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

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OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Headings

Figures

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    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.

References

1

Ali ZSMa TSOzturk AKMalhotra NRSchuster JMMarcotte PJ: Pre-optimization of spinal surgery patients: development of a neurosurgical enhanced recovery after surgery (ERAS) protocol. Clin Neurol Neurosurg 164:1421532018

2

Archer KRWegener STSeebach CSong YSkolasky RLThornton C: The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions. Spine (Phila Pa 1976) 36:155415622011

3

Baldini GBagry HAprikian ACarli F: Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 110:113911572009

4

Black N: Patient reported outcome measures could help transform healthcare. BMJ 346:f1672013

5

Brescia ATomassini FBerardi GSebastiani CPezzatini MDall’Oglio A: 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 Surg 69:3593652017

6

Christelis NWallace SSage CEBabitu ULiew SDugal J: An enhanced recovery after surgery program for hip and knee arthroplasty. Med J Aust 202:3633682015

7

Clarke HSoneji NKo DTYun LWijeysundera DN: Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ 348:g12512014

8

Dangayach NSCaridi JBederson JMayer SA: Enhanced Recovery After Neurosurgery: paradigm shift and call to arms. World Neurosurg 100:6836852017

9

Fehlings MGTetreault LNater AChoma THarrop JMroz T: The aging of the global population: the changing epidemiology of disease and spinal disorders. Neurosurgery 77 (Suppl 4):S1S52015

10

Feneley RPainter DEvans AStickler D: Bladder catheterisation. Br J Gen Pract 52:5002002

11

Feneley RCHopley IBWells PN: Urinary catheters: history, current status, adverse events and research agenda. J Med Eng Technol 39:4594702015

12

Garcia MMGulati SLiepmann DStackhouse GBGreene KStoller ML: Traditional Foley drainage systems—do they drain the bladder? J Urol 177:2032072007

13

Grotle MVøllestad NKBrox JI: Clinical course and impact of fear-avoidance beliefs in low back pain: prospective cohort study of acute and chronic low back pain: II. Spine (Phila Pa 1976) 31:103810462006

14

Kahokehr ASammour TZargar-Shoshtari KThompson LHill AG: Implementation of ERAS and how to overcome the barriers. Int J Surg 7:16192009

15

Kashefi CMesser KBarden RSexton CParsons JK: Incidence and prevention of iatrogenic urethral injuries. J Urol 179:225422582008

16

Kehlet H: Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78:6066171997

17

Landers MRCreger RVBaker CVStutelberg KS: The use of fear-avoidance beliefs and nonorganic signs in predicting prolonged disability in patients with neck pain. Man Ther 13:2392482008

18

Manchikanti LHelm S IIFellows BJanata JWPampati VGrider JS: Opioid epidemic in the United States. Pain Physician 15 (3 Suppl):ES9ES382012

19

Manchikanti LSingh A: Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician 11 (2 Suppl):S63S882008

20

McEvoy MDScott MJGordon DBGrant SAThacker JKMWu CL: 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

21

Melnyk MCasey RGBlack PKoupparis AJ: Enhanced recovery after surgery (ERAS) protocols: time to change practice? Can Urol Assoc J 5:3423482011

22

Milles G: Catheter-induced hemorrhagic pseudopolyps of the urinary bladder. JAMA 193:9689691965

23

Pereira Gomes Morais ERiera RPorfírio GJMacedo CRSarmento Vasconcelos Vde Souza Pedrosa A: Chewing gum for enhancing early recovery of bowel function after caesarean section. Cochrane Database Syst Rev 10:CD0115622016

24

Rajpal SGordon DBPellino TAStrayer ALBrost DTrost GR: Comparison of perioperative oral multimodal analgesia versus IV PCA for spine surgery. J Spinal Disord Tech 23:1391452010

25

Saint SKowalski CPKaufman SRHofer TPKauffman CAOlmsted RN: Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis 46:2432502008

26

Short VHerbert GPerry RAtkinson CNess ARPenfold C: Chewing gum for postoperative recovery of gastrointestinal function. Cochrane Database Syst Rev (2):CD0065062015

27

Sun ECDarnall BDBaker LCMackey S: Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med 176:128612932016

28

Valderas JMKotzeva AEspallargues MGuyatt GFerrans CEHalyard MY: The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature. Qual Life Res 17:1791932008

29

Wainwright TWImmins TMiddleton RG: Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery. Best Pract Res Clin Anaesthesiol 30:911022016

30

Wang MYChang HKGrossman J: Reduced acute care costs with the ERAS® minimally invasive transforaminal lumbar interbody fusion compared with conventional minimally invasive transforaminal lumbar interbody fusion. Neurosurgery 83:8278342018

31

Wang MYChang PYGrossman J: Development of an Enhanced Recovery After Surgery (ERAS) approach for lumbar spinal fusion. J Neurosurg Spine 26:4114182017

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