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

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  • 1 Department of Neurosurgery,
  • | 2 Center for Clinical Epidemiology and Biostatistics, and
  • | 3 Department of Anesthesia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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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.

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.

In Brief

The authors conducted a pilot prospective cohort analysis comparing clinical outcomes after implementation of an enhanced recovery after surgery (ERAS) protocol compared to a historical control cohort in patients undergoing elective spine/peripheral nerve surgery. The authors demonstrate that 1) establishing a multi-intervention program like ERAS is feasible in this population, and 2) the opioid-sparing multimodal ERAS pain management regimen safely reduces postoperative opioid requirements when compared to traditional postoperative care. The authors conclude that their ERAS program adds to the value and quality of spinal surgical care.

In recent years, enhanced recovery after surgery (ERAS) protocols have emerged as multimodal approaches designed to improve clinical outcomes in surgical patients. ERAS engages all healthcare providers in a longitudinal fashion, with an underlying theme of reduction of the dramatic stress response due to surgery. Coordination among multiple teams (outpatient staff, anesthesia team, surgical team, in-house ward staff, etc.) and dedicated interventional education as well as engagement of patients is critical to ensure a unified approach to the patient’s surgical journey in order to deliver a higher quality of care.14

Since the inception of ERAS,16 multiple surgical fields such as colorectal,5 urology,21 and orthopedic joint surgery6 have applied their respective protocols with varying levels of success. Because the national opioid epidemic is a growing concern in the medical community, and in particular in surgical populations, we hypothesized that the patient-centered approach inherent to ERAS has the potential to decrease overall opioid use both in the short and long term.7,18,24 Indeed, the United States makes up less than 5% of the world’s population but is responsible for 80% of the world’s prescription opioids.19 Directly addressing opioid use with patients as well as the active introduction of a multimodal, opioid-sparing ERAS pain regimen aims to combat this growing public health concern.

In today’s aging population of patients with spinal disorders and multiple comorbid conditions, a comprehensive care pathway like ERAS serves to reduce overall surgical morbidity.9 A neurosurgical ERAS pathway aims to optimize the pre-, peri-, and postoperative care of patients in order to result in a more efficient recovery.8 Despite the success of ERAS in other fields of surgery, development and application of such a pathway has been limited in neurosurgery. There have been some early investigations of its application to lumbar fusion surgery via a minimally invasive surgical procedure,30,31 but no reports have been published on a comprehensive ERAS pathway in elective spine and peripheral nerve surgery. We present our institution’s initial experience with implementation of ERAS in elective spine and peripheral nerve surgery and assess its impact on perioperative and postoperative opioid use.

Methods

Study Design

This is a prospective cohort analysis to evaluate the impact of a novel ERAS protocol for patients undergoing elective spine or peripheral nerve surgery by the same attending neurosurgeons (Z.A., A.O., W.W.) who operate at a single hospital (Pennsylvania Hospital) within the University of Pennsylvania Health System. The 2 cohorts underwent treatment at a single institution before ERAS implementation (September–December 2016) and after ERAS implementation (April–June 2017). Clinical outcomes before and after ERAS implementation were assessed. This study was approved as quality improvement by the institutional review board at the University of Pennsylvania.

Patient Inclusion and Exclusion Criteria

Inclusion criteria consisted of the following: clinical history and diagnostic imaging supporting the need for elective spine or peripheral nerve surgery, age older than 18 years, and the ability to understand and actively participate in the program as deemed by the attending neurosurgeon. Exclusion criteria included the following: contraindications to elective spine or peripheral nerve surgery as deemed by the attending neurosurgeon, diagnosis of liver disease, and pregnancy.

Control Group

The control group was a historical cohort of 74 patients who underwent elective spine and peripheral nerve surgery at Pennsylvania Hospital between September and December 2016. These patients included all individuals who had at least 1-month follow-up data in historical medical records and who underwent traditional surgical care at the discretion of the attending neurosurgeon in a nonstandardized fashion. This care included routine Foley catheter placement peri- or postoperatively, and routine postoperative pain management with patient-controlled analgesia (PCA) postoperatively (i.e., postoperative day [POD] 0–1), among other routine parameters. Patients fasted the night before surgery, beginning at midnight.

ERAS Group

The ERAS group comprised 201 consecutive eligible patients who underwent surgery between April and June 2017 at the same institution. Once an attending neurosurgeon determined that a patient was a candidate for elective spine or peripheral nerve surgery, the patient was prospectively asked for consent and enrolled into a unique ERAS protocol, which is outlined here (Fig. 1) and has previously been published in full.1

FIG. 1.
FIG. 1.

