Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution

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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.

ABBREVIATIONS BMI = 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.

Article Information

Correspondence Zarina S. Ali: University of Pennsylvania, Philadelphia, PA. zarina.ali@uphs.upenn.edu.

INCLUDE WHEN CITING Published online January 25, 2019; DOI: 10.3171/2018.9.SPINE18681.

Disclosures Dr. Welch reports ownership of Transcendental Spine.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Illustration showing the pre-, peri-, and postoperative components of the Penn Neurosurgery ERAS protocol. Figure is available in color online only.

  • View in gallery

    Illustration highlighting the various components of the pain management protocol within ERAS. IV = intravenous; PACU = postanesthesia care unit. Figure is available in color online only.



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