing intraopera-
tive sof t tissue d i sru pti on and bloo d loss.
53
The
inclusion of MIS in ERAS p athways is ai med at
improving cost-effectiveness and enhancing post-
operative recov ery. P rior research comparin g MIS
TLIF/PLI F w ith the tradi ti ona l o pe n ap pr oac h
suggests that MIS results in reduced hospital
costs,
26,53,54
LOS,
53,55,56
and blood loss.
53,56
How-
ever, the benefits of MIS on overall clinical
outcomes r emain contr oversial,
3,55
with some
studies achiev ing r educed short-term readmissio n
andcomplicationrates,
56
and o th ers fin din g no
additional short- or long-te rm clinical benefits
compared with the open surgic al approach.
53–55
From curren t evi denc e, i t se ems tha t MIS p roc e-
dures are more cos t-effec tive an d yiel d com parable
clinical outcomes.
The MIS approach was adopted by sever al
ERAS prot oc ols for l um bar fusio n o r decompre s-
sion procedures (Tabl e 3). Grasu et al
25
also
employed MIS technique for an ERAS metas tatic
tumor r ese ct i on protoco l. Brusk o et al
29
employed
MIS technique fo r 1- to 3-level p osteri or-only
lumbar fusion surgeries. Debono et al
23
and Soffin
et al
38
pursued a proto col for l umbar micro-
discectomy.
23,38
In ERAS st udi es, MIS techniq ue
involved a smal l incisi on, tubular working channels
and endoscopy, percutaneous screw insertion,
expandabl e cage im pl ants ,
24,26,38–40
and robotic
and microsc op e guida nce .
38–40
Thus far, the use of MIS in spine ERAS studies
has been associa ted w ith va rious positive out-
comes, e speci all y for MIS TLIF procedures (Table
1). For e xa mple , W ang et al
26
reported reduced
intraopera ti ve time, LOS, compl i cati on rate, and
acute care costs, and Feng et al
34
reported reduced
LOS and mean costs but no difference in intraop-
erative time or co mplica tion and readmission rates.
Interestingly, Wang et al
26
were abl e to enhanc e the
cost-e ffectiv eness of MIS TL IF using only 6
perioperative ERAS interventions, 3 of whi ch
pertaine d to an MIS sur gi cal a pp roac h (w orki ng
channel endoscop e, expa ndab le cage, small - cal ib er
percutaneous scre ws). Results by Wang a nd
colleagues
26
suggest t hat the use o f MI S m ay
account signific ant l y for the benefits of ERAS
pathways.
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Maintaining Homeostasis (Blood Loss, Fluids,
Temperature)
Managing body homeostasis during surgery helps to
reduce postoperative complications and enhance the
return of normal bodily functions.
2
In particular,
the management of blood loss, normovolemia, and
normothermia has emerged as a popular inclusion
in ERAS pathways. Minimizing blood loss in turn
can reduce the risk of hypotension, end-organ
damage, and coagulopathy, as well as complications
related to blood transfusions. Maintaining normo-
volemia for patients undergoing major spine surgery
has been associated with reduced blood loss and
transfusion, improved post operative respiratory
function, faster return of bowel function, and
reduced LOS.
57
Conversel y, ove rhyd rati on and
underhydration of the patient intraoperatively have
been associated with increased complications.
2
Monitoring and maintaining body temperature
during surgery is similarly important for postoper-
ative recovery, because hypothermia increases the
risk of wound infection after spine surgery.
58
For blood loss management, tranexamic acid—
which has been reported to decrease bleeding and
transfusions during spine surgery
59
—was adminis-
tered intraoperatively in several spine ERAS path-
ways (Table 3). In the studies, tranexamic acid was
given as an IV bolus before skin incision and as an
infusion through the procedure. Bolus dosage varied
(2 g, 20 mg/kg, 0.5 g/hr, or 1 g prior to incision and
another 1 g over 8 hours)
21,30,31
because optimal
dosing for surgery has not yet been determined.