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

Patients underwent extensive preoperative education with the surgeon and advanced care provider in the neurosurgery clinic about the ERAS standardized approach to their pre-, peri-, and postoperative care. In the preoperative setting, patients received surgical site care education. Patients who met the criteria were requested to obtain additional consultations in the preoperative time period with the following specialists: pain management for patients on significant preoperative opioid medications (requiring a > 30 morphine equivalent dose [MED] for > 4 weeks); sleep medicine if the patient had a score of > 2 on the STOP-BANG sleep apnea screening questionnaire; primary care for smoking cessation initiation if applicable; endocrine for diabetic patients with serum glucose > 200 g/dl or HbA1c > 8%. All patients were provided with written educational materials detailing their ERAS surgical journey, as well as being given written educational materials provided by a nutritionist about preoperative protein intake optimization and smoking cessation education if applicable. Patients in the ERAS group completed the Risk Assessment and Prediction Tool (RAPT) preoperatively as a means of educating patients and their families about their discharge disposition. Preoperative nutrition screening for patients with body mass index (BMI) < 18.5 or > 25 kg/m2 with serum albumin levels was performed; patients were referred for nutrition consultation if albumin was < 3.5 g/dl. Patients were also asked to consent to receive mobile text message reminders prior to and following their surgery; this application was facilitated through a pilot program called “Engaged Recovery at Penn” through the Penn Innovation Center. No additional resources were required other than establishing open lines of communication with consulting services to facilitate appointments.

In the perioperative setting, patients were instructed to take a carbohydrate load (20 oz Gatorade or Powerade) the day prior to and on the day of surgery, 2 hours before their scheduled arrival to the hospital. Perioperative pain control was performed via an opioid-sparing multimodality regimen (Fig. 2), which was adapted from the ERAS pathway created by McEvoy et al.20 The Penn Neurosurgery ERAS Pain Management Protocol includes preoperative administration of gabapentin, elimination of the routine use of postoperative intravenous opioids via PCA pumps, and use of acetaminophen. Additionally, local infiltration of bupivacaine at the time of closure was also administered. Other intraoperative analgesia was provided as per the anesthesiologist. Patients were also provided with 1 packet of chewing gum and asked to comply with chewing 1 piece of gum 3 times daily postoperatively to reduce the risk of postoperative ileus.23,26

FIG. 2.
FIG. 2.

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.

Surgery was performed using a Safe Spinal Surgery Checklist, which was designed to engage all operating room staff just prior to closure of the wound to ensure completion of all elements of the desired procedure, including use of drains, local anesthetic, and other components of surgery as deemed necessary by the attending neurosurgeon. Postoperative nursing instructions in the ERAS pathway included the instruction to assist the patients in getting out of bed within 6 hours of surgery. Additionally, nurses were instructed to ambulate patients 3–5 times daily beginning on POD 1 unless bed rest restrictions were applied as deemed by the attending surgeon. Mobilization was defined as any active movement from the bed. Nursing was also encouraged to assist all patients in having meals out of the bed and in a chair. Foley catheter use was limited to those patients with intraoperative durotomies or greater than 3 levels of thoracolumbosacral fusion procedures. A standard wound care regimen was established in which all patients received a chlorhexidine bath daily beginning on POD 1 while in the hospital. After the in-patient hospitalization, in addition to routine follow-up with the surgeon, patients are instructed to follow up routinely with their primary care provider within 2 weeks to maintain continuity of medical care. Patients were also provided with a Web link via text message with resources on nutrition, exercise, and mindfulness after surgery. A postacute care resource triage pathway was developed to provide guidance to nursing home and rehabilitation centers for managing acute neurosurgical patient issues.

Study Parameters

Primary outcomes included the following: opioid and nonopioid consumption on POD 1, need for opioid use at 1 month postoperatively, and patient-reported pain scores. Secondary outcomes included mobilization and ambulation status on POD 0–1, Foley catheter use (intraoperative and postoperative), need for straight catheterization, hospital length of stay (LOS; days), need for ICU admission, discharge status, and readmission within 30 days. Complications were defined as infection, reoperation, deep venous thrombosis or pulmonary embolism, durotomy, cardiac arrest, death, or any adverse event that could be attributed to the surgery and verified via the electronic medical record. Patient-reported outcomes (PROs) were measured using the EuroQol–5 Dimensions Scale (EQ-5D), Oswestry Disability Index (ODI) for patients undergoing lumbar surgery, and the Neck Disability Index (NDI) for patients undergoing cervical surgery. Patients were asked to complete each appropriate questionnaire at their preoperative and 1-month postoperative visit. The mean change in score was calculated for patients with complete pre- and postoperative scores.

Statistical Analysis

Comparisons among various patient characteristics and measurements for the 2 patient groups (control vs ERAS) were performed with independent 2-sample t-tests for continuous variables and Fisher’s exact test for categorical variables. All data for the study were collected and analyzed by independent observers in collaboration with a biostatistician (M.J.K.). SAS software version 9.4 (SAS Institute) was used for all analyses.

