Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery

View More View Less
  • Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

OBJECTIVE

Spine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate.

METHODS

Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care.

RESULTS

Of 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference −1.22 days [95% CI −1.98 to −0.47]) and lumbar spine ERAS protocols (−1.53 days [95% CI −2.89 to −0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use.

CONCLUSIONS

Present data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.

ABBREVIATIONS ERAS = Enhanced Recovery After Surgery; LOS = length of stay; MIS = minimally invasive surgery; POD = postoperative day; PRO = patient-reported outcome; RCT = randomized controlled trial; TLIF = transforaminal lumbar interbody fusion; TXA = tranexamic acid; VTE = venous thromboembolism.

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Correspondence Daniel M. Sciubba: Johns Hopkins University School of Medicine, Baltimore, MD. dsciubb1@jhmi.edu.

INCLUDE WHEN CITING Published online November 6, 2020; DOI: 10.3171/2020.6.SPINE20795.

Disclosures Dr. Theodore: royalties from Globus Medical and DePuy Synthes; stock ownership in Globus Medical; consultant for Globus Medical; and scientific advisory board/other office for Globus Medical. Dr. Sciubba: consultant for Baxter, DePuy Synthes, Globus Medical, K2M, Medtronic, NuVasive, and Stryker. Unrelated grant support from Baxter Medical, North American Spine Society, and Stryker.

  • 1

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

  • 2

    Ljungqvist O. Enhanced recovery after surgery: a paradigm shift in perioperative care. In: Ljungqvist O, Francis NK, Urman RD, eds. Enhanced Recovery After Surgery. 1st ed. Springer International Publishing; 2020:39.

    • Search Google Scholar
    • Export Citation
  • 3

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

    • Search Google Scholar
    • Export Citation
  • 4

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

    • Search Google Scholar
    • Export Citation
  • 5

    Wessels F, Lenhart M, Kowalewski KF, Early recovery after surgery for radical cystectomy: comprehensive assessment and meta-analysis of existing protocols. World J Urol. 2020.

    • Search Google Scholar
    • Export Citation
  • 6

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

    • Search Google Scholar
    • Export Citation
  • 7

    Liu B, Liu S, Wang Y, Enhanced recovery after intraspinal tumor surgery: a single-institutional randomized controlled study. World Neurosurg. 2020;136:e542–e552.

    • Search Google Scholar
    • Export Citation
  • 8

    Ali ZS, Flanders TM, Ozturk AK, Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution. J Neurosurg Spine. 2019;30(4):532540.

    • Search Google Scholar
    • Export Citation
  • 9

    Bradywood A, Farrokhi F, Williams B, Reduction of inpatient hospital length of stay in lumbar fusion patients with implementation of an evidence-based clinical care pathway. Spine (Phila Pa 1976). 2017;42(3):169176.

    • Search Google Scholar
    • Export Citation
  • 10

    Wang MY, Chang HK, Grossman J. Reduced acute care costs with the ERAS® minimally invasive transforaminal lumbar interbody fusion compared with conventional minimally invasive transforaminal lumbar interbody fusion. Neurosurgery. 2018;83(4):827834.

    • Search Google Scholar
    • Export Citation
  • 11

    Ren Y, Yu Q-F, Feng X-Q, Application of enhanced recovery after surgery program for posterior lumbar decompression and fusion. TMR Integr Nurs. 2019;3(1):3541.

    • Search Google Scholar
    • Export Citation
  • 12

    Brusko GD, Kolcun JPG, Heger JA, Reductions in length of stay, narcotics use, and pain following implementation of an enhanced recovery after surgery program for 1- to 3-level lumbar fusion surgery. Neurosurg Focus. 2019;46(4):E4.

    • Search Google Scholar
    • Export Citation
  • 13

    Smith J, Probst S, Calandra C, Enhanced recovery after surgery (ERAS) program for lumbar spine fusion. Perioper Med (Lond). 2019;8(1):4.

