Clinical utility of enhanced recovery after surgery pathways in pediatric spinal deformity surgery: systematic review of the literature

Zach Pennington Departments of Neurosurgery and

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Ethan Cottrill Departments of Neurosurgery and

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Daniel Lubelski Departments of Neurosurgery and

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Jeff Ehresman Departments of Neurosurgery and

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Kurt Lehner Departments of Neurosurgery and

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Mari L. Groves Departments of Neurosurgery and

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Paul Sponseller Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

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Daniel M. Sciubba Departments of Neurosurgery and

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OBJECTIVES

More than 7500 children undergo surgery for scoliosis each year, at an estimated annual cost to the health system of $1.1 billion. There is significant interest among patients, parents, providers, and payors in identifying methods for delivering quality outcomes at lower costs. Enhanced recovery after surgery (ERAS) protocols have been suggested as one possible solution. Here the authors conducted a systematic review of the literature describing the clinical and economic benefits of ERAS protocols in pediatric spinal deformity surgery.

METHODS

The authors identified all English-language articles on ERAS protocol use in pediatric spinal deformity surgery by using the following databases: PubMed/MEDLINE, Web of Science, Cochrane Reviews, EMBASE, CINAHL, and OVID MEDLINE. Quantitative analyses of comparative articles using random effects were performed for the following clinical outcomes: 1) length of stay (LOS); 2) complication rate; 3) wound infection rate; 4) 30-day readmission rate; 5) reoperation rate; and 6) postoperative pain scores.

RESULTS

Of 950 articles reviewed, 7 were included in the qualitative analysis and 6 were included in the quantitative analysis. The most frequently cited benefits of ERAS protocols were shorter LOS, earlier urinary catheter removal, and earlier discontinuation of patient-controlled analgesia pumps. Quantitative analyses showed ERAS protocols to be associated with shorter LOS (mean difference −1.12 days; 95% CI −1.51, −0.74; p < 0.001), fewer postoperative complications (OR 0.37; 95% CI 0.20, 0.68; p = 0.001), and lower pain scores on postoperative day (POD) 0 (mean −0.92; 95% CI −1.29, −0.56; p < 0.001) and POD 2 (−0.61; 95% CI −0.75, −0.47; p < 0.001). There were no differences in reoperation rate or POD 1 pain scores. ERAS-treated patients had a trend toward higher 30-day readmission rates and earlier discontinuation of patient-controlled analgesia (both p = 0.06). Insufficient data existed to reach a conclusion about cost differences.

CONCLUSIONS

The results of this systematic review suggest that ERAS protocols may shorten hospitalizations, reduce postoperative complication rates, and reduce postoperative pain scores in children undergoing scoliosis surgery. Publication biases exist, and therefore larger, prospective, multicenter data are needed to validate these results.

ABBREVIATIONS

AIS = adolescent idiopathic scoliosis; ERAS = enhanced recovery after surgery; LOS = length of stay; NMS = neuromuscular scoliosis; PCA = patient-controlled analgesia; POD = postoperative day; PRO = patient-reported outcome; PT = physical therapy.

OBJECTIVES

More than 7500 children undergo surgery for scoliosis each year, at an estimated annual cost to the health system of $1.1 billion. There is significant interest among patients, parents, providers, and payors in identifying methods for delivering quality outcomes at lower costs. Enhanced recovery after surgery (ERAS) protocols have been suggested as one possible solution. Here the authors conducted a systematic review of the literature describing the clinical and economic benefits of ERAS protocols in pediatric spinal deformity surgery.

METHODS

The authors identified all English-language articles on ERAS protocol use in pediatric spinal deformity surgery by using the following databases: PubMed/MEDLINE, Web of Science, Cochrane Reviews, EMBASE, CINAHL, and OVID MEDLINE. Quantitative analyses of comparative articles using random effects were performed for the following clinical outcomes: 1) length of stay (LOS); 2) complication rate; 3) wound infection rate; 4) 30-day readmission rate; 5) reoperation rate; and 6) postoperative pain scores.

RESULTS

Of 950 articles reviewed, 7 were included in the qualitative analysis and 6 were included in the quantitative analysis. The most frequently cited benefits of ERAS protocols were shorter LOS, earlier urinary catheter removal, and earlier discontinuation of patient-controlled analgesia pumps. Quantitative analyses showed ERAS protocols to be associated with shorter LOS (mean difference −1.12 days; 95% CI −1.51, −0.74; p < 0.001), fewer postoperative complications (OR 0.37; 95% CI 0.20, 0.68; p = 0.001), and lower pain scores on postoperative day (POD) 0 (mean −0.92; 95% CI −1.29, −0.56; p < 0.001) and POD 2 (−0.61; 95% CI −0.75, −0.47; p < 0.001). There were no differences in reoperation rate or POD 1 pain scores. ERAS-treated patients had a trend toward higher 30-day readmission rates and earlier discontinuation of patient-controlled analgesia (both p = 0.06). Insufficient data existed to reach a conclusion about cost differences.

CONCLUSIONS

The results of this systematic review suggest that ERAS protocols may shorten hospitalizations, reduce postoperative complication rates, and reduce postoperative pain scores in children undergoing scoliosis surgery. Publication biases exist, and therefore larger, prospective, multicenter data are needed to validate these results.

In Brief

Enhanced recovery after surgery protocols have gained a significant foothold in adult general surgery populations for their ability to improve outcomes and reduce costs. In this study the authors systematically review the application of enhanced recovery after surgery protocols to pediatric scoliosis populations and find that these protocols may shorten hospitalizations, reduce complication rates, and reduce postoperative pain. This is the first quantitative analysis of the pediatric enhanced recovery after surgery literature, and it highlights the need for additional, high-quality studies.

Annually more than 7500 pediatric patients undergo surgery for correction of scoliotic deformity1 at an estimated cost of $60,000–$180,000 per patient.2,3 Of note, although the overall population is small, data suggest that the costs associated with surgical intervention are increasing, with a national annual bill of $1.1 billion in 2012.4 Because of this rising cost and the increased incentive being placed on value-based care, there has been interest on behalf of surgeons, patients, and payors in how to reduce overall spending. Cost analyses have demonstrated that facility costs (including implants), length of stay (LOS) in the intensive care unit, and inpatient room costs account for the bulk of spending on pediatric scoliosis surgery episodes of care.4–6 As a result, expediting patient discharge may constrain cost increases.7 Analysis of population-level all-payer data suggests that this has been occurring nationwide without negative effects on patient morbidity.8

Pursuant to this drive to reduce LOS, there has been interest in developing streamlined care pathways capable of accelerating patient discharge. Enhanced recovery after surgery (ERAS) pathways are now being applied to both adult9,10 and pediatric spine surgery populations.11–17 Despite the growing body of evidence, no quantitative review exists summarizing the existing literature on outcomes of pediatric spinal deformity ERAS protocols. To address this, we report a systematic review of the literature on ERAS for pediatric scoliosis to 1) identify the components of previously described pediatric spine ERAS protocols; 2) determine whether ERAS protocols reduce LOS, complication rates, and costs in pediatric patients with scoliosis; and 3) highlight areas for continuing investigation in pediatric spine ERAS interventions.

Methods

We conducted a literature search on March 22, 2020, using the following search string, which was modified to fit the input of each of the queried databases: (eras OR “enhanced recovery after surgery” OR “fast recovery” OR “fast track”) AND (spine OR spinal OR “spine surgery” OR “laminectomy” OR “interbody fusion” OR “diskectomy” OR “discectomy” OR “spinal fusion”). Queried databases included PubMed/MEDLINE, Web of Science, the Cochrane Reviews library, EMBASE, CINAHL, and OVID MEDLINE. Additionally, we queried the bibliographies of included studies for additional relevant articles.

To be included, articles had to meet the following criteria: 1) describe the application of an ERAS protocol to 5 or more pediatric patients undergoing elective surgery for scoliotic deformity; 2) include only patients age 18 years or younger; and 3) report results for at least one of the following outcomes: LOS/hospitalization, complication rate, postoperative pain scores, postoperative opioid use, or postoperative quality of life/patient-reported outcomes (PROs). We defined ERAS protocols as those implementing at least 2 interventions across the surgical population (e.g., multimodal analgesia and early mobilization); single interventions (e.g., early mobilization alone) were not classified as ERAS protocols. We excluded articles for the following reasons: only abstracts were available; no primary data were provided (i.e., articles were reviews, opinion pieces, commentaries, perspectives, or technical notes); or the study population included both adult and pediatric patients. Articles were screened using Covidence software and were assigned levels of evidence based on the classification adopted by the North American Spine Society.18 Articles were independently screened by 2 reviewers (Z.P. and E.C.), with a third reviewer (J.E.) serving as referee in cases of disagreement.