Results

Table 1 summarizes the patient demographics for each group. The control group consisted of 74 patients, and the ERAS group was composed of 201 patients. The 2 groups were similar in age, BMI, sex, history of prior spine surgery, preoperative narcotic use, and smoking status. The groups were also similar in preoperative overall health index measured using the EQ-5D and the preoperative disability index measured by the ODI and NDI. Medical comorbidities (such as obstructive sleep apnea, diabetes, chronic obstructive pulmonary disease) in each group were not significantly different. The distribution of surgical procedures between groups was also similar, with the majority of surgeries consisting of laminectomies, discectomies, and foraminotomies (Table 1). Less than 10% of surgeries in both groups consisted of other surgeries; in the control group there were 4 peripheral nerve surgeries, 2 hardware revision/removal surgeries, and 1 repair of durotomy. In the ERAS group there were 4 deep muscle biopsies, 4 peripheral nerve cases, 3 hardware removals, 2 tumor resections, 1 spinal cord detethering, and 1 arachnoid cyst fenestration. The majority of surgeries were performed under general anesthesia. Less than 10% of cases in both groups consisted of outpatient surgery.

TABLE 1.

Baseline demographic data in patients with elective spine and peripheral nerve surgery

CharacteristicControl, n = 74ERAS, n = 201p Value
Age, yrsμ = 62.9 (σ = 11.3)μ = 60.5 (σ = 14.5)0.14
BMIμ = 30.2 (σ = 5.6)μ = 29.7 (σ = 5.4)0.56
Males42 (56.8%)106 (52.7%)0.59*
Prior spinal surgery28 (37.8%)68 (33.8%)0.57*
Preop narcotic use19 (25.7%)47 (23.4%)0.75*
Obstructive sleep apnea13 (17.6%)31 (15.4%)0.71*
Smoking status0.41*
 Current11 (14.9%)20 (10.0%)
 Former30 (40.5%)78 (38.8%)
 Never33 (44.6%)103 (51.2%)
Diabetes16 (21.6%)32 (15.9%)0.29*
Chronic obstructive pulmonary disease4 (5.4%)9 (4.5%)0.75*
Procedures
 1: laminectomy/discectomy/foraminotomy31 (41.9%)95 (47.3%)0.46*
 2: thoracolumbosacral fusion
  <4 levels12 (16.2%)47 (23.4%)
  ≥4 levels3 (4.1%)4 (2.0%)
 3: cervicothoracic laminectomy w/ or w/o fusion
  <4 levels5 (6.8%)17 (8.5%)
  ≥4 levels11 (14.9%)10 (5.0%)
 4: anterior cervical discectomy & fusion
  Total5 (6.8%)13 (6.5%)
  1 level2 (2.7%)9 (4.5%)
  2 levels3 (4.1%)4 (2.0%)
  3 levels0 (0.0%)0 (0.0%)
 5: other7 (9.5%)15 (7.5%)
Patient status
 Inpatient67 (90.5%)182 (90.5%)0.61*
 Outpatient7 (9.5%)15 (7.5%)
 Observational0 (0.0%)4 (2.0%)
Anesthetic type
 General64 (86.5%)180 (89.6%)0.40*
 Spinal10 (13.5%)18 (9.0%)
 MAC0 (0.0%)3 (1.5%)

MAC = monitored anesthesia care; μ = average; σ = standard deviation.

Unless otherwise stated, there were 74 patients in the control group and 201 in the ERAS group.

Compares association between the 2 groups using Fisher’s exact test.

Compares mean differences, pooled method (assuming equal variances across the groups).

Compares mean differences, Satterthwaite method (assuming unequal variances across the groups).

Table 2 outlines opioid and nonopioid consumption in the control group as compared to the ERAS group. A greater proportion of ERAS patients received a combination of at least 3 (72.6% vs 41.9%, p < 0.001) or 4 (44.8% vs 18.9%, p < 0.001) nonopioid agents compared to control patients. PCA use was almost completely eliminated in the ERAS group (0.5%), whereas more than half (54.1%) of patients used PCAs in the control group (p < 0.001). Similarly, the proportion of ERAS patients using opioids at 1 month postoperatively was significantly reduced as compared to the non-ERAS group, half of whom were still using narcotics (38.8% vs 52.7%, p = 0.041). Ketorolac (23.9% vs 10.8%, p = 0.018) and gabapentin (80.6% vs 21.6%, p < 0.001) were more frequently administered to the ERAS patients compared to the control group. Acetaminophen and cyclobenzaprine were used in both populations, with a tendency to be used more frequently in the ERAS group. A similar number of patients in both groups used dexamethasone and diazepam as adjuncts to pain control. Maximum pain scores on POD 0–3 in patients remaining in the hospital were not significantly different between ERAS and control groups (Table 2).

TABLE 2.