Other methods of minimizing blood loss include
minimal use of blood transfusions and preoperative
arterial em bolizati on for high-risk bleeding tu-
mors,
25
making available autologous cell-salvage
transfusions,
40
and administering oral iron supple-
ments or iron transfusions for anemic patients prior
to surgery.
34
Consequently, Feng et al
34
and Dagal
et al
32
were able to significantly reduce intraopera-
tive blood loss for MIS TLIF and various major
spine procedures, respectively. Chakravarthy et al
31
also report ed de cre as ed blo od tran sf usi on s for
ERAS patients undergoing major and complex
spine surgeries. Other studies that administered
tranexamic acid did not report a comparative blood
loss measure.
25
For maintaining normovolemia intraoperatively,
a combination of hemodynamic monitoring and as-
needed fluid replacement therapy was used (Table
3). This type of intervention is known as goal-
directed fluid therapy (GDFT).
60
According to the
American Society for Enhanced Recovery, the goal
of GDFT is to achieve a net ‘‘zero-fluid balance’’
(euvolemia) perioperatively in order to reduce
postoperative complications and LOS.
60
Thiele et
al
60
recommend the use of isotonic IV crystalloids
(salt solution with small molecules) for fluid
replacement, which was employed by Chakravarthy
et al.
31
Other ERAS protocols that implemented
GDFT did not specify their method of fluid therapy.
Ljungqvist
2
further recommends the use of a
combination of colloids (which contain larger
molecules) and crystalloids, and warns against the
use of 0.9% saline, which can cause prolonged
postoperative fluid retention. Of note, both Thiele et
al
60
and Ljungqvist
2
formulated their guidelines
based on data from ERAS colorectal surgery. But
there seems to be no consensus for optimal GDFT
for spine surgery.
2,60
Finally, normothermia was monitored and main-
tained intraoperatively in a number of s tudies
(Table 3). Optimal body temperature was set
between 368Cand378C an d wa s mon itored
throughout the pr ocedure. Various method s of
body warming were used intraoperatively, like hot
air blankets, fluid warmers, and a convective
warming device.
Deep Venous Thrombosis, Infection, and
Postoperative Nausea and Vomiting Prophylaxis
Deep venous thrombosis, infection, and postopera-
tive nausea and vomiting (PONV) are postoperative
complications that can significantly hinder patient
recovery. To avoid such complications, prophylactic
measures have been incorporated into spine ERAS
protocols (Table 3). For antithrombotic prophylax-
is, compression stockings/devices and low–molecu-
lar weight heparin were used intraoperatively.
24,35,40
Postoperative thromboprophylaxis has been imple-
mented as well, also in the form of compression
devices, heparin, and early and frequent ambula-
tion.
31,35
Notably, Sivaganesan et al
35
reserved the
use of che moprophylaxis for unc ommon cases,
namely for cases involving combined anterior and
posterior approach, trauma, spinal cord injury,
tumor, and hypercoagulable-state pat ients; only
mechanical prophylaxis was used f or common
elective spine surgeries.
To reduce the risk of infection, several types of
antimicrobial agents and routines have been docu-
mented in the literature. For example, Bradywood
Tong et al.
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et al
22
required that patients take chlorhexidine
showersorbathspriortosurgery,giventhat
preoperative bathing is believed to reduce bacterial
load; Feng et al
34
administered 1.5 g cefuroxime
close to time of incision
34
;andSmithetal
36
administered 2 to 3 g of Ancef, 900 mg of
Clindamycin, or 15 mg/kg Vancomycin.
36
These
interventions were mostly perioperative in nature,
with the exception of the chlorhexidine baths.
For PONV prophylaxis, Soffin and col-
leagues
37–39
employed both perioperative prophy-
laxis and postoperative treatments in a series of
spine ERAS protocols. Perioperatively, patients at
high risk for PONV were given a scopolamine patch
(1.5 g transdermal) in the surgical holding area,
37,39
as well as 4 to 8 mg of dexamethasone on induction
and 4 to 8 mg of ondansetron 30 minutes prior to
emergence from anesthesia.