Quantitative Analysis

Our quantitative analysis included all studies that directly compared outcomes between patients treated using conventional care and ERAS protocols. All quantitative analyses were performed using RevMan 5.3 (Cochrane) using random-effects modeling. Risk ratios were used for dichotomous outcomes and mean differences (± SD) were used for continuous outcomes.

Results

We identified 950 unique articles, of which 67 underwent full-text review, yielding 7 articles for inclusion in the qualitative analysis11–17 and 6 articles for inclusion in the quantitative analysis11,13–17 (Fig. 1). Reasons for exclusion were as follows: describing adult patients (n = 27), being abstracts only (n = 19), failing to present primary data (n = 12), failing to describe the ERAS protocol (n = 1), and lacking full-text English translation (n = 1). Of the included studies, 6 were level III11,13–17 and 1 was level IV.12

FIG. 1.
FIG. 1.

PRISMA flow diagram for the results of the literature search. Figure is available in color online only.

Qualitative Synthesis

The 7 identified studies11–17 included 592 pediatric patients with scoliosis treated under 6 distinct protocols (Table 1). Six studies examined patients undergoing treatment for adolescent idiopathic scoliosis (AIS),12–17 with the remaining study examining ERAS implementation in patients being treated for neuromuscular scoliosis (NMS).11 The most common elements in the described ERAS protocols were as follows: multimodal, opioid-sparing analgesia during the intraoperative or postoperative period (5 studies);12–16 urinary catheter removal within 24–48 hours postoperatively (7 studies);11–17 early patient-controlled analgesia (PCA) discontinuation (6 studies);11,13–17 early surgical drain removal (3 studies);11–13 early resumption of enteral feeding (5 studies);11–13,16,17 implementation of a postoperative bowel regimen (3 studies);12,16,17 and early postoperative mobilization (6 studies).11,12,15–17 Six studies11,13–17 directly compared patients treated under ERAS and conventional pathways. The most commonly identified benefits were shorter LOS (6 studies),11,13–17 earlier urinary catheter removal (2 studies),14,16 earlier PCA discontinuation (2 studies), and lower 30-day reoperation rates (2 studies).13,17 Studies examining PROs found ERAS-treated patients to have decreased postoperative pain scores (2 studies)14,17 and increased satisfaction with their care.16 Additionally, Sanders et al.17 performed a cost analysis and found that ERAS implementation was associated with a significant reduction in total costs of care.

TABLE 1.

Summary of ERAS protocols compared with conventional care in pediatric spine surgery

Authors & YearNo. of PtsSurgery TypePopulation DetailsProtocolResults*
Bellaire et al., 201911 (level III)42Posterior fusion for NMSComparison of 42 pts treated under ERAS pathway to 30 historical controls treated w/ standard carePreopEBL: 38% lower; 850 ± 468 vs 526 ± 293 mL; p = 0.002
All pts w/ NMS secondary to level 4 or 5 cerebral palsy; groups comparable in palsy severity, baseline feeding & respiratory status, curve severity, & baseline neurological & orthopedic comorbidities NoneOp time: 4.6 ± 0.9 vs 4.9 ± 1.0 hrs; NS
IntraopLOS: 4.0 ± 1.5 vs 4.9 ± 1.4 days; p = 0.015
 NoneICU time: 3.3 ± 2.0 vs 3.1 ± 1.4 days; NS
PostopCR: 33% vs 52%; NS
 Baseline diet on POD 1Foley removal: 1.5 ± 1.1 vs 1.9 ± 1.2 days; NS
 Stop PCA on POD 1 & start PO analgesiaTime to PT: 1.4 ± 1.1 vs 1.7 ± 1.1 days; NS
 Remove Foley on POD 1Stop PCA: 1.5 ± 1.1 vs 1.8 ± 1.0 days; NS
 Remove drain on POD 1WI rate: 13.6% vs 10%; NS
 Start PT on POD 1Readmit rate (30 days): 23.9% vs 6.7%; NS
 D/c from hospital on POD 3–4Reop rate (90 days): 10% vs 7%; NS
Chan et al., 201712 (level IV)74Posterior fusion for AISNo comparison groupPreopEBL: 824.3 ± 418.2 mL
Prospective series of 74 pts w/ AIS undergoing surgical correction using ERAS protocol Aerobic exercise regimenOp time: 2.2 ± 0.3 hrs
 Folate supplementationLOS: 86.2 ± 14.4 hrs
 Support groupFoley removal: 18.7 ± 4.8 hrs
IntraopTime to PT: sitting @ 20.6 ± 9.1 hrs; ambulation @ 27.2 ± 0.5 hrs
 IV dexamethasone & ondansetron for nausea prophylaxisTime to PO analgesia: 81.1% by 36 hrs
 Fentanyl/morphine bolus prior to emergence
 Tranexamic acid (20 mg/kg)
 Local bupivacaine
 Infection prophylaxis w/ 1.5 g IV cefuroxime
Postop
 Multimodal analgesia
 Liquid diet POD 0; soft foods POD 1
 Foley removal POD 1
 IV cefuroxime POD 1
 Drain removal when output <200 mL/day
 Mobilization POD 1–2
 Bowel regimen
Fletcher et al., 201713 (level III)105Single-stage posterior fusion for AISComparison of 105 pts undergoing posterior fusion under ERAS pathway & 45 contemporary controls treated w/ conventional pathwayPreopEBL: median 275 vs 350 mL; NS
Populations comparable in age, major thoracic curves; ERAS cohort had lower implant density & shorter fusion constructs Hospital tour & anesthesia consultationOp time: median 187 vs 235 mins; p < 0.001
 Preop skin preparation w/ chlorhexidineLOS: median 2.17 vs 4.21 days; p < 0.001
IntraopCR: 7.6% vs 20%; p = 0.03
 NoneWI rate: 7.0% vs 11.0%; NS
PostopReop rate (30 days): 0.9% vs 8.9%; p = 0.03
 Stop PCA & start PO analgesia POD 1
 Multimodal, opioid-sparing analgesia
 Remove Foley POD 1
 Resume regular diet POD 1
 Remove drain POD 1–2
 D/c from hospital POD 2–3
Gornitzky et al., 201614 (level III)58Posterior fusion for AISComparison of 58 pts undergoing posterior fusion for AIS using ERAS pathway & 80 historical controls managed using traditional carePreopLOS: 3.5 ± 0.8 vs 5.0 ± 0.8 days; p < 0.001
Pts similar in age, sex, & weight NoneFoley removal: 1.5 ± 0.5 vs 2.0 ± 0.4 days; p < 0.001
IntraopStop PCA: 2.0 ± 0.6 vs 3.6 ± 0.8 days; p < 0.001
 NoneReadmit rate (30 days): 5.2% vs 2.5%; NS
PostopLower opioid consumption POD 0 (p < 0.001)
 Multimodal opioid-sparing analgesiaLower pain scores POD 0–2 (all p < 0.03)
 POD 0 mobilizationSimilar antiemetic use
 Begin PO analgesia POD 1
 Stop PCA POD 2
 Remove Foley POD 2
 D/c from hospital POD 2–3
Muhly et al., 201615 (level III)84Posterior fusion for AISComparison of 84 adolescent pts treated w/ ERAS & 134 historical controls treated w/ conventional care pathway; 104 additional pts represented a transition populationPreopLOS: 4 vs 5.7 days; p < 0.05
Populations comparable in age, weight, & sex makeup NoneReop rate (30 days): 3.6% vs 2.9%; NS
IntraopAdherence to pathway ≥86% for studied elements
 NoneLower POD 0–1 pain scores; NS
Postop
 Mobilization POD 0
 Multimodal, opioid-sparing analgesia
 Transition to PO analgesia, POD 1
 Stop PCA POD 2
 Remove Foley POD 2
 Goal of d/c on POD 3
Rao et al., 201716 (level III)139Posterior fusion for AISComparison of 139 pts treated using ERAS protocol (100 under 1st version; 39 under revised version) & 51 historical controls treated using conventional carePreopControl vs second protocol
Populations comparable in age, height, weight, & curve severity NoneOp time: 4.7 ± 1.0 vs 2.9 ± 3.7 hrs; p < 0.001
IntraopLOS: 83 ± 27 vs 98 ± 23 hrs; p < 0.05
 IV cefazolin for infection prophylaxisCR: 3% vs 12%; NS
PostopFoley removal: 42.1 ± 13.6 vs 57.4 ± 15.7 hrs; p < 0.001
 Multimodal, opioid-sparing analgesia; start PO POD 0; full PO regimen by POD 3Stop PCA: 43.9 ± 11.1 vs 55.6 ± 15.0 hrs, p < 0.01; equal postop pain scores POD 0–4
 Stop PCA POD 1–2, as toleratedLess time to sitting (40.2 ± 15.4 vs 28.4 ± 13.6 hrs; p < 0.001)
 Clear liquid diet POD 1, advance as tolerated; regular diet POD 3Higher patient satisfaction w/ care & information; better patient comfort (all p < 0.05)
 Remove Foley POD 1 or when epidural catheter stopped
 Incentive spirometer
 Sitting POD 1; walk POD 2
 Hemovac removal POD 2
 IV cefazolin for infection prophylaxis until drain removed
 Stop epidural analgesia POD 3
Sanders et al., 201717 (level III)90Single-stage posterior fusion for AISComparison of 90 pts treated under ERAS pathway & 194 historical controls managed w/ traditional carePreopEBL: 479.7 vs 586.6 mL; p = 0.03
Groups comparable in age, sex makeup, construct length, primary curve severity, & ASA score Pt education & expectation managementOp time: 252.0 vs 275.9 mins; p = 0.04
Longer FU in traditional care pathwayIntraopLOS: 3.7 ± 0.9 vs 5.0 ± 1.3 days; p < 0.01
 NoneCR: 2.2% vs 5.5%; NS
PostopWI rate: 3.3% vs 3.6%; NS
 Sitting POD 0Reop (any) rate: 2.2% vs 9.3%; p = 0.03
 Clear liquids POD 0Return to ED (90 days): 4.4% vs 1.0%; NS
 Ambulation POD 1Lower total costs by $5280; p < 0.01
 Remove Foley POD 1Higher pain scores POD 2–4 (all p < 0.01)
 Stop PCA POD 1
 High-fiber PO diet POD 1