Opioid and nonopioid pain medication use in patients with elective spine and peripheral nerve surgery

Variable*Control, n = 74ERAS, n = 201p Value
Opioid medications
 PCA use40 (54.1%)1 (0.5%)<0.001
 No. of patients using any opioid on POD 1 [66/183]63 (95.5%)164 (89.6%)0.21
Maximum overall pain scoreμ = 8.1 (σ = 1.9)μ = 8.0 (σ = 2.2)0.76
 POD 0 [73/199]n = 73/74; μ = 6.4 (σ = 2.7)n = 199/201; μ = 6.6 (σ = 2.9)0.56
 POD 1 [65/181]n = 65/66; μ = 7.6 (σ = 2.4)n = 181/183; μ = 7.5 (σ = 2.3)0.69
 POD 2 [52/139]n = 52/54; μ = 7.6 (σ = 1.9)n = 139/139; μ = 7.1 (σ = 2.4)0.14
 POD 3 [34/78]n = 34/35; μ = 6.5 (σ = 2.6)n = 78/81; μ = 6.9 (σ = 2.4)0.43
Narcotic use postop (1 mo)39 (52.7%)78 (38.8%)0.041
Nonopioid medications
 Acetaminophen62 (83.8%)182 (90.5%)0.13
 Dexamethasone12 (16.2%)27 (13.4%)0.56
 Ketorolac8 (10.8%)48 (23.9%)0.018
 Valium45 (60.8%)119 (59.2%)0.89
 Cyclobenzaprine33 (44.6%)105 (52.2%)0.28
 Gabapentin16 (21.6%)162 (80.6%)<0.001
 ≥3 multimodal nonopioid agents31 (41.9%)146 (72.6%)<0.001
 ≥4 multimodal nonopioid agents14 (18.9%)90 (44.8%)<0.001

Boldface type indicates statistical significance.

Numbers in brackets represent patients from the control group/ERAS group.

Compares association between the 2 groups using Fisher’s exact test.

Compares mean differences, pooled method (assuming equal variances across the groups).

Mobilization and ambulation data were limited in both groups due to lack of nursing data entry. However, based on the available data, the ERAS group demonstrated greater mobilization on POD 0 (53.4% vs 17.1%, p < 0.001) and on POD 1 (84.1% vs 45.7%, p < 0.001) as compared to the control group. Ambulation was also found to be greater in the ERAS group on POD 0 (46.9% vs 17.1%, p = 0.001) and POD 1 (64.2% vs 28.6%, p < 0.001) compared to the control group. Postoperative Foley use was significantly decreased in the ERAS group (20.4% vs 47.3%, p < 0.001) without a significant increase in straight catheterization (11.9% vs 8.1%, p = 0.51).

With regard to resource utilization (Table 3), implementation of ERAS did not significantly increase overall LOS (3.6 vs 4.0 days, p = 0.37) or ICU admission (11.9% vs 14.9%, p = 0.54). The readmission rate at 30 days was also not found to be significantly different between the ERAS patients and the control group (3.0% vs 5.4%, p = 0.47). There was no significant difference in change in PROs (Table 4) at 1 month postoperatively measured with the EQ-5D (−0.5 vs −0.8, p = 0.38), ODI (−4.3 vs −11.8, p = 0.12), or NDI (11.1 vs 11.1, p = 1.00).

TABLE 3.

Mobilization and/or ambulation, urinary retention, and disposition in patients with elective spine and peripheral nerve surgery

Variable*Control, n = 74ERAS, n = 201p Value
Mobilization
 POD 0 [35/178]n = 35/74; 6 (17.1%)n = 178/201; 95 (53.4%)<0.001
 POD 1 [35/164]n = 35/66; 16 (45.7%)n = 164/183; 138 (84.1%)<0.001
Ambulation
 POD 0 [35/177]n = 35/74; 6 (17.1%)n = 177/201; 83 (46.9%)0.001
 POD 1 [35/162]n = 35/66; 10 (28.6%)n = 162/183; 104 (64.2%)<0.001
Urinary retention
 No Foley30 (40.5%)88 (43.8%)<0.001
 Intraop Foley only9 (12.2%)72 (35.8%)
 Postop Foley35 (47.3%)41 (20.4%)
 Straight catheterization6 (8.1%)24 (11.9%)0.51
Disposition
 Overall LOS (days)μ = 4.0 (σ = 3.2)μ = 3.6 (σ = 2.4)0.37
 ICU admission11 (14.9%)24 (11.9%)0.54
 Complications12 (16.2%)22 (10.9%)0.30
 Readmission w/in 30 days4 (5.4%)6 (3.0%)0.47

Boldface type indicates statistical significance.

Numbers in brackets represent patients from the control group/ERAS group.

Compares association between the 2 groups using Fisher’s exact test.

Compares mean differences, Satterthwaite method (assuming unequal variances across the groups).

TABLE 4.