38
Postoperatively,
PONV was treated with IV metoclopramide (10
mg) or ondansetron (4 mg), plus a scopolamine
patch (1.5 mg transdermal) if PONV was refracto-
ry.
38,39
Carr et al
30
also administered IV ondanse-
tron int ra-operatively as prophylaxis. Bednar
21
administered IV/PO dexamethasone 4 mg every 6
hours postoperatively until discharge.
Catheter and Surgical Drain Sparing
Several spine ERAS protocols emphasized sparing
the use of Foley catheters and surgical site drains—
either avoiding use or performing early removal
(Table 3). The use of Foley catheters and surgical
drains has been associated with postsurgical infec-
tion of the urinary tract and wound site, respective-
ly. To minimize such complications and to facilitate
patient mobility, Ali et al
27
reported significantly
decreased Foley catheter placements intraoperative-
ly, as well as postoperatively for patients without
bed restrictions; however, there was no significant
difference in complication rate (which included
infection rate) in pre-ERAS intervention versus
post-ERAS intervention pati ents in this study.
Staartj e s et a l
40
used surgical drains only for
patients who underwent mini-open decompression
or MIS PLIF procedures; the authors also stressed
the removal of catheters and drains as soon as
possible postoperatively. Likewise, Debono et al
23
and Sivaganesan et al
35
reported no drain use for
lumbar microdiscectomy and various elective spine
surgery procedures, respectively; Debono et al
33
described a drastic reduction in drain use for
ACDF, ALIF, and PLIF procedures; Soffin et al
37
omitted the use of catheters or drains for ACDF
and cervical disc arthroplasty (CDA) surgeries.
37
Wang et al
24
avoided the use of a Foley catheter
altogether. In studies that did not emphasize
catheter or wound drain sparing, most documented
removal on POD1
31,36
or POD2/3
22,30,32
in order to
facilitation mobilization.
Postoperative ERAS Elements
Postoperative Pain Modulation
In addition to perioperative medication regimens
for patients und er goi ng spi ne sur ger y (see t he
‘‘Pr eemptive Analgesi a’’ and ‘‘Intraoper ative
MMA’’ sections), postoperative MMA measures
have bee n imple mented. A varie ty of MMA
combinations have been administered to supplement
PCA opioid consumption. Common elements of a
postoperative MMA cocktail include gabapentin/
pregabalin,
22,24,25,32,34–36,38,39
acetamino-
phen,
22,24,25,27,30,32,37–39
and celecoxib and other
NSAIDs.
22,25,27,33–40
Other nonopioid options in-
clude dexamethasone,
27
paracetamol,
40
and keta-
mine.
28
To maximize opioid sparing, some studies
also avoided the use of long-acting opioids
24,40
and
implemented early discontinuation of PCA.
22
For
various types of lumbar decompression surgeries,
Soffin et al
38
stratified postoperative MMA and
opioid use based on numeric rating scale pain
scores: patients with numeric rating scale scores of 4
or less only received nonopioid interventions
(acetaminophen, ketorolac, gabapenti n); patients
with scores 5 to 7 could receive 50 mg of tramadol;
and patients with scores 8 to 10 received 5 mg of
oxycodone.
38
Interestingly, Soffin and colleagues
found decreased perioperative opioid consumption,
but no significant changes in postoperative pain
scores or opioid consumption compared with the
pre-ERAS control group. For 1- or 2-level lumbar
fusion procedures, Smith et al
36
administered a
postoperative cocktail of 200 mg of celecoxib PO,
300 m g of gabapentin PO, and 975 mg of
acetaminophen PO; the authors reported a decrease
from 7% to 0% in PCA use and a decrease from
14% to 5.2% in the use of long-acting opioids.