ASA = American Society of Anesthesiologists; CR = complication rate; d/c = discharge; EBL = estimated blood loss; ED = emergency department; FU = follow-up; IV = intravenous; NS = not significant; PO = per os (by mouth); pt = patient; readmit = readmission; WI = wound infection.

Values are expressed as the mean ± SD unless otherwise noted.

Quantitative Synthesis

All 6 comparative studies11,13–17 were included in the quantitative analysis. ERAS protocols were associated with decreased LOS (−1.12 days, 95% CI −1.51, −0.74; Fig. 2A) and a lower complication rate (OR 0.37, 95% CI 0.20, 0.68; Fig. 2B). There were no significant differences between groups in wound infection rate (Fig. 2C), 30-day readmission rate (Fig. 2D), or reoperation rate (Fig. 2E). Evaluation of pain outcomes demonstrated no difference between groups in time to discontinuation of PCA (Fig. 3A). Immediate postoperative pain scores were lower in the ERAS group (−0.92, 95% CI −1.29, −0.56; Fig. 3B). Pain scores did not differ significantly between groups on postoperative day (POD) 1 (Fig. 3C); however, POD 2 pain scores were significantly lower in the ERAS group (−0.61, 95% CI −0.75, −0.47; Fig. 3D).

FIG. 2.
FIG. 2.

Forest plots showing ERAS protocols were associated with the following: a decrease in LOS/hospitalization (A); a decrease in perioperative complication rate (B); no change in wound infection rate (C); no change in 30-day readmission rate (D); and no change in reoperation rate (E). M-H = Mantel-Haenszel. Figure is available in color online only.

FIG. 3.
FIG. 3.

Forest plots showing ERAS protocols were associated with the following: no change in time to PCA discontinuation (A); lower immediate postoperative pain scores (B); no change in POD 1 pain scores (C); and lower POD 2 pain scores (D). Figure is available in color online only.

Discussion

Herein we present the first systematic review and quantitative analysis of the literature evaluating the use of ERAS protocols in pediatric patients undergoing surgical correction of scoliotic deformity. We found that ERAS implementation was associated with a 1.12-day reduction in average LOS, a 63% lower complication rate, and significantly lower postoperative pain scores on POD 0 (−0.92 points) and POD 2 (−0.61 points). These benefits occurred without increases in wound infection rate, 30-day readmission rate, or overall reoperation rate. However, it must be noted that all series included in the quantitative review prioritized early discharge as part of their protocol, raising the possibility that similar benefits could be achieved without implementing all other aspects of the ERAS protocol. Similarly, with the exception of the work by Fletcher et al.,13 all studies included in the quantitative analysis used historical controls, meaning that the observed benefits could be due to selection bias. Based on the results of Fletcher et al., however, it does not appear that the decreases in LOS or postoperative complications suffer from selection bias, because the authors of that study reported both outcomes to be superior in the ERAS-treated patients. Nevertheless, their study did not record postoperative pain scores, and so there exists the possibility that these suffer from selection bias. In this regard, we also note that although the postoperative pain scores were superior in the ERAS group from a statistical standpoint, the difference does not meet previously published values for the minimum clinically important difference in the visual analog scale score for back pain (−1.2 to −2.0).19 Therefore, the difference in pain outcomes between patients treated under ERAS and conventional care protocols may be clinically insignificant.

We also examined reductions in costs of care among patients treated with ERAS protocols. Only one such analysis was identified:17 a small study demonstrating a $5000/case (22%) reduction in costs among 90 ERAS-treated patients relative to 194 historical controls. Despite the limited quality of these data, they suggest that ERAS is at worst a cost-neutral intervention and at best may lead to significant cost savings. Consequently, the present analysis, as a whole, suggests ERAS implementation to be a cost-effective means of safely accelerating discharge in pediatric patients undergoing surgery for scoliosis. Although increasing cost-effectiveness remains a focus across the field of spine surgery, reducing costs and improving outcomes is of particular importance in the pediatric deformity population. Surgery for pediatric deformity correction is among the most expensive pediatric procedures, with an estimated cost of up to $180,000 per patient.2,3 Additionally, because patients have the expectation of a long postoperative survival, identifying interventions to reduce spending and improve outcomes is in the best interest of patients, providers, and payors.

ERAS Protocols in Spine Surgery

First described in the cardiac literature in the 1990s,20 ERAS protocols have gained significant acceptance within the general surgery literature. Benefits including shorter hospitalization times, lower readmission rates, and lower costs have been described in multiple specialties within general surgery, including colorectal surgery,21 hepatobiliary surgery,22 urology,23 and thoracic surgery.24 Subsequently, several studies were published describing the implementation of ERAS in adult9,10 and pediatric spine surgery patients.11–17 In one of the first papers, Muhly et al.15 outlined a “rapid recovery pathway” for children undergoing surgery for idiopathic scoliosis at a tertiary care center. The authors observed significant reductions in LOS and postoperative pain scores. Importantly, this occurred without increases in readmission rates, suggesting that the pathway could safely accelerate patient discharge. Others have shown similar findings.11,13,14,16,17

It must be noted that all of these studies are retrospective in nature, and the majority have used retrospective control groups, significantly limiting the ability to generalize based on these results. Nevertheless, as mentioned previously, Fletcher et al.13 performed a retrospective review using a contemporary control cohort and found that their ERAS protocol reduced LOS by 48% in 105 patients undergoing surgery for AIS. The authors13 additionally showed a nearly 3-fold reduction in complications among the group treated with the ERAS protocol (7.1% vs 20%), driven primarily by reductions in revision surgery (0% vs 6.7%) and superficial wound infections (5.9% vs 8.9%). The authors do not explain how the ERAS protocol was able to mitigate these reductions. However, the lower infection rate may be due to earlier drain discharge, which has been tied to lower infection rates in the adult literature.25 Alternatively, earlier discharge home may remove patients from potential sources of infection, such as hospital staff. Staff interactions and daily wound checks carry the potential for wound contamination.26 Consequently, by expediting discharge and reducing the total number of postoperative wound checks, ERAS protocols may lower the potential for wound inoculation and subsequent infection.