    • Search Google Scholar
    • Export Citation
  • 14

    Feng C, Zhang Y, Chong F, Establishment and implementation of an Enhanced Recovery After Surgery (ERAS) pathway tailored for minimally invasive transforaminal lumbar interbody fusion surgery. World Neurosurg. 2019;129:e317e323.

    • Search Google Scholar
    • Export Citation
  • 15

    Heo DH, Park CK. Clinical results of percutaneous biportal endoscopic lumbar interbody fusion with application of enhanced recovery after surgery. Neurosurg Focus. 2019;46(4):E18.

    • Search Google Scholar
    • Export Citation
  • 16

    Grasu RM, Cata JP, Dang AQ, Implementation of an Enhanced Recovery After Spine Surgery program at a large cancer center: a preliminary analysis. J Neurosurg Spine. 2018;29(5):588598.

    • Search Google Scholar
    • Export Citation
  • 17

    Venkata HK, van Dellen JR. A perspective on the use of an enhanced recovery program in open, non-instrumented day surgery for degenerative lumbar and cervical spinal conditions. J Neurosurg Sci. 2018;62(3):245254.

    • Search Google Scholar
    • Export Citation
  • 18

    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.

    • Search Google Scholar
    • Export Citation
  • 19

    Angus M, Jackson K, Smurthwaite G, The implementation of enhanced recovery after surgery (ERAS) in complex spinal surgery. J Spine Surg. 2019;5(1):116123.

    • Search Google Scholar
    • Export Citation
  • 20

    Hawasli AH, Ray WZ, Goad MA, Project management for developing a spine “enhanced recovery after surgery” program in a large university-affiliated hospital. J Neurosurg Sci. 2020;64(2):206212.

    • Search Google Scholar
    • Export Citation
  • 21

    Soffin EM, Wetmore DS, Barber LA, An enhanced recovery after surgery pathway: association with rapid discharge and minimal complications after anterior cervical spine surgery. Neurosurg Focus. 2019;46(4):E9.

    • Search Google Scholar
    • Export Citation
  • 22

    Fleege C, Arabmotlagh M, Almajali A, Rauschmann M. Prä- und postoperative Fast-track-Behandlungskonzepte in der Wirbelsäulenchirurgie: Patienteninformation und Patientenkooperation. Orthopade. 2014;43(12):10621069.

    • Search Google Scholar
    • Export Citation
  • 23

    Wang MY, Chang P-Y, Grossman J. Development of an Enhanced Recovery After Surgery (ERAS) approach for lumbar spinal fusion. J Neurosurg Spine. 2017;26(4):411418.

    • Search Google Scholar
    • Export Citation
  • 24

    Zhang CH, Yan BS, Xu BS, Study on feasibility of enhanced recovery after surgery combined with mobile microendoscopic discectomy-transforaminal lumbar interbody fusion in the treatment of lumbar spondylolisthesis. Article in Chinese. Zhonghua Yi Xue Za Zhi. 2017;97(23):17901795.

    • Search Google Scholar
    • Export Citation
  • 25

    Soffin EM, Vaishnav AS, Wetmore DS, Design and implementation of an enhanced recovery after surgery (ERAS) program for minimally invasive lumbar decompression spine surgery: initial experience. Spine (Phila Pa 1976). 2019;44(9):E561E570.

    • Search Google Scholar
    • Export Citation
  • 26

    Soffin EM, Wetmore DS, Beckman JD, Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study. Neurosurg Focus. 2019;46(4):E8.

    • Search Google Scholar
    • Export Citation
  • 27

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

    • Search Google Scholar
    • Export Citation
  • 28

    Carr DA, Saigal R, Zhang F, Enhanced perioperative care and decreased cost and length of stay after elective major spinal surgery. Neurosurg Focus. 2019;46(4):E5.