Importantly, several research groups have inves-
tigated the effects of postoperative MMA for non-
ERAS spine surgery, which yielded varied out-
comes.
45,47,61,62
In a randomized controlled trial,
Korkmaz et al
61
studied the effect of either IV 1 g of
metamizol, 1 g of paracetamol, or 8 mg of
lornoxicam supplementation after wound closure
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for lumbar disc surgery. These analgesics were
administered in tandem with conventional postop-
erative PCA of morphine.
61
The authors reported
decreased VAS pain scores in the first 24 hours after
surgery for patients who received metamizol and
paracetamol, but not lornoxicam; PCA use in the
paracetamol group also significantly decreased over
time.
61
Other studies demonstrated the postopera-
tive use of MMA pain management with nonsteroi-
dal anti-inflammatories (NSAIDs) and GABA-
acting drugs. Mathiesen et al
45
compared the
administration of a cocktail o f acetaminophen,
NSAIDs, gabapentin, S-ketamine, and dexametha-
sone versus PCA morphine in patients undergoing
spinal fusion surgery. Results suggest that patients
who received the MMA cocktail required less opioid
consumption and could mobilize earlier with
physical therapy compared with control patients
who only depended on PCA morphine.
45
Likewise,
Garcia et al
62
studied the effect of giving celecoxib,
pregabalin, and extended-release oxycodone supple-
mentation for PCA morphine compared with the IV
morphine infusion alone. Total morphine consump-
tion and VAS scores were lower in patients receiving
the MMA regimen compared with control.
62
Final-
ly, a meta-analysis by Yu et al
47
analyzing the use of
pregabalin and gabapentin in the postoperative
period dem onstr ated th at gaba pentin PO was
efficacious in the management of postoperative pain
at all time points on POD1, an d thus may
significantly reduce total opioid consumption with-
out increasing the incidence of adverse effects.
Pregabalin also was found to be efficacious in the
management of postoperative pain, but more trials
were needed to further evaluate its effectiveness.
47
Early Mobilization and Physical Rehabilitation
Early mobilization of the patient is a critical
prerequisite for achieving early discharge, which is
one of the goals of ERAS. Here, early mobilization
is defined as getting the patient out of bed on POD0
or POD1,
63
which may involve physical therapy,
occupational therapy, or other exercises. In a review
of the effects of early mobilization after various
types of surgeries, Epstein
63
described correlations
with reduced morbidity and LOS. However, re-
search on mobilization/rehabilitation following
spine surgery remains scarc e. Ni elsen et a l
64
implemented a pre-habilitation (6- to 8-week exer-
cise regimen and smoking/drinking cessation) and
early rehabilitation program for patients undergo-
ing surgery for degenerative lumbar disease; the
authors reported reduced LOS and impro ved
patient satisfaction for patients who received this
intervention, although postoperative complication
rate and pain did not significantly change.
Although only 1 ERAS protocol included a
‘‘p re- ha bil i tat ion ’’ regimen,
28
many other protocols
encourage early mobiliza tion a nd p rovid ed p hysi-
cal rehabil it atio n se rvi ce s (Tab le 4) . In th e ERA S
protocols, patient mobilization started as early as
less than 90 minutes after ar rival at t he PACU
followin g a l am in ect omy/ lam in ot omy/ mi cro di sce c-
tomy proced ure.
38
Early mobilization g oals includ-
ed independence in performing log roll,
22
movement out of bed and to chair 3 times per
day,
25,39
working with physical therapy/occupa-
tional ther apy,
25,31,36–39
or even being disc harg ed
after surge ry .
20
Most protocols did not provide
much detail b eyond when early mobilization began
and whether physical therapy/occupa tional th era-
py was offer ed ; ev en the n, t he re w as c onsi de rab le
variety in early mobilizat ion requir ements. B ecause
of the paucity of research on this to pic, ther e seems
to be no consensus on whic h fea tur es of ear ly
mobilization and physical rehabilitation are most
beneficial to patient s.