Bellaire and colleagues11 similarly found that ERAS implementation significantly reduced complications in a population of 72 pediatric patients undergoing posterior instrumented fusion for NMS (33% vs 52%). However, in this study the biggest difference was in rates of pulmonary complications (21% vs 38%), probably due to more aggressive early postoperative mobilization. Neither Rao et al.16 nor Sanders et al.17 found ERAS implementation to mediate significant reductions in postoperative complications, although rates were lower in the ERAS group in the Rao study. The data are therefore too limited to draw conclusions about the exact mechanism by which ERAS reduces postoperative complications. Yet based on the present evidence, we speculate that lower complication rates may stem from more aggressive postoperative mobilization and an overall reduction in staff interactions, lowering the risk of wound site inoculation.

Second, prolonged LOS is directly tied to increased costs. Elsamadicy et al.32 retrospectively reviewed an all-payer database of 3759 adolescent patients undergoing posterior fusion for AIS. Comparing outcomes between those with prolonged LOS (defined as LOS > 6 days) and those with normal LOS showed a significant cost savings in the cohort with shorter hospitalizations. These savings approached $19,000 per patient, or roughly a 26% cost savings. Based on the results of our review and recent estimates of hospital costs for admitted inpatients ($2000–$2650/day) by the Kaiser Foundation,33 we would estimate that the savings that could be realized by ERAS implementation would fall short of this at $2200–$3000 per patient. Nevertheless, given the thousands of patients who undergo surgery for pediatric scoliosis each year,1 there could be significant cost savings for the healthcare system as a whole.

Developing ERAS Protocols for Pediatric Patients With Scoliosis

As suggested by the findings in Table 2, there exists a relatively large amount of heterogeneity with regard to what should be included in an ERAS protocol. All included studies reported early postoperative mobilization and physical therapy (PT), along with early resumption of the patient’s regular diet, usually in a graded fashion (e.g., “sips and chips” followed by clear liquids, etc.). Most studies also used multimodal analgesia and early transition from the intravenous PCA to an oral pain regimen. Use of multimodal analgesia is supported by level I evidence in the pediatric spine surgery population.34,35 Two randomized controlled trials34,35 have shown benefit with postoperative gabapentin in reducing pain scores and decreasing narcotic consumption. Retrospective cohort studies have similarly provided support for the inclusion of acetaminophen36 and NSAIDs, such as ketorolac,37,38 in postoperative multimodal pain regimens. Although NSAIDs have been suggested to increase pseudarthrosis risk,39 more recent evidence from the pediatric spine literature has shown short-term NSAID usage to not impact long-term fusion outcomes.40,41 Alternative analgesia modalities have also been explored, including intrathecal morphine injection42 and the use of epidural catheters for morphine delivery.43,44 Intrathecal morphine appears to reduce overall narcotic usage relative to PCA alone,42 and also appears to produce less respiratory depression42 and allow for quicker ambulation and urinary catheter removal relative to epidural analgesia.43,44

TABLE 2.

Comparison of ERAS protocols in the included studies

Study*
ERAS Protocol1234567
Preop phase
 Aerobic exercise regimen
 Oral medication (hematinic) regimen to increase hemoglobin levels
 Back strengthening & flexibility exercise regimen
 Enrollment in scoliosis support group
 Patient education regarding postop course (e.g., pain management & mobilization)
 Preop multimodal analgesia (e.g., acetaminophen & gabapentin)
Intraop phase
 Cell salvage to reduce transfusion requirements
 Local analgesia w/ subcutaneous amino amide anesthetic (e.g., bupivacaine)
 Prophylactic IV antibiotics
 Goal-directed fluid repletion (target MAP ≥60 mm Hg)
 Dual antiemetic prophylaxis (e.g., dexamethasone & ondansetron)
 Intrathecal morphine
Postop phase
 Early return to regular diet (target POD 1–2)
 Early mobilization & PT (start POD 1–2)
 Multimodal analgesia (e.g., acetaminophen, opioids, ketorolac, &/or benzodiazepines)
 Transition from PCA to oral analgesia regimen (target POD 1–2)
 Bowel regimen
  Inpatient
  Outpatient
 Antiemetic prophylaxis (e.g., ondansetron)
 Incentive spirometer
 Postop IV antibiotic prophylaxis
Catheter/drain management
 Early Foley removal (target POD 1)
 Early surgical drain removal (target POD 1–2)

MAP = mean arterial pressure.

1 = Bellaire et al., 201911; 2 = Chan et al., 201712; 3 = Fletcher et al., 201713; 4 = Gornitzky et al., 201614; 5 = Muhly et al., 201615; 6 = Rao et al., 201716; 7 = Sanders et al., 201717.

Rao et al. used epidural analgesia versus PCA in some patients.

Most protocols also included expedited removal of indwelling urinary catheters and surgical drains. Prolonged indwelling time for drains has been associated with increased infection risk in the adult spine populations,25 and prolonged indwelling time for urinary catheters has been associated with increased risk of urinary tract infection in multiple surgical populations.45,46 Beyond these interventions, there was significant heterogeneity in what elements were included in the ERAS protocol. This is consistent with findings reported by qualitative reviews of the adult spine ERAS literature,20,47,48 which raises the question of what should be included in an ERAS protocol. Preliminarily, it would be recommended that protocols should comprise those interventions supported by high-quality data. However, level I and level II evidence is difficult to generate in surgical and pediatric populations. There is level I evidence supporting the use of high-dose tranexamic acid (> 20 mg/kg) for reducing intraoperative blood loss in the adolescent scoliosis surgery population.49,50 Similarly, there is level I evidence suggesting that an intraoperative one-time dose of dexamethasone (0.15 mg/kg) can reduce postoperative nausea and vomiting.51 Consequently, we would recommend the inclusion of these interventions in care pathways for pediatric patients with scoliosis.

There is little high-quality evidence for other interventions in the pediatric scoliosis literature. There are multiple retrospective studies that support the use of preoperative intravenous antibiotic prophylaxis,52 local analgesia with amino amide anesthetics (e.g., bupivacaine) delivered via percutaneous catheters to reduce postoperative opioid use,53,54 and intraoperative cell salvage to minimize allogeneic transfusion requirements.55,56 We find all of these interventions to be reasonable parts of an ERAS pathway, although higher-quality evidence is required to make definitive recommendations regarding their routine use. Similarly, preoperative autologous blood donation appears to reduce allogeneic transfusion rates; however, the evidence appears somewhat equivocal, limiting recommendations regarding its use.57–60 Additionally, the cost-effectiveness of this intervention is unclear in light of improved perioperative blood management strategies (e.g., intraoperative cell salvage).58 At present, level II evidence does not support the routine use of preoperative bowel preparation in the pediatric spine surgery population.61 Investigation into the implementation of postoperative bowel regimens has been conducted, but poor patient compliance appears to be a limitation to this intervention.62 There is also insufficient evidence to recommend routine mechanical venous thromboembolism prophylaxis versus no intervention. However, for patients at high risk for venous thromboembolism, there is weak evidence to suggest that mobilization and mechanical prophylaxis provide similar outcomes to chemoprophylaxis.63 This further supports the inclusion of early mobilization in ERAS protocols. Several of the aforementioned interventions were used in the protocol of Chan et al.,12 who reported good overall outcomes in their cohort of 74 AIS patients undergoing posterior fusion. However, they did not include a comparison group receiving the conventional care pathway, and interventions were implemented as an entire ERAS pathway, so the size of the benefit conferred by each intervention is unclear.

Effective preoperative patient and parent education also appears to mediate superior postoperative PROs. It is likely that the establishment of a therapeutic bond between the surgeon, the patient, and the family decreases patient and family anxiety and produces a better matching of preoperative expectations to postoperative outcomes. Rhodes et al.64 provided evidence supporting this in a prospective study of 65 patients with AIS randomized to standard preoperative counseling or an interventional preoperative education and orientation course. Both the patients and the parents of patients enrolled in the course reported higher satisfaction than those in the control group, although the difference in parental satisfaction did not reach significance.