PROs in patients with elective spine and peripheral nerve surgery

Outcome*Control, n = 74ERAS, n = 201p Value
Preop PRO score
 EQ-5D [74/180]μ = 8.8 (σ = 1.7)μ = 9.1 (σ = 1.6)0.29
 ODI [37/145]μ = 40.5 (σ = 17.4)μ = 43.3 (σ = 18.1)0.41
 NDI [13/32]μ = 38.0 (σ = 20.6)μ = 40.4 (σ = 20.0)0.72
 Overall health rating [74/183]μ = 62.5 (σ = 22.4)μ = 66.6 (σ = 19.4)0.14
Postop PRO score (1 mo)
  EQ-5D [61/95]μ = 8.0 (σ = 2.0)μ = 8.4 (σ = 1.8)0.20
  ODI [21/78]μ = 25.4 (σ = 16.5)μ = 37.8 (σ = 19.9)0.010
  NDI [9/18]μ = 43.1 (σ = 18.8)μ = 40.8 (σ = 13.6)0.71
  Overall health rating [61/100]μ = 71.8 (σ = 21.3)μ = 73.0 (σ = 19.1)0.70
Δ in PRO scores
 ΔEQ-5D [61/91]μ = −0.8 (σ = 2.0)μ = −0.5 (σ = 2.0)0.38
 ΔODI [18/72]μ = −11.8 (σ = 12.9)μ = −4.3 (σ = 19.1)0.12
 ΔNDI [7/14]μ = 11.1 (σ = 22.6)μ = 11.1 (σ = 16.5)1.00
 ΔOverall health rating [61/97]μ = 8.3 (σ = 25.9)μ = 4.5 (σ = 22.6)0.33

Δ = change.

Boldface type indicates statistical significance.

Numbers in brackets represent patients from the control group/ERAS group.

Compares mean differences, pooled method (assuming equal variances across the groups).

Discussion

Wainwright et al. first proposed the application of ERAS in major spine surgery.29 Since then, ERAS has made initial forays into the population undergoing elective minimally invasive spine surgery.30,31 We report the clinical outcomes of the first prospective cohort study in which a novel ERAS protocol was used in a heterogeneous population that underwent elective spine and peripheral nerve surgery.

The current opioid epidemic is a public health emergency in the United States.18 Three-quarters of our institution’s spinal and peripheral nerve surgical population represent opioid-naïve patients. There is an increasing amount of data supporting the finding that between 3% and 7% of opioid-naïve patients undergoing surgery continued to take opioids 1 year after surgery.27 Decreasing opioid use after spine surgery is a daunting task, but our multidimensional ERAS protocol addresses this issue, in part, by using a multimodal, opioid-sparing approach to spine surgery pain management. PCA use with intravenous opioids was nearly completely eliminated in the ERAS group (0.5% vs 54.1%, p < 0.001). This was accomplished without an increase in pain scores in the ERAS population, suggesting that routine PCA use is not necessary in this population. We believe that the addition of multiple nonopioid agents, such as acetaminophen and preoperative gabapentin, among other agents, helps to mitigate the need for routine PCA use and overall opioid use in patients following spine surgery. Most notably, our results show that the adoption of an opioid-sparing multimodal pain regimen following spine surgery via an ERAS pathway resulted in reduced opioid use at 1 month postoperatively. This has profound implications in helping to limit the chronic opioid dependency in patients following spine surgery, but further studies will need to assess the durability of this change.

The cognitive-behavioral phenomenon of fear avoidance further perpetuates pain in the patient undergoing spine surgery.13,17 Postoperative fear of movement has strong associations with pain, disability, and physical health in patients who undergo spine surgery.2 To combat this, strict parameters for early ambulation were prescribed in the ERAS protocol, and indeed, the ERAS group exhibited greater mobilization and ambulation on POD 0–1 than the control group. We believe that addressing the fear of movement immediately in the postoperative period by encouraging timely postoperative mobility and ambulation reduces immobility and enhances recovery. Early and aggressive mobility in the ERAS cohort did not result in increased pain, and no changes in LOS were observed in our pilot program. This may be due to a modest sample size.

Foley catheters are associated with acute25 and chronic12 urinary tract infections, urethral trauma,15 kidney and bladder damage,11 bladder stones,10 and pseudopolyps.22 Conscious limitation of the use of Foley catheters in the patient undergoing spine surgery has the potential to avoid or minimize numerous adverse effects as well as allow for ease in patient mobility and ambulation. The ERAS group demonstrated significantly less postoperative Foley use compared to the pre-ERAS group. This factor was not found to result in an increase in straight catheterization. Because postoperative urinary retention (POUR) can increase the LOS and impact surgical morbidity,3 avoiding the use of Foley catheters is a major goal during the inpatient period for patients who do not require bed restrictions. Our findings suggest that such avoidance may be associated with improved inpatient mobility and ambulation.

ERAS implementation did not result in increased overall LOS or ICU admission. Patients in the ERAS group demonstrated a trend toward reduced LOS, which perhaps may be more apparent with a larger cohort analysis. The readmission and complications rates at 30 days were not found to be significantly different, although these conclusions may also be limited due to the small sample size.