Early Nutrition
Early commencement of postoperative enteral
nutrition is an established ERAS intervention in
other surgical specialties. For instance, in the ERAS
guidelines for colonic resection
2
and rectal/pelvic
surgery,
65
early oral intake of liquids, solids, or
nutritional supplements is recommended.
2
Indeed,
early postoperative enteral nutrition may decrease
postsurgical infection rates, reduce LOS and hospi-
tal cost, and reduce postoperative ileus when
compared to late enteral or parenteral feeding.
66–70
Early nutrition was commonly advised for spine
surgery patients treated under ERAS guidelines
(Table 4). In the spine ERAS protocols, a subset of
studies initiated a clear liquid diet at POD0 or
POD1 that advanced to a regular diet as tolerat-
ed,
22,25,34,40
whereas others permitted a regular diet
of solids and liquids on POD0 or POD1.
30,32,36,38–40
Some protocols initiated oral intake as soon as the
patient recovered from anesthesia.
34,37–39
These
early nutrition guidelines were similar across the
different ERAS protocols, regardless of whether the
patients had undergone major or minor surgery.
Tong et al.
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Early Discharge Criteria
Currently, there does not seem to be a consensus on
the criteria for early discharge in spine surgery
(Table 5). This diversity may be due in part to the
different spine procedures for which the protocols
were developed. Nevertheless, current ERAS dis-
charge criteria include physical therapy clearance,
pain control, mobility, tolerating diet, and scoring
systems such as the Aldrete
37
and Chung postanes-
thetic discharge scoring system.
23,33,71
CONCLUSIONS
Research on ERAS protocols for spine surgery is
still in the nascent stages. Although there are
commonalities between existing spine ERAS proto-
cols, there is also much diversity. Notably, studies
included in this review varied in their methodology,
the number of ERAS interventions per protocol, the
types of spine surgery, and the degree to which their
data were analyzed and reported. In turn, this
review was limited in its ability to assess the efficacy
of ERAS protocols.
Overall, ERAS protocols seem to improve cost-
effectiveness without compromising the quality of
patient care. MMA administration as an ERAS
intervention may be linked directly to decreased
opioid consumption, which was reported in several
studies included in this review. Moreover, MMA
administration has been associated independently
with decreased opioid consumption in a non-ERAS
setting. Study outcomes suggest that improved cost-
effectiveness may be achievable through ERAS, in
particular via reductions in LOS, cost, and opioid
consumption.
Currently, it is difficult to isolate the effect of any
one ERAS element on patient outcome; it is also
difficult to determine whether ERAS would be more
successful for particular spine surgeries. Different
spine procedures vary in their expected surgical
stress levels and recovery rates, and the age and
comorbidity status of patients vary as well; different
ERAS interventions may then disproportionately
benefit certain patient populations compared with
others. However, these distinctions have not been
made yet in the literature; in fact, in most studies,
the same ERAS protocol was implemented across a
number of different spine procedures.
From a review of the relevant studies, it is clear
that much investigation is still needed to determine
the ideal ERAS elements that are more effective for
particular patient populations, spine surgeries, and
pathology—such as deformity, tumor resection, and
degenerative spine. Focused studies in these areas
may allow for more ac curat e analyses o f the
effectiveness of particul ar ERAS elements . As
research on spine ERAS pathways grows, greater
consensus and protocol standardization may be
achieved to benefit patient care.
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Disclosures and COI: The authors received no
funding for this study and report no conflicts of
interest.
Corresponding Author: Jeffrey M. Spivak,
MD, Langone Orthopedic Hospital, 301 East 17th
Street, New York, NY 10010. Phone: (646) 501-
Published 28 August 2020
This manuscript is generously published free of
charge by ISASS, the International Society for the
Advancement of Spine Surgery. Copyright Ó 2020
ISASS. To see more or order reprints or permis-
sions, see http://ijssurgery.com.
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