Considering these data, we argue that effective ERAS protocols should include interventions in all 3 phases of care: preoperative, intraoperative, and postoperative. Preoperatively, we believe that patients and parents should be educated about the patient’s condition and the expected outcomes of surgery to help manage expectations and improve postoperative satisfaction. Intraoperative cell salvage should be considered to reduce intraoperative blood loss and transfusion risk, and lower implant densities may be considered for certain populations (e.g., patients with Lenke 1 curves) to reduce operating time, blood loss, and care costs.65,66 Postoperatively, patients should undergo early mobilization and PT, early diet advancement, and early removal of urinary catheters and surgical drains. Multimodal postoperative analgesia should be pursued, including gabapentin and a short course of NSAIDs. Additionally, the use of intrathecal morphine and local analgesia with amino amide anesthetics (e.g., bupivacaine) can potentially improve postoperative pain, decrease opioid use, and expedite discontinuation of PCA. We have summarized these interventions into a proposed “best practices” ERAS protocol, which is presented as Table 3.

TABLE 3.

Proposed “best practices” ERAS protocol based on the studies identified in the present review

Intervention by Phase
PreopIntraopPostop
Pt & parent education & expectation managementIntraop cell salvage (autotransfusion) to lower allogeneic transfusion riskEarly mobilization & PT (POD 1 or as soon as safe)
Multimodal analgesia including acetaminophen & gabapentinLenke 1 curves—consider using lower implant densityEarly resumption of regular diet (POD 1 or as soon as pt can tolerate)
Prophylactic IV antibiotics (e.g., cefazolin, cefuroxime)Multimodal analgesia including acetaminophen, ketorolac, gabapentin/pregabalin, & opioids (as needed)
Local analgesia w/ amino amide anesthetics (e.g., bupivacaine)Early PCA discontinuation & transition to oral analgesia regimen (target POD 1–2)
Antiemetic prophylaxis (e.g., ondansetron)
Incentive spirometer

Limitations

This study has several limitations. First, the included studies are level III or IV evidence. They all have a moderate to high potential for bias, which limits our ability to apply the present findings to other populations. The limited data quality also prevented us from performing a meaningful quantitative analysis of the ability of ERAS protocols to reduce healthcare spending within the pediatric scoliosis population. Because this is one of the touted benefits of ERAS implementation, the inability to evaluate this outcome highlights the need for additional research. An additional limitation to the present results is that the analysis used a combination of patients with NMS and AIS. Prior evidence suggests that patients with NMS generally have higher complication rates, undergo more invasive surgeries, and have longer hospitalizations.67 However, the interventions included in the NMS ERAS protocol and the AIS protocols showed a significant degree of overlap. Additionally, the analysis examined only differences in complications, LOS, etc., and not absolute rates. Consequently, we thought that these studies could be pooled, thereby giving an estimate of the overall benefit of ERAS implementation in pediatric patients with scoliosis.

The present results are also limited by the fact that only 1 included study15 reported the degree of provider compliance with the ERAS protocol. Although they reported that compliance exceeded 90% for all interventions within 6–9 months of implementation, it is possible that the other studies had lower levels of provider compliance. In such a case, the differences between outcomes under the ERAS and conventional care protocols may have been masked by poor provider compliance, creating the impression of no difference even though the 2 protocols actually resulted in clinically significant differences. For this reason, prospective randomized studies including compliance data are necessary to truly appreciate the impact of ERAS protocols. Last, we found significant heterogeneity across the published ERAS protocols. To reach generalizable conclusions regarding the effectiveness of ERAS for spine surgery, it will be necessary to outline a concrete definition of what should be included in a spine ERAS protocol.

Conclusions

Here we report the first systematic review of the use of ERAS protocols in pediatric patients with scoliosis. Across all studies the most popular ERAS protocol elements were early postoperative mobilization, multimodal postoperative analgesia, early urinary catheter and drain removal, and early diet advancement. We found that ERAS protocol usage was associated with shorter hospitalizations, lower postoperative complication rates, and lower postoperative pain scores. Importantly, these benefits were realized without increases in wound infection, 30-day readmission, or reoperation. Although it is clear that a more homogeneous definition of what defines an ERAS protocol is necessary, these preliminary data suggest that ERAS protocol implementation may result in better overall outcomes for pediatric patients with scoliosis.

Acknowledgments

Mr. Cottrill has an F30 grant from the National Institute on Aging (unrelated to this study). Dr. Sciubba receives grant support from Baxter Medical, North American Spine Society, and Stryker (also unrelated to this study).

Disclosures

Dr. Sponseller is a consultant for Depuy Synthes, OrthoPediatrics, and Pacira. He reports receiving royalties from DePuy Synthes and Globus Medical. Dr. Sciubba is a consultant for Baxter, DePuy Synthes, Globus Medical, K2M, Medtronic, NuVasive, and Stryker.

Author Contributions

Conception and design: Pennington, Cottrill. Acquisition of data: Pennington, Cottrill. Analysis and interpretation of data: Pennington. Drafting the article: Pennington, Cottrill, Lubelski. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Sciubba. Statistical analysis: Pennington. Study supervision: Sciubba.

Supplemental Information

Online-Only Content

Supplemental material is available with the online version of the article.

References

  • 1

    George J, Das S, Egger AC, et al. Influence of intraoperative neuromonitoring on the outcomes of surgeries for pediatric scoliosis in the United States. Spine Deform. 2019;7(1):2732.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Barsdorf AI, Sproule DM, Kaufmann P. Scoliosis surgery in children with neuromuscular disease: findings from the US National Inpatient Sample, 1997 to 2003. Arch Neurol. 2010;67(2):231235.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Vigneswaran HT, Grabel ZJ, Eberson CP, et al. Surgical treatment of adolescent idiopathic scoliosis in the United States from 1997 to 2012: an analysis of 20,346 patients. J Neurosurg Pediatr. 2015;16(3):322328.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Martin CT, Pugely AJ, Gao Y, et al. Increasing hospital charges for adolescent idiopathic scoliosis in the United States. Spine (Phila Pa 1976). 2014;39(20):16761682.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Workman JK, Wilkes J, Presson AP, et al. Variation in adolescent idiopathic scoliosis surgery: implications for improving healthcare value. J Pediatr. 2018;195:213219.e3.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Kamerlink JR, Quirno M, Auerbach JD, et al. Hospital cost analysis of adolescent idiopathic scoliosis correction surgery in 125 consecutive cases. J Bone Joint Surg Am. 2010;92(5):10971104.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Malik AT, Yu E, Kim J, Khan SN. Understanding costs in a 90-day episode of care following posterior spinal fusions for adolescent idiopathic scoliosis. World Neurosurg. 2019;130:e535e541.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Yoshihara H, Yoneoka D. National trends in spinal fusion for pediatric patients with idiopathic scoliosis: demographics, blood transfusions, and in-hospital outcomes. Spine (Phila Pa 1976). 2014;39(14):11441150.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Chakravarthy VB, Yokoi H, Coughlin DJ, et al. Development and implementation of a comprehensive spine surgery enhanced recovery after surgery protocol: the Cleveland Clinic experience. Neurosurg Focus. 2019;46(4):E11.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Staartjes VE, de Wispelaere MP, Schröder ML. Improving recovery after elective degenerative spine surgery: 5-year experience with an enhanced recovery after surgery (ERAS) protocol. Neurosurg Focus. 2019;46(4):E7.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Bellaire LL, Bruce RW Jr, Ward LA, et al. Use of an accelerated discharge pathway in patients with severe cerebral palsy undergoing posterior spinal fusion for neuromuscular scoliosis. Spine Deform. 2019;7(5):804811.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Chan CYW, Loo SF, Ong JY, et al. Feasibility and outcome of an accelerated recovery protocol in Asian adolescent idiopathic scoliosis patients. Spine (Phila Pa 1976). 2017;42(24):E1415E1422.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Fletcher ND, Andras LM, Lazarus DE, et al. Use of a novel pathway for early discharge was associated with a 48% shorter length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. J Pediatr Orthop. 2017;37(2):9297.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Gornitzky AL, Flynn JM, Muhly WT, Sankar WN. A rapid recovery pathway for adolescent idiopathic scoliosis that improves pain control and reduces time to inpatient recovery after posterior spinal fusion. Spine Deform. 2016;4(4):288295.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Muhly WT, Sankar WN, Ryan K, et al. Rapid recovery pathway after spinal fusion for idiopathic scoliosis. Pediatrics. 2016;137(4):e20151568.