    • Search Google Scholar
    • Export Citation
  • 29

    Debono B, Corniola MV, Pietton R, Benefits of Enhanced Recovery After Surgery for fusion in degenerative spine surgery: impact on outcome, length of stay, and patient satisfaction. Neurosurg Focus. 2019;46(4):E6.

    • Search Google Scholar
    • Export Citation
  • 30

    Dagal A, Bellabarba C, Bransford R, Enhanced perioperative care for major spine surgery. Spine (Phila Pa 1976). 2019;44(13):959966.

  • 31

    Sivaganesan A, Wick JB, Chotai S, Perioperative protocol for elective spine surgery is associated with reduced length of stay and complications. J Am Acad Orthop Surg. 2019;27(5):183189.

    • Search Google Scholar
    • Export Citation
  • 32

    Li J, Li H, Xv Z-K, Enhanced recovery care versus traditional care following laminoplasty: A retrospective case-cohort study. Medicine (Baltimore). 2018;97(48):e13195.

    • Search Google Scholar
    • Export Citation
  • 33

    Nazarenko AG, Konovalov NA, Krut’ko AV, Postoperative applications of the fast track technology in patients with herniated intervertebral discs of the lumbosacral spine. Vopr neirokhirurgii Im N N Burdenko. 2016;80(4):512.

    • Search Google Scholar
    • Export Citation
  • 34

    North American Spine Society. Levels of evidence for primary research question as adopted by the North American Spine Society January 2005. Published 2004. Accessed July 24, 2020. https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/LevelsofEvidence.pdf

    • Search Google Scholar
    • Export Citation
  • 35

    Goldstein CL, Macwan K, Sundararajan K, Rampersaud YR. Perioperative outcomes and adverse events of minimally invasive versus open posterior lumbar fusion: meta-analysis and systematic review. J Neurosurg Spine. 2016;24(3):416427.

    • Search Google Scholar
    • Export Citation
  • 36

    Lu VM, Kerezoudis P, Gilder HE, Minimally invasive surgery versus open surgery spinal fusion for spondylolisthesis: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2017;42(3):E177E185.

    • Search Google Scholar
    • Export Citation
  • 37

    Pennington Z, Ahmed AK, Molina CA, Minimally invasive versus conventional spine surgery for vertebral metastases: a systematic review of the evidence. Ann Transl Med. 2018;6(6):103.

    • Search Google Scholar
    • Export Citation
  • 38

    Rasouli MR, Rahimi-Movaghar V, Shokraneh F, Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation. Cochrane Database Syst Rev. 2014;(9):CD010328.

    • Search Google Scholar
    • Export Citation
  • 39

    Feng S, Tian W, Wei Y. Clinical effects of oblique lateral interbody fusion by conventional open versus percutaneous robot-assisted minimally invasive pedicle screw placement in elderly patients. Orthop Surg. 2020;12(1):8693.

    • Search Google Scholar
    • Export Citation
  • 40

    Wainwright TW, Immins T, Middleton RG. Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery. Best Pract Res Clin Anaesthesiol. 2016;30(1):91102.

    • Search Google Scholar
    • Export Citation
  • 41

    Missios S, Bekelis K. Hospitalization cost after spine surgery in the United States of America. J Clin Neurosci. 2015;22(10):16321637.

    • Search Google Scholar
    • Export Citation
  • 42

    Henry J Kaiser Family Foundation. Hospital Adjusted Expenses per Inpatient Day by Ownership | The Henry J. Kaiser Family Foundation. Published 2016. Accessed July 24, 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

    • Search Google Scholar
    • Export Citation
  • 43

    Agency for Healthcare Research and Quality (AHRQ). HCUP Fast Stats - Most Common Operations During Inpatient Stays. Healthcare Cost and Utilization Project (HCUP). Published 2014. Accessed July 24, 2020. https://www.hcup-us.ahrq.gov/faststats/NationalProceduresServlet?year1=2014&characteristic1=0&included1=0&year2=2005&characteristic2=0&included2=0&expansionInfoState=hide&dataTablesState=hide&definitionsState=show&exportState=hide

    • Search Google Scholar
    • Export Citation
  • 44

    Martin BI, Turner JA, Mirza SK, Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997–2006. Spine (Phila Pa 1976). 2009;34(19):20772084.

