Experience with an Enhanced Recovery After Spine Surgery protocol at an academic community hospital

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  • 1 Departments of Neurosurgery,
  • 2 Physical Medicine and Rehabilitation, and
  • 4 Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine;
  • 3 Neuroscience Administration, Johns Hopkins Bayview Medical Center, Baltimore, Maryland; and
  • 5 Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California
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OBJECTIVE

Enhanced Recovery After Surgery (ERAS) protocols have rapidly gained popularity in multiple surgical specialties and are recognized for their potential to improve patient outcomes and decrease hospitalization costs. However, they have only recently been applied to spinal surgery. The goal in the present work was to describe the development, implementation, and impact of an Enhanced Recovery After Spine Surgery (ERASS) protocol for patients undergoing elective spine procedures at an academic community hospital.

METHODS

A multidisciplinary team, drawing on prior publications and spine surgery best practices, collaborated to develop an ERASS protocol. Patients undergoing elective cervical or lumbar procedures were prospectively enrolled at a single tertiary care center; interventions were standardized across the cohort for pre-, intra-, and postoperative care using standardized order sets in the electronic medical record. Protocol efficacy was evaluated by comparing enrolled patients to a historic cohort of age- and procedure-matched controls. The primary study outcomes were quantity of opiate use in morphine milligram equivalents (MMEs) on postoperative day (POD) 1 and length of stay. Secondary outcomes included frequency and duration of indwelling urinary catheter use, discharge disposition, 30-day readmission and reoperation rates, and complication rates. Multivariable linear regression was used to determine whether ERASS protocol use was independently predictive of opiate use on POD 1.

RESULTS

In total, 97 patients were included in the study cohort and were compared with a historic cohort of 146 patients. The patients in the ERASS group had lower POD 1 opiate use than the control group (26 ± 33 vs 42 ± 40 MMEs, p < 0.001), driven largely by differences in opiate-naive patients (16 ± 21 vs 38 ± 36 MMEs, p < 0.001). Additionally, patients in the ERASS group had shorter hospitalizations than patients in the control group (51 ± 30 vs 62 ± 49 hours, p = 0.047). On multivariable regression, implementation of the ERASS protocol was independently predictive of lower POD 1 opiate consumption (β = −7.32, p < 0.001). There were no significant differences in any of the secondary outcomes.

CONCLUSIONS

The authors found that the development and implementation of a comprehensive ERASS protocol led to a modest reduction in postoperative opiate consumption and hospital length of stay in patients undergoing elective cervical or lumbar procedures. As suggested by these results and those of other groups, the implementation of ERASS protocols may reduce care costs and improve patient outcomes after spine surgery.

ABBREVIATIONS ACDF = anterior cervical discectomy and fusion; ERAS = Enhanced Recovery After Surgery; ERASS = Enhanced Recovery After Spine Surgery; ICU = intensive care unit; MI = minimally invasive; MME = morphine milligram equivalent; ODI = Oswestry Disability Index; PCA = patient-controlled analgesia; POD = postoperative day; PRO = patient-reported outcome; TLIF = transforaminal lumbar interbody fusion.

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Contributor Notes

Correspondence Nicholas Theodore: The Johns Hopkins School of Medicine, Baltimore, MD. theodore@jhmi.edu.

INCLUDE WHEN CITING Published online December 25, 2020; DOI: 10.3171/2020.7.SPINE20358.

R.Y. and E.C. contributed equally to this work.

Disclosures Dr. Witham is a consultant for DePuy Synthes, Globus, Stryker, SpineAlign LLC, and Augmendics and owns stock in Additive Orthopedics and Augmendics. Dr. Theodore receives royalties from DePuy Synthes and Globus Medical Inc. and is a consultant for Globus Medical Inc.

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