  • 16

    Rao RR, Hayes M, Lewis C, et al. Mapping the road to recovery: shorter stays and satisfied patients in posterior spinal fusion. J Pediatr Orthop. 2017;37(8):e536e542.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Sanders AE, Andras LM, Sousa T, et al. Accelerated discharge protocol for posterior spinal fusion patients with adolescent idiopathic scoliosis decreases hospital postoperative charges 22%. Spine (Phila Pa 1976). 2017;42(2):9297.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    North American Spine Society. Levels of Evidence for Primary Research Question as Adopted by the North American Spine Society January 2005. Accessed August 5, 2020. https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/LevelsofEvidence.pdf

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Bae J, Theologis AA, Strom R, et al. Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance. J Neurosurg Spine. 2018;28(1):4049.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Elsarrag M, Soldozy S, Patel P, et al. Enhanced recovery after spine surgery: a systematic review. Neurosurg Focus. 2019;46(4):E3.

  • 21

    Lee L, Mata J, Ghitulescu GA, et al. Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg. 2015;262(6):10261033.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Melloul E, Hübner M, Scott M, et al. Guidelines for perioperative care for liver surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg. 2016;40(10):24252440.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Wessels F, Lenhart M, Kowalewski KF, et al. Early recovery after surgery for radical cystectomy: comprehensive assessment and meta-analysis of existing protocols. World J Urol. Published online March 2, 2020. doi:10.1007/s00345-020-03133-y

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Li S, Zhou K, Che G, et al. Enhanced recovery programs in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials. Cancer Manag Res. 2017;9:657670.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Pennington Z, Lubelski D, Molina C, et al. Prolonged post-surgical drain retention increases risk for deep wound infection after spine surgery. World Neurosurg. 2019;130:e846e853.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Wathen C, Kshettry VR, Krishnaney A, et al. The association between operating room personnel and turnover with surgical site infection in more than 12 000 neurosurgical cases. Neurosurgery. 2016;79(6):889894.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Ramirez JM, Eberson CP. The role of rehabilitation in the management of adolescent idiopathic scoliosis. R I Med J (2013). 2017;100(11):2225.

  • 28

    Roddy E, Diab M. Rates and risk factors associated with unplanned hospital readmission after fusion for pediatric spinal deformity. Spine J. 2017;17(3):369379.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Vivas AC, Pahys JM, Jain A, et al. Early and late hospital readmissions after spine deformity surgery in children with cerebral palsy. Spine Deform. 2020;8(3):507516.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Menendez JY, Omar NB, Chagoya G, et al. Patient satisfaction in spine surgery: a systematic review of the literature. Asian Spine J. 2019;13(6):10471057.

  • 31

    Olivero W, Wang H, Vinson D, et al. Correlation between Press Ganey scores and quality outcomes from the National Neurosurgery Quality and Outcomes Database (lumbar spine) for a hospital employed neurosurgical practice. Neurosurgery. 2018;65(CN_suppl_1):3436.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Elsamadicy AA, Koo AB, Kundishora AJ, et al. Impact of patient and hospital-level risk factors on extended length of stay following spinal fusion for adolescent idiopathic scoliosis. J Neurosurg Pediatr. 2019;24(4):469475.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Henry J Kaiser Family Foundation. Hospital adjusted expenses per inpatient day by ownership. Accessed August 5, 2020. https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day-by-ownership/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Anderson DE, Duletzke NT, Pedigo EB, Halsey MF. Multimodal pain control in adolescent posterior spinal fusion patients: a double-blind, randomized controlled trial to validate the effect of gabapentin on postoperative pain control, opioid use, and patient satisfaction. Spine Deform. 2020;8(2):177185.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Rusy LM, Hainsworth KR, Nelson TJ, et al. Gabapentin use in pediatric spinal fusion patients: a randomized, double-blind, controlled trial. Anesth Analg. 2010;110(5):13931398.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Chidambaran V, Subramanyam R, Ding L, et al. Cost-effectiveness of intravenous acetaminophen and ketorolac in adolescents undergoing idiopathic scoliosis surgery. Paediatr Anaesth. 2018;28(3):237248.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Munro HM, Walton SR, Malviya S, et al. Low-dose ketorolac improves analgesia and reduces morphine requirements following posterior spinal fusion in adolescents. Can J Anaesth. 2002;49(5):461466.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Rosenberg RE, Trzcinski S, Cohen M, et al. The association between adjuvant pain medication use and outcomes following pediatric spinal fusion. Spine (Phila Pa 1976). 2017;42(10):E602E608.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Sivaganesan A, Chotai S, White-Dzuro G, et al. The effect of NSAIDs on spinal fusion: a cross-disciplinary review of biochemical, animal, and human studies. Eur Spine J. 2017;26(11):27192728.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Vitale MG, Choe JC, Hwang MW, et al. Use of ketorolac tromethamine in children undergoing scoliosis surgery. An analysis of complications. Spine J. 2003;3(1):5562.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Sucato DJ, Lovejoy JF, Agrawal S, et al. Postoperative ketorolac does not predispose to pseudoarthrosis following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2008;33(10):11191124.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Milbrandt TA, Singhal M, Minter C, et al. A comparison of three methods of pain control for posterior spinal fusions in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2009;34(14):14991503.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Li Y, Hong RA, Robbins CB, et al. Intrathecal morphine and oral analgesics provide safe and effective pain control after posterior spinal fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2018;43(2):E98E104.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Hong RA, Gibbons KM, Li GY, et al. A retrospective comparison of intrathecal morphine and epidural hydromorphone for analgesia following posterior spinal fusion in adolescents with idiopathic scoliosis. Pediatr Anesth. 2017;27(1):9197.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Huang H, Dong L, Gu L. The timing of urinary catheter removal after gynecologic surgery: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2020;99(2):e18710.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Lee Y, McKechnie T, Springer JE, et al. Optimal timing of urinary catheter removal following pelvic colorectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis. 2019;34(12):20112021.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Dietz N, Sharma M, Adams S, et al. Enhanced recovery after surgery (ERAS) for spine surgery: a systematic review. World Neurosurg. 2019;130:415426.

  • 48

    Corniola MV, Debono B, Joswig H, et al. Enhanced recovery after spine surgery: review of the literature. Neurosurg Focus. 2019;46(4):E2.

  • 49

    Goobie SM, Zurakowski D, Glotzbecker MP, et al. Tranexamic acid is efficacious at decreasing the rate of blood loss in adolescent scoliosis surgery: a randomized placebo-controlled trial. J Bone Joint Surg Am. 2018;100(23):20242032.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Yuan Q-M, Zhao Z-H, Xu B-S. Efficacy and safety of tranexamic acid in reducing blood loss in scoliosis surgery: a systematic review and meta-analysis. Eur Spine J. 2017;26(1):131139.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51

    Wakamiya R, Seki H, Ideno S, et al. Effects of prophylactic dexamethasone on postoperative nausea and vomiting in scoliosis correction surgery: a double-blind, randomized, placebo-controlled clinical trial. Sci Rep. 2019;9(1):2119.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52

    Labbé A-C, Demers A-M, Rodrigues R, et al. Surgical-site infection following spinal fusion: a case-control study in a children’s hospital. Infect Control Hosp Epidemiol. 2003;24(8):591595.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 53

    Wade Shrader M, Nabar SJ, Jones JS, et al. Adjunctive pain control methods lower narcotic use and pain scores for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. Spine Deform. 2015;3(1):8287.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 54

    Ross PA, Smith BM, Tolo VT, Khemani RG. Continuous infusion of bupivacaine reduces postoperative morphine use in adolescent idiopathic scoliosis after posterior spine fusion. Spine (Phila Pa 1976). 2011;36(18):14781483.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55

    Liang J, Shen J, Chua S, et al. Does intraoperative cell salvage system effectively decrease the need for allogeneic transfusions in scoliotic patients undergoing posterior spinal fusion? A prospective randomized study. Eur Spine J. 2015;24(2):270275.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56

    Bowen RE, Gardner S, Scaduto AA, et al. Efficacy of intraoperative cell salvage systems in pediatric idiopathic scoliosis patients undergoing posterior spinal fusion with segmental spinal instrumentation. Spine (Phila Pa 1976). 2010;35(2):246251.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57

    Boniello AJ, Verma K, Peters A, et al. Pre-operative autologous blood donation does not affect pre-incision hematocrit in adolescent idiopathic scoliosis patients. A retrospective cohort of a prospective randomized trial. Int J Spine Surg. 2016;10:27.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 58

    Sanpera I, Burgos-Flores J, Barrios C, et al. Is autologous blood transfusion cost effective in adolescent idiopathic scoliosis? Acta Orthop Belg. 2016;82(4):901906.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 59

    Ridgeway S, Tai C, Alton P, et al. Pre-donated autologous blood transfusion in scoliosis surgery. J Bone Joint Surg Br. 2003;85(7):10321036.