The major goals of the ERAS pathway are to optimize the surgical experience for patients and improve their clinical outcomes. The patient population undergoing spine and peripheral nerve surgery is indeed heterogeneous. This care paradigm relies on the multidisciplinary and collaborative care of all individuals involved in the patient’s surgical journey to engage in the patient’s care in a relatively standardized fashion. We believe that the incremental benefits of the various elements of the ERAS pathway translate into improved overall care in the form of a reduction in opioid use.

Future directions aim to include cost-effectiveness of the ERAS protocol as well as PRO measures with well-validated questionnaires such as the Patient-Reported Outcomes Measurement Information System (PROMIS), ODI, NDI, and EQ-5D. PROs have become the gold standard to measure clinical efficacy after a surgical intervention,4,28 and such questionnaires in the pre- and postoperative time points provide both the patient and the neurosurgeon with insight into the patient’s overall clinical function and improvement. We also hope to study the effects of the ERAS protocol on overall health, such as long-term improvements in BMI and A1C.

Limitations of the Study

There are several limitations to this study. This is a prospective cohort analysis limited by a moderate sample size. The control group is a historical one, and the data were reviewed retrospectively. Randomization and blinding were not performed. Data collection is limited to the information provided in medical records. Minor protocol deviations from this multimodal pathway were not well documented and are difficult to assess. Baseline activity level and cognitive function can lead to bias within the ERAS or control groups. Differences in these factors were not fully explored but could introduce selection bias. We hope that a future randomized controlled design can help eliminate any forms of selection bias. Although we monitored medical comorbidities and assessed for overall trends, we have not yet studied the compliance of patients in performing all recommended preoperative consultations. However, we believe that the value of a formalized ERAS pathway allows for better surgical education for patients preoperatively. Because expectations drive patients’ outcomes, we believe that ERAS aids in aligning expectations and personalizing surgical education.

Despite these limitations, this study demonstrates the safety and efficacy of our Penn Neurosurgery ERAS protocol. We continue to refine the pathway and monitor outcomes. An ERAS pathway similar to this one can be safely incorporated in other centers performing spine and peripheral nerve surgery and, based on these data, has the potential to result in improved outcomes.

Conclusions

ERAS engages each aspect of the patient’s surgical journey in order to improve outcomes in a multidisciplinary, multimodal approach. In the patient undergoing elective spine and peripheral nerve surgery, ERAS is feasible and necessary to optimize the value of neurosurgical care. The present study has shown that our ERAS protocol greatly improves postoperative mobilization and ambulation and, most importantly, has the potential to safely reduce opioid use both in the perioperative period and at 1 month after surgery, with important potential for relief of chronic opioid dependence.

Acknowledgments

We thank the personnel in the Neurosurgery Clinical Research Division, who contributed to data acquisition in this manuscript. Some data capture was made possible by the Neurosurgery Quality Improvement Initiative (NQII) EpiLog project. We also thank the Penn Innovation Center for allowing us to participate in Engaged Recovery at Penn.

Disclosures

Dr. Welch reports ownership of Transcendental Spine.

Author Contributions

Conception and design: Ali, Kallan. Acquisition of data: Leszinsky, McShane. Analysis and interpretation of data: Ali, Kallan. Drafting the article: Ali, Flanders. Critically revising the article: Ali, Flanders, Ozturk, Malhotra, McShane, Chen, Schuster, Grady, Welch. Reviewed submitted version of manuscript: Ali, Flanders, Ozturk, Malhotra, Leszinsky, Gardiner, Rupich, Chen, Schuster, Marcotte, Grady, Fleisher, Welch. Approved the final version of the manuscript on behalf of all authors: Ali. Statistical analysis: Kallan. Administrative/technical/material support: Ali, Flanders, Leszinsky, McShane, Gardiner, Rupich, Marcotte, Grady, Fleisher, Welch. Study supervision: Ali, Gardiner, Rupich, Grady, Fleisher, Welch.

Supplemental Information

Previous Presentations

Part of this work was presented at the AANS annual meeting plenary session: “Enhanced Recovery After Surgery (ERAS) decreases post-operative opioid use in elective spine and peripheral nerve surgery.” AANS annual meeting, Plenary I; New Orleans, LA, April 30, 2018. A portion of this work was also presented at the AANS Spine section meeting: “Enhanced Recovery After Surgery (ERAS) protocol in spinal and peripheral nerve surgery improves postoperative mobility and ambulation.” DSPN (Disorders of the Spine and Peripheral Nerves) meeting; Orlando, FL, March 16, 2018.

