Enhanced recovery after surgery (ERAS) protocols address pre-, peri-, and postoperative factors of a patient’s surgical journey. The authors sought to assess the effects of a novel ERAS protocol on clinical outcomes for patients undergoing elective spine or peripheral nerve surgery.
The authors conducted a prospective cohort analysis comparing clinical outcomes of patients undergoing elective spine or peripheral nerve surgery after implementation of the ERAS protocol compared to a historical control cohort in a tertiary care academic medical center. Patients in the historical cohort (September–December 2016) underwent traditional surgical care. Patients in the intervention group (April–June 2017) were enrolled in a unique ERAS protocol created by the Department of Neurosurgery at the University of Pennsylvania. Primary objectives were as follows: opioid and nonopioid pain medication consumption, need for opioid use at 1 month postoperatively, and patient-reported pain scores. Secondary objectives were as follows: mobilization and ambulation status, Foley catheter use, need for straight catheterization, length of stay, need for ICU admission, discharge status, and readmission within 30 days.
A total of 201 patients underwent surgical care via an ERAS protocol and were compared to a total of 74 patients undergoing traditional perioperative care (control group). The 2 groups were similar in baseline demographics. Intravenous opioid medications postoperatively via patient-controlled analgesia was nearly eliminated in the ERAS group (0.5% vs 54.1%, p < 0.001). This change was not associated with an increase in the average or daily pain scores in the ERAS group. At 1 month following surgery, a smaller proportion of patients in the ERAS group were using opioids (38.8% vs 52.7%, p = 0.041). The ERAS group demonstrated greater mobilization on postoperative day 0 (53.4% vs 17.1%, p < 0.001) and postoperative day 1 (84.1% vs 45.7%, p < 0.001) compared to the control group. Postoperative Foley use was decreased in the ERAS group (20.4% vs 47.3%, p < 0.001) without an increase in the rate of straight catheterization (8.1% vs 11.9%, p = 0.51).
Implementation of this novel ERAS pathway safely reduces patients’ postoperative opioid requirements during hospitalization and 1 month postoperatively. ERAS results in improved postoperative mobilization and ambulation.
ABBREVIATIONSBMI = body mass index; EQ-5D = EuroQol–5 Dimensions Scale; ERAS = enhanced recovery after surgery; LOS = hospital length of stay; NDI = Neck Disability Index; ODI = Oswestry Disability Index; PCA = patient-controlled analgesia; POD = postoperative day; PRO = patient-reported outcome.
Correspondence Zarina S. Ali: University of Pennsylvania, Philadelphia, PA. email@example.com.INCLUDE WHEN CITING Published online January 25, 2019; DOI: 10.3171/2018.9.SPINE18681.Disclosures Dr. Welch reports ownership of Transcendental Spine.
AliZSMaTSOzturkAKMalhotraNRSchusterJMMarcottePJ: Pre-optimization of spinal surgery patients: development of a neurosurgical enhanced recovery after surgery (ERAS) protocol. Clin Neurol Neurosurg164:142–1532018
AliZS, MaTS, OzturkAK, MalhotraNR, SchusterJM, MarcottePJ, : Pre-optimization of spinal surgery patients: development of a neurosurgical enhanced recovery after surgery (ERAS) protocol. 164:142–153, 20182923264510.1016/j.clineuro.2017.12.003)| false
ArcherKRWegenerSTSeebachCSongYSkolaskyRLThorntonC: The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions. Spine (Phila Pa 1976)36:1554–15622011
ArcherKR, WegenerST, SeebachC, SongY, SkolaskyRL, ThorntonC, : The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions. 36:1554–1562, 201110.1097/BRS.0b013e3181f8c6f421270700)| false
BresciaATomassiniFBerardiGSebastianiCPezzatiniMDall’OglioA: Development of an enhanced recovery after surgery (ERAS) protocol in laparoscopic colorectal surgery: results of the first 120 consecutive cases from a university hospital. Updates Surg69:359–3652017
BresciaA, TomassiniF, BerardiG, SebastianiC, PezzatiniM, Dall’OglioA, : Development of an enhanced recovery after surgery (ERAS) protocol in laparoscopic colorectal surgery: results of the first 120 consecutive cases from a university hospital. 69:359–365, 201710.1007/s13304-017-0432-128332129)| false
GrotleM, VøllestadNK, BroxJI: Clinical course and impact of fear-avoidance beliefs in low back pain: prospective cohort study of acute and chronic low back pain: II. 31:1038–1046, 200610.1097/01.brs.0000214878.01709.0e16641782)| false
LandersMR, CregerRV, BakerCV, StutelbergKS: The use of fear-avoidance beliefs and nonorganic signs in predicting prolonged disability in patients with neck pain. 13:239–248, 20081738257610.1016/j.math.2007.01.010)| false
ManchikantiLSinghA: Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician11 (2 Suppl):S63–S882008
ManchikantiL, SinghA: Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. 11 (2 Suppl):S63–S88, 2008)| false
McEvoyMDScottMJGordonDBGrantSAThackerJKMWuCL: American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1—from the preoperative period to PACU. Perioper Med (Lond)6:82017
McEvoyMD, ScottMJ, GordonDB, GrantSA, ThackerJKM, WuCL, : American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1—from the preoperative period to PACU. 6:8, 201728413629)| false
Pereira Gomes MoraisERieraRPorfírioGJMacedoCRSarmento VasconcelosVde Souza PedrosaA: Chewing gum for enhancing early recovery of bowel function after caesarean section. Cochrane Database Syst Rev10:CD0115622016
Pereira Gomes MoraisE, RieraR, PorfírioGJ, MacedoCR, Sarmento VasconcelosV, de Souza PedrosaA, : Chewing gum for enhancing early recovery of bowel function after caesarean section. 10:CD011562, 2016)| false
SaintS, KowalskiCP, KaufmanSR, HoferTP, KauffmanCA, OlmstedRN, : Preventing hospital-acquired urinary tract infection in the United States: a national study. 46:243–250, 20081817125610.1086/524662)| false
SunEC, DarnallBD, BakerLC, MackeyS: Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. 176:1286–1293, 20162740045810.1001/jamainternmed.2016.3298)| false
ValderasJM, KotzevaA, EspallarguesM, GuyattG, FerransCE, HalyardMY, : The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature. 17:179–193, 200810.1007/s11136-007-9295-018175207)| false