  • 60

    Bess RS, Lenke LG, Bridwell KH, et al. Wasting of preoperatively donated autologous blood in the surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2006;31(20):23752380.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 61

    Smith JT, Smith MS. Does a preoperative bowel preparation reduce bowel morbidity and length of stay after scoliosis surgery? A randomized prospective study. J Pediatr Orthop. 2013;33(8):e69e71.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 62

    Rhodes LN, Loman DG, Bultas MW. Comparison of two postoperative bowel regimens in children with scoliosis repair. Orthop Nurs. 2016;35(1):1319.

  • 63

    Kochai A, Cicekli O, Bayam L, et al. Is pharmacological anticoagulant prophylaxis necessary for adolescent idiopathic scoliosis surgery? Medicine (Baltimore). 2019;98(29):e16552.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 64

    Rhodes L, Nash C, Moisan A, et al. Does preoperative orientation and education alleviate anxiety in posterior spinal fusion patients? A prospective, randomized study. J Pediatr Orthop. 2015;35(3):276279.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 65

    Bharucha NJ, Lonner BS, Auerbach JD, et al. Low-density versus high-density thoracic pedicle screw constructs in adolescent idiopathic scoliosis: do more screws lead to a better outcome? Spine J. 2013;13(4):375381.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 66

    Shen M, Jiang H, Luo M, et al. Comparison of low density and high density pedicle screw instrumentation in Lenke 1 adolescent idiopathic scoliosis. BMC Musculoskelet Disord. 2017;18(1):336.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 67

    Heffernan MJ, Seehausen DA, Andras LM, Skaggs DL. Comparison of outcomes after posterior spinal fusion for adolescent idiopathic and neuromuscular scoliosis: does the surgical first assistant’s level of training matter? Spine (Phila Pa 1976). 2014;39(8):648655.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

Supplementary Materials

  • Collapse
  • Expand

Image from Quon et al. (pp 131–138).

  • FIG. 1.

    PRISMA flow diagram for the results of the literature search. Figure is available in color online only.

  • FIG. 2.

    Forest plots showing ERAS protocols were associated with the following: a decrease in LOS/hospitalization (A); a decrease in perioperative complication rate (B); no change in wound infection rate (C); no change in 30-day readmission rate (D); and no change in reoperation rate (E). M-H = Mantel-Haenszel. Figure is available in color online only.

  • FIG. 3.

    Forest plots showing ERAS protocols were associated with the following: no change in time to PCA discontinuation (A); lower immediate postoperative pain scores (B); no change in POD 1 pain scores (C); and lower POD 2 pain scores (D). Figure is available in color online only.

  • 1

    George J, Das S, Egger AC, et al. Influence of intraoperative neuromonitoring on the outcomes of surgeries for pediatric scoliosis in the United States. Spine Deform. 2019;7(1):2732.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Barsdorf AI, Sproule DM, Kaufmann P. Scoliosis surgery in children with neuromuscular disease: findings from the US National Inpatient Sample, 1997 to 2003. Arch Neurol. 2010;67(2):231235.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Vigneswaran HT, Grabel ZJ, Eberson CP, et al. Surgical treatment of adolescent idiopathic scoliosis in the United States from 1997 to 2012: an analysis of 20,346 patients. J Neurosurg Pediatr. 2015;16(3):322328.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Martin CT, Pugely AJ, Gao Y, et al. Increasing hospital charges for adolescent idiopathic scoliosis in the United States. Spine (Phila Pa 1976). 2014;39(20):16761682.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Workman JK, Wilkes J, Presson AP, et al. Variation in adolescent idiopathic scoliosis surgery: implications for improving healthcare value. J Pediatr. 2018;195:213219.e3.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Kamerlink JR, Quirno M, Auerbach JD, et al. Hospital cost analysis of adolescent idiopathic scoliosis correction surgery in 125 consecutive cases. J Bone Joint Surg Am. 2010;92(5):10971104.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Malik AT, Yu E, Kim J, Khan SN. Understanding costs in a 90-day episode of care following posterior spinal fusions for adolescent idiopathic scoliosis. World Neurosurg. 2019;130:e535e541.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Yoshihara H, Yoneoka D. National trends in spinal fusion for pediatric patients with idiopathic scoliosis: demographics, blood transfusions, and in-hospital outcomes. Spine (Phila Pa 1976). 2014;39(14):11441150.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Chakravarthy VB, Yokoi H, Coughlin DJ, et al. Development and implementation of a comprehensive spine surgery enhanced recovery after surgery protocol: the Cleveland Clinic experience. Neurosurg Focus. 2019;46(4):E11.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Staartjes VE, de Wispelaere MP, Schröder ML. Improving recovery after elective degenerative spine surgery: 5-year experience with an enhanced recovery after surgery (ERAS) protocol. Neurosurg Focus. 2019;46(4):E7.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Bellaire LL, Bruce RW Jr, Ward LA, et al. Use of an accelerated discharge pathway in patients with severe cerebral palsy undergoing posterior spinal fusion for neuromuscular scoliosis. Spine Deform. 2019;7(5):804811.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Chan CYW, Loo SF, Ong JY, et al. Feasibility and outcome of an accelerated recovery protocol in Asian adolescent idiopathic scoliosis patients. Spine (Phila Pa 1976). 2017;42(24):E1415E1422.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Fletcher ND, Andras LM, Lazarus DE, et al. Use of a novel pathway for early discharge was associated with a 48% shorter length of stay after posterior spinal fusion for adolescent idiopathic scoliosis. J Pediatr Orthop. 2017;37(2):9297.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Gornitzky AL, Flynn JM, Muhly WT, Sankar WN. A rapid recovery pathway for adolescent idiopathic scoliosis that improves pain control and reduces time to inpatient recovery after posterior spinal fusion. Spine Deform. 2016;4(4):288295.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Muhly WT, Sankar WN, Ryan K, et al. Rapid recovery pathway after spinal fusion for idiopathic scoliosis. Pediatrics. 2016;137(4):e20151568.

  • 16

    Rao RR, Hayes M, Lewis C, et al. Mapping the road to recovery: shorter stays and satisfied patients in posterior spinal fusion. J Pediatr Orthop. 2017;37(8):e536e542.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Sanders AE, Andras LM, Sousa T, et al. Accelerated discharge protocol for posterior spinal fusion patients with adolescent idiopathic scoliosis decreases hospital postoperative charges 22%. Spine (Phila Pa 1976). 2017;42(2):9297.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    North American Spine Society. Levels of Evidence for Primary Research Question as Adopted by the North American Spine Society January 2005. Accessed August 5, 2020. https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/LevelsofEvidence.pdf

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Bae J, Theologis AA, Strom R, et al. Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance. J Neurosurg Spine. 2018;28(1):4049.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Elsarrag M, Soldozy S, Patel P, et al. Enhanced recovery after spine surgery: a systematic review. Neurosurg Focus. 2019;46(4):E3.

  • 21

    Lee L, Mata J, Ghitulescu GA, et al. Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg. 2015;262(6):10261033.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Melloul E, Hübner M, Scott M, et al. Guidelines for perioperative care for liver surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg. 2016;40(10):24252440.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Wessels F, Lenhart M, Kowalewski KF, et al. Early recovery after surgery for radical cystectomy: comprehensive assessment and meta-analysis of existing protocols. World J Urol. Published online March 2, 2020. doi:10.1007/s00345-020-03133-y

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Li S, Zhou K, Che G, et al. Enhanced recovery programs in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials. Cancer Manag Res. 2017;9:657670.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Pennington Z, Lubelski D, Molina C, et al. Prolonged post-surgical drain retention increases risk for deep wound infection after spine surgery. World Neurosurg. 2019;130:e846e853.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Wathen C, Kshettry VR, Krishnaney A, et al. The association between operating room personnel and turnover with surgical site infection in more than 12 000 neurosurgical cases. Neurosurgery. 2016;79(6):889894.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Ramirez JM, Eberson CP. The role of rehabilitation in the management of adolescent idiopathic scoliosis. R I Med J (2013). 2017;100(11):2225.