    • Search Google Scholar
    • Export Citation
  • 45

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

    • Search Google Scholar
    • Export Citation
  • 46

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

  • 47

    Ehresman J, Pennington Z, Schilling A, Cost-benefit analysis of tranexamic acid and blood transfusion in elective lumbar spine surgery for degenerative pathologies. J Neurosurg Spine. 2020;33(2):177185.

    • Search Google Scholar
    • Export Citation
  • 48

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

    • Search Google Scholar
    • Export Citation
  • 49

    Burgess LC, Wainwright TW. What is the evidence for early mobilisation in elective spine surgery? A narrative review. Healthcare (Basel). 2019;7(3):92.

    • Search Google Scholar
    • Export Citation
  • 50

    Cassinelli EH, Dean CL, Garcia RM, Ketorolac use for postoperative pain management following lumbar decompression surgery: a prospective, randomized, double-blinded, placebo-controlled trial. Spine (Phila Pa 1976). 2008;33(12):13131317.

    • Search Google Scholar
    • Export Citation
  • 51

    Khurana G, Jindal P, Sharma JP, Bansal KK. Postoperative pain and long-term functional outcome after administration of gabapentin and pregabalin in patients undergoing spinal surgery. Spine (Phila Pa 1976). 2014;39(6):E363E368.

    • Search Google Scholar
    • Export Citation
  • 52

    Ozgencil E, Yalcin S, Tuna H, Perioperative administration of gabapentin 1,200 mg day-1 and pregabalin 300 mg day-1 for pain following lumbar laminectomy and discectomy: a randomised, double-blinded, placebo-controlled study. Singapore Med J. 2011;52(12):883889.

    • Search Google Scholar
    • Export Citation
  • 53

    Khan ZH, Rahimi M, Makarem J, Khan RH. Optimal dose of pre-incision/post-incision gabapentin for pain relief following lumbar laminectomy: a randomized study. Acta Anaesthesiol Scand. 2011;55(3):306312.

    • Search Google Scholar
    • Export Citation
  • 54

    Garcia RM, Cassinelli EH, Messerschmitt PJ, A multimodal approach for postoperative pain management after lumbar decompression surgery: a prospective, randomized study. J Spinal Disord Tech. 2013;26(6):291297.

    • Search Google Scholar
    • Export Citation
  • 55

    Mathiesen O, Dahl B, Thomsen BA, A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery. Eur Spine J. 2013;22(9):20892096.

    • Search Google Scholar
    • Export Citation
  • 56

    Raja S DC, Shetty AP, Subramanian B, A prospective randomized study to analyze the efficacy of balanced pre-emptive analgesia in spine surgery. Spine J. 2019;19(4):569577.

    • Search Google Scholar
    • Export Citation
  • 57

    Bekelis K, Calnan D, Simmons N, Effect of an immersive preoperative virtual reality experience on patient reported outcomes: a randomized controlled trial. Ann Surg. 2017;265(6):10681073.

    • Search Google Scholar
    • Export Citation
  • 58

    Kesänen J, Leino-Kilpi H, Lund T, Increased preoperative knowledge reduces surgery-related anxiety: a randomised clinical trial in 100 spinal stenosis patients. Eur Spine J. 2017;26(10):25202528.

    • Search Google Scholar
    • Export Citation
  • 59

    Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine (Phila Pa 1976). 2014;39(18):14491457.

    • Search Google Scholar
    • Export Citation
  • 60

    Papanastassiou I, Anderson R, Barber N, Effects of preoperative education on spinal surgery patients. SAS J. 2011;5(4):120124.