References

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    Ali ZS, Ma TS, Ozturk AK, Malhotra NR, Schuster JM, Marcotte PJ, et al.: Pre-optimization of spinal surgery patients: development of a neurosurgical enhanced recovery after surgery (ERAS) protocol. Clin Neurol Neurosurg 164:142153, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Archer KR, Wegener ST, Seebach C, Song Y, Skolasky RL, Thornton C, et al.: The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions. Spine (Phila Pa 1976) 36:15541562, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Baldini G, Bagry H, Aprikian A, Carli F: Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 110:11391157, 2009

  • 4

    Black N: Patient reported outcome measures could help transform healthcare. BMJ 346:f167, 2013

  • 5

    Brescia A, Tomassini F, Berardi G, Sebastiani C, Pezzatini M, Dall’Oglio A, et al.: 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 69:359365, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Christelis N, Wallace S, Sage CE, Babitu U, Liew S, Dugal J, et al.: An enhanced recovery after surgery program for hip and knee arthroplasty. Med J Aust 202:363368, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN: Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ 348:g1251, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Dangayach NS, Caridi J, Bederson J, Mayer SA: Enhanced Recovery After Neurosurgery: paradigm shift and call to arms. World Neurosurg 100:683685, 2017

  • 9

    Fehlings MG, Tetreault L, Nater A, Choma T, Harrop J, Mroz T, et al.: The aging of the global population: the changing epidemiology of disease and spinal disorders. Neurosurgery 77 (Suppl 4):S1S5, 2015

    • Search Google Scholar
    • Export Citation
  • 10

    Feneley R, Painter D, Evans A, Stickler D: Bladder catheterisation. Br J Gen Pract 52:500, 2002

  • 11

    Feneley RC, Hopley IB, Wells PN: Urinary catheters: history, current status, adverse events and research agenda. J Med Eng Technol 39:459470, 2015

  • 12

    Garcia MM, Gulati S, Liepmann D, Stackhouse GB, Greene K, Stoller ML: Traditional Foley drainage systems—do they drain the bladder? J Urol 177:203207, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Grotle M, Vøllestad NK, Brox 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) 31:10381046, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kahokehr A, Sammour T, Zargar-Shoshtari K, Thompson L, Hill AG: Implementation of ERAS and how to overcome the barriers. Int J Surg 7:1619, 2009

  • 15

    Kashefi C, Messer K, Barden R, Sexton C, Parsons JK: Incidence and prevention of iatrogenic urethral injuries. J Urol 179:22542258, 2008

  • 16

    Kehlet H: Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78:606617, 1997

  • 17

    Landers MR, Creger RV, Baker CV, Stutelberg KS: The use of fear-avoidance beliefs and nonorganic signs in predicting prolonged disability in patients with neck pain. Man Ther 13:239248, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Manchikanti L, Helm S II, Fellows B, Janata JW, Pampati V, Grider JS, et al.: Opioid epidemic in the United States. Pain Physician 15 (3 Suppl):ES9ES38, 2012

    • Search Google Scholar
    • Export Citation
  • 19

    Manchikanti L, Singh 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):S63S88, 2008

    • Search Google Scholar
    • Export Citation
  • 20

    McEvoy MD, Scott MJ, Gordon DB, Grant SA, Thacker JKM, Wu CL, et al.: 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) 6:8, 2017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Melnyk M, Casey RG, Black P, Koupparis AJ: Enhanced recovery after surgery (ERAS) protocols: time to change practice? Can Urol Assoc J 5:342348, 2011

  • 22

    Milles G: Catheter-induced hemorrhagic pseudopolyps of the urinary bladder. JAMA 193:968969, 1965

  • 23

    Pereira Gomes Morais E, Riera R, Porfírio GJ, Macedo CR, Sarmento Vasconcelos V, de Souza Pedrosa A, et al.: Chewing gum for enhancing early recovery of bowel function after caesarean section. Cochrane Database Syst Rev 10:CD011562, 2016

    • Search Google Scholar
    • Export Citation
  • 24

    Rajpal S, Gordon DB, Pellino TA, Strayer AL, Brost D, Trost GR, et al.: Comparison of perioperative oral multimodal analgesia versus IV PCA for spine surgery. J Spinal Disord Tech 23:139145, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Saint S, Kowalski CP, Kaufman SR, Hofer TP, Kauffman CA, Olmsted RN, et al.: Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis 46:243250, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Short V, Herbert G, Perry R, Atkinson C, Ness AR, Penfold C, et al.: Chewing gum for postoperative recovery of gastrointestinal function. Cochrane Database Syst Rev (2):CD006506, 2015

    • Search Google Scholar
    • Export Citation
  • 27

    Sun EC, Darnall BD, Baker LC, Mackey S: Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med 176:12861293, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Valderas JM, Kotzeva A, Espallargues M, Guyatt G, Ferrans CE, Halyard MY, et al.: The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature. Qual Life Res 17:179193, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

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

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    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 83:827834, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

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

    • Crossref
    • Search Google Scholar
    • Export Citation

Multidisciplinary surgical planning for a patient with myxoid liposarcoma extending from C4 to T1. See the article by Ahmed et al. (pp 424–431).

  • 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.