  • 28

    Roddy E, Diab M. Rates and risk factors associated with unplanned hospital readmission after fusion for pediatric spinal deformity. Spine J. 2017;17(3):369379.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Vivas AC, Pahys JM, Jain A, et al. Early and late hospital readmissions after spine deformity surgery in children with cerebral palsy. Spine Deform. 2020;8(3):507516.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Menendez JY, Omar NB, Chagoya G, et al. Patient satisfaction in spine surgery: a systematic review of the literature. Asian Spine J. 2019;13(6):10471057.

  • 31

    Olivero W, Wang H, Vinson D, et al. Correlation between Press Ganey scores and quality outcomes from the National Neurosurgery Quality and Outcomes Database (lumbar spine) for a hospital employed neurosurgical practice. Neurosurgery. 2018;65(CN_suppl_1):3436.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Elsamadicy AA, Koo AB, Kundishora AJ, et al. Impact of patient and hospital-level risk factors on extended length of stay following spinal fusion for adolescent idiopathic scoliosis. J Neurosurg Pediatr. 2019;24(4):469475.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Henry J Kaiser Family Foundation. Hospital adjusted expenses per inpatient day by ownership. Accessed August 5, 2020. https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day-by-ownership/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Anderson DE, Duletzke NT, Pedigo EB, Halsey MF. Multimodal pain control in adolescent posterior spinal fusion patients: a double-blind, randomized controlled trial to validate the effect of gabapentin on postoperative pain control, opioid use, and patient satisfaction. Spine Deform. 2020;8(2):177185.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Rusy LM, Hainsworth KR, Nelson TJ, et al. Gabapentin use in pediatric spinal fusion patients: a randomized, double-blind, controlled trial. Anesth Analg. 2010;110(5):13931398.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Chidambaran V, Subramanyam R, Ding L, et al. Cost-effectiveness of intravenous acetaminophen and ketorolac in adolescents undergoing idiopathic scoliosis surgery. Paediatr Anaesth. 2018;28(3):237248.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Munro HM, Walton SR, Malviya S, et al. Low-dose ketorolac improves analgesia and reduces morphine requirements following posterior spinal fusion in adolescents. Can J Anaesth. 2002;49(5):461466.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Rosenberg RE, Trzcinski S, Cohen M, et al. The association between adjuvant pain medication use and outcomes following pediatric spinal fusion. Spine (Phila Pa 1976). 2017;42(10):E602E608.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Sivaganesan A, Chotai S, White-Dzuro G, et al. The effect of NSAIDs on spinal fusion: a cross-disciplinary review of biochemical, animal, and human studies. Eur Spine J. 2017;26(11):27192728.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Vitale MG, Choe JC, Hwang MW, et al. Use of ketorolac tromethamine in children undergoing scoliosis surgery. An analysis of complications. Spine J. 2003;3(1):5562.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Sucato DJ, Lovejoy JF, Agrawal S, et al. Postoperative ketorolac does not predispose to pseudoarthrosis following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2008;33(10):11191124.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Milbrandt TA, Singhal M, Minter C, et al. A comparison of three methods of pain control for posterior spinal fusions in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2009;34(14):14991503.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Li Y, Hong RA, Robbins CB, et al. Intrathecal morphine and oral analgesics provide safe and effective pain control after posterior spinal fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2018;43(2):E98E104.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Hong RA, Gibbons KM, Li GY, et al. A retrospective comparison of intrathecal morphine and epidural hydromorphone for analgesia following posterior spinal fusion in adolescents with idiopathic scoliosis. Pediatr Anesth. 2017;27(1):9197.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Huang H, Dong L, Gu L. The timing of urinary catheter removal after gynecologic surgery: a meta-analysis of randomized controlled trials. Medicine (Baltimore). 2020;99(2):e18710.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Lee Y, McKechnie T, Springer JE, et al. Optimal timing of urinary catheter removal following pelvic colorectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis. 2019;34(12):20112021.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Dietz N, Sharma M, Adams S, et al. Enhanced recovery after surgery (ERAS) for spine surgery: a systematic review. World Neurosurg. 2019;130:415426.

  • 48

    Corniola MV, Debono B, Joswig H, et al. Enhanced recovery after spine surgery: review of the literature. Neurosurg Focus. 2019;46(4):E2.

  • 49

    Goobie SM, Zurakowski D, Glotzbecker MP, et al. Tranexamic acid is efficacious at decreasing the rate of blood loss in adolescent scoliosis surgery: a randomized placebo-controlled trial. J Bone Joint Surg Am. 2018;100(23):20242032.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Yuan Q-M, Zhao Z-H, Xu B-S. Efficacy and safety of tranexamic acid in reducing blood loss in scoliosis surgery: a systematic review and meta-analysis. Eur Spine J. 2017;26(1):131139.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51

    Wakamiya R, Seki H, Ideno S, et al. Effects of prophylactic dexamethasone on postoperative nausea and vomiting in scoliosis correction surgery: a double-blind, randomized, placebo-controlled clinical trial. Sci Rep. 2019;9(1):2119.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52

    Labbé A-C, Demers A-M, Rodrigues R, et al. Surgical-site infection following spinal fusion: a case-control study in a children’s hospital. Infect Control Hosp Epidemiol. 2003;24(8):591595.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 53

    Wade Shrader M, Nabar SJ, Jones JS, et al. Adjunctive pain control methods lower narcotic use and pain scores for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion. Spine Deform. 2015;3(1):8287.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 54

    Ross PA, Smith BM, Tolo VT, Khemani RG. Continuous infusion of bupivacaine reduces postoperative morphine use in adolescent idiopathic scoliosis after posterior spine fusion. Spine (Phila Pa 1976). 2011;36(18):14781483.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55

    Liang J, Shen J, Chua S, et al. Does intraoperative cell salvage system effectively decrease the need for allogeneic transfusions in scoliotic patients undergoing posterior spinal fusion? A prospective randomized study. Eur Spine J. 2015;24(2):270275.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56

    Bowen RE, Gardner S, Scaduto AA, et al. Efficacy of intraoperative cell salvage systems in pediatric idiopathic scoliosis patients undergoing posterior spinal fusion with segmental spinal instrumentation. Spine (Phila Pa 1976). 2010;35(2):246251.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57

    Boniello AJ, Verma K, Peters A, et al. Pre-operative autologous blood donation does not affect pre-incision hematocrit in adolescent idiopathic scoliosis patients. A retrospective cohort of a prospective randomized trial. Int J Spine Surg. 2016;10:27.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 58

    Sanpera I, Burgos-Flores J, Barrios C, et al. Is autologous blood transfusion cost effective in adolescent idiopathic scoliosis? Acta Orthop Belg. 2016;82(4):901906.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 59

    Ridgeway S, Tai C, Alton P, et al. Pre-donated autologous blood transfusion in scoliosis surgery. J Bone Joint Surg Br. 2003;85(7):10321036.

  • 60

    Bess RS, Lenke LG, Bridwell KH, et al. Wasting of preoperatively donated autologous blood in the surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2006;31(20):23752380.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 61

    Smith JT, Smith MS. Does a preoperative bowel preparation reduce bowel morbidity and length of stay after scoliosis surgery? A randomized prospective study. J Pediatr Orthop. 2013;33(8):e69e71.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 62

    Rhodes LN, Loman DG, Bultas MW. Comparison of two postoperative bowel regimens in children with scoliosis repair. Orthop Nurs. 2016;35(1):1319.

  • 63

    Kochai A, Cicekli O, Bayam L, et al. Is pharmacological anticoagulant prophylaxis necessary for adolescent idiopathic scoliosis surgery? Medicine (Baltimore). 2019;98(29):e16552.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 64

    Rhodes L, Nash C, Moisan A, et al. Does preoperative orientation and education alleviate anxiety in posterior spinal fusion patients? A prospective, randomized study. J Pediatr Orthop. 2015;35(3):276279.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 65

    Bharucha NJ, Lonner BS, Auerbach JD, et al. Low-density versus high-density thoracic pedicle screw constructs in adolescent idiopathic scoliosis: do more screws lead to a better outcome? Spine J. 2013;13(4):375381.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 66

    Shen M, Jiang H, Luo M, et al. Comparison of low density and high density pedicle screw instrumentation in Lenke 1 adolescent idiopathic scoliosis. BMC Musculoskelet Disord. 2017;18(1):336.

    • Crossref
    • PubMed