  • 61

    Zakaria HM, Bazydlo M, Schultz L, Ambulation on postoperative day #0 is associated with decreased morbidity and adverse events after elective lumbar spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative (MSSIC). Neurosurgery. 2020;87(2):320328.

    • Search Google Scholar
    • Export Citation
  • 62

    Chen C-Y, Chang C-W, Lee S-T, Is rehabilitation intervention during hospitalization enough for functional improvements in patients undergoing lumbar decompression surgery? A prospective randomized controlled study. Clin Neurol Neurosurg. 2015;129(suppl 1):S41S46.

    • Search Google Scholar
    • Export Citation
  • 63

    Oestergaard LG, Christensen FB, Nielsen CV, Early versus late initiation of rehabilitation after lumbar spinal fusion: economic evaluation alongside a randomized controlled trial. Spine (Phila Pa 1976). 2013;38(23):19791985.

    • Search Google Scholar
    • Export Citation
  • 64

    Takahashi H, Yokoyama Y, Iida Y, Incidence of venous thromboembolism after spine surgery. J Orthop Sci. 2012;17(2):114117.

  • 65

    Li G, Sun T-W, Luo G, Zhang C. Efficacy of antifibrinolytic agents on surgical bleeding and transfusion requirements in spine surgery: a meta-analysis. Eur Spine J. 2017;26(1):140154.

    • Search Google Scholar
    • Export Citation
  • 66

    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.

    • Search Google Scholar
    • Export Citation
  • 67

    Mu X, Wei J, Wang C, Intravenous administration of tranexamic acid significantly reduces visible and hidden blood loss compared with its topical administration for double-segment posterior lumbar interbody fusion: a single-center, placebo-controlled, randomized trial. World Neurosurg. 2019;122:e821e827.

    • Search Google Scholar
    • Export Citation
  • 68

    Collen JF, Jackson JL, Shorr AF, Moores LK. Prevention of venous thromboembolism in neurosurgery: a metaanalysis. Chest. 2008;134(2):237249.

    • Search Google Scholar
    • Export Citation
  • 69

    Yang S-Y, Jun N-H, Choi Y-S, Efficacy of dexamethasone added to ramosetron for preventing postoperative nausea and vomiting in highly susceptible patients following spine surgery. Korean J Anesthesiol. 2012;62(3):260265.

    • Search Google Scholar
    • Export Citation
  • 70

    Bacchin MR, Ceria CM, Giannone S, Goal-directed fluid therapy based on stroke volume variation in patients undergoing major spine surgery in the prone position: a cohort study. Spine (Phila Pa 1976). 2016;41(18):E1131E1137.

    • Search Google Scholar
    • Export Citation
  • 71

    Alfonso AR, Hutzler L, Lajam C, Institution-wide blood management protocol reduces transfusion rates following spine surgery. Int J Spine Surg. 2019;13(3):270274.

    • Search Google Scholar
    • Export Citation
  • 72

    Dilmen OK, Yentur E, Tunali Y, Does preoperative oral carbohydrate treatment reduce the postoperative surgical stress response in lumbar disc surgery? Clin Neurol Neurosurg. 2017;153:8286.

    • Search Google Scholar
    • Export Citation
  • 73

    He X, Sun T, Wang J, Application of vancomycin powder to reduce surgical infection and deep surgical infection in spinal surgery: a meta-analysis. Clin Spine Surg. 2019;32(4):150163.

    • Search Google Scholar
    • Export Citation
  • 74

    Tubaki VR, Rajasekaran S, Shetty AP. Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients. Spine (Phila Pa 1976). 2013;38(25):21492155.

    • Search Google Scholar
    • Export Citation
  • 75

    Canan CE, Myers JA, Owens RK, Blood salvage produces higher total blood product costs in single-level lumbar spine surgery. Spine (Phila Pa 1976). 2013;38(8):703708.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 279 279 279
Full Text Views 40 40 40
PDF Downloads 25 25 25
EPUB Downloads 0 0 0