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

View More View Less
  • 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
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

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.

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 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.

  • 1

    Ali ZS, Ma TS, Ozturk AK, Malhotra NR, Schuster JM, Marcotte PJ, : 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, : 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, : 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, : 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, : 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, : 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, : 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, : 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, : 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, : 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, : 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, : 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

Metrics

All Time Past Year Past 30 Days
Abstract Views 1516 790 69
Full Text Views 445 165 3
PDF Downloads 370 109 4
EPUB Downloads 0 0 0