  • 1

    Ali ZS, Ma TS, Ozturk AK, Malhotra NR, Schuster JM, Marcotte PJ, et al.: Pre-optimization of spinal surgery patients: development of a neurosurgical enhanced recovery after surgery (ERAS) protocol. Clin Neurol Neurosurg 164:142153, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Archer KR, Wegener ST, Seebach C, Song Y, Skolasky RL, Thornton C, et al.: The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions. Spine (Phila Pa 1976) 36:15541562, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Baldini G, Bagry H, Aprikian A, Carli F: Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 110:11391157, 2009

  • 4

    Black N: Patient reported outcome measures could help transform healthcare. BMJ 346:f167, 2013

  • 5

    Brescia A, Tomassini F, Berardi G, Sebastiani C, Pezzatini M, Dall’Oglio A, et al.: 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 69:359365, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Christelis N, Wallace S, Sage CE, Babitu U, Liew S, Dugal J, et al.: An enhanced recovery after surgery program for hip and knee arthroplasty. Med J Aust 202:363368, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN: Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ 348:g1251, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Dangayach NS, Caridi J, Bederson J, Mayer SA: Enhanced Recovery After Neurosurgery: paradigm shift and call to arms. World Neurosurg 100:683685, 2017

  • 9

    Fehlings MG, Tetreault L, Nater A, Choma T, Harrop J, Mroz T, et al.: The aging of the global population: the changing epidemiology of disease and spinal disorders. Neurosurgery 77 (Suppl 4):S1S5, 2015

    • Search Google Scholar
    • Export Citation
  • 10

    Feneley R, Painter D, Evans A, Stickler D: Bladder catheterisation. Br J Gen Pract 52:500, 2002

  • 11

    Feneley RC, Hopley IB, Wells PN: Urinary catheters: history, current status, adverse events and research agenda. J Med Eng Technol 39:459470, 2015

  • 12

    Garcia MM, Gulati S, Liepmann D, Stackhouse GB, Greene K, Stoller ML: Traditional Foley drainage systems—do they drain the bladder? J Urol 177:203207, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Grotle M, Vøllestad NK, Brox 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) 31:10381046, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kahokehr A, Sammour T, Zargar-Shoshtari K, Thompson L, Hill AG: Implementation of ERAS and how to overcome the barriers. Int J Surg 7:1619, 2009

  • 15

    Kashefi C, Messer K, Barden R, Sexton C, Parsons JK: Incidence and prevention of iatrogenic urethral injuries. J Urol 179:22542258, 2008

  • 16

    Kehlet H: Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78:606617, 1997

  • 17

    Landers MR, Creger RV, Baker CV, Stutelberg KS: The use of fear-avoidance beliefs and nonorganic signs in predicting prolonged disability in patients with neck pain. Man Ther 13:239248, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Manchikanti L, Helm S II, Fellows B, Janata JW, Pampati V, Grider JS, et al.: Opioid epidemic in the United States. Pain Physician 15 (3 Suppl):ES9ES38, 2012

    • Search Google Scholar
    • Export Citation
  • 19

    Manchikanti L, Singh 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):S63S88, 2008

    • Search Google Scholar
    • Export Citation
  • 20

    McEvoy MD, Scott MJ, Gordon DB, Grant SA, Thacker JKM, Wu CL, et al.: 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) 6:8, 2017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Melnyk M, Casey RG, Black P, Koupparis AJ: Enhanced recovery after surgery (ERAS) protocols: time to change practice? Can Urol Assoc J 5:342348, 2011

  • 22

    Milles G: Catheter-induced hemorrhagic pseudopolyps of the urinary bladder. JAMA 193:968969, 1965

  • 23

    Pereira Gomes Morais E, Riera R, Porfírio GJ, Macedo CR, Sarmento Vasconcelos V, de Souza Pedrosa A, et al.: Chewing gum for enhancing early recovery of bowel function after caesarean section. Cochrane Database Syst Rev 10:CD011562, 2016

    • Search Google Scholar
    • Export Citation
  • 24

    Rajpal S, Gordon DB, Pellino TA, Strayer AL, Brost D, Trost GR, et al.: Comparison of perioperative oral multimodal analgesia versus IV PCA for spine surgery. J Spinal Disord Tech 23:139145, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Saint S, Kowalski CP, Kaufman SR, Hofer TP, Kauffman CA, Olmsted RN, et al.: Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis 46:243250, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Short V, Herbert G, Perry R, Atkinson C, Ness AR, Penfold C, et al.: Chewing gum for postoperative recovery of gastrointestinal function. Cochrane Database Syst Rev (2):CD006506, 2015

    • Search Google Scholar
    • Export Citation
  • 27

    Sun EC, Darnall BD, Baker LC, Mackey S: Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med 176:12861293, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Valderas JM, Kotzeva A, Espallargues M, Guyatt G, Ferrans CE, Halyard MY, et al.: The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature. Qual Life Res 17:179193, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

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

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    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 83:827834, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

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

    • Crossref
    • Search Google Scholar
    • Export Citation

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