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

Zach Pennington Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

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Ethan Cottrill Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

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Daniel Lubelski Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

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Jeff Ehresman Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

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Nicholas Theodore Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

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Daniel M. Sciubba Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

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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.

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.

In Brief

Enhanced Recovery After Surgery (ERAS) protocols—multimodal care pathways designed to accelerate postoperative patient recovery—have been widely adopted in general surgery and are increasingly being employed in spine surgery. The present systematic review found that spine ERAS protocols decrease hospitalization times without altering complication or readmission rates. However, this review also highlights the absence of a current consensus on what constitutes a spine ERAS protocol and identifies the need for further high-quality evidence.

In an effort to reduce variability, improve outcomes, and reduce cost in spinal surgery, there has been a recent drive to identify care pathways that result in consistently good, cost-effective outcomes for patients. This drive has led to the development of Enhanced Recovery After Surgery (ERAS) pathways, which were first described as “fast-track surgery” in the cardiac surgery literature in the 1990s.1 ERAS pathways are defined by the ERAS Society as any perioperative care pathway designed to accelerate patient recovery after major surgery.2 Elements of ERAS are evidence-based and may address topics such as nutrition, postoperative analgesia, and mobilization. ERAS protocols aim to reduce complication rates and length of stay (LOS), accelerate functional recovery, and increase cost-effectiveness by reducing hospitalizations, readmissions, and personnel costs.1 They have been shown to have many of these benefits when implemented in general surgical fields, including colorectal surgery,3 hepatobiliary surgery,4 urology,5 and thoracic surgery.6 Their implementation within spine surgery is newer, with increasing publications in recent years.7–33 We sought to perform a systematic review of the adult spine population to 1) identify the commonly employed components in previously published spine surgery ERAS protocols; 2) evaluate the evidence base for spine ERAS protocols with regard to the ability to lower costs, LOS, complication rates, and opioid use; and 3) highlight shortcomings in the existing data and identify areas for further research.

Methods

We conducted a literature search according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on March 22, 2020, using the following search string, which was modified to fit the input of each of the queried databases: (“eras” OR “enhanced recovery after surgery” OR “fast recovery” OR “fast track”) AND (“spine” OR “spinal” OR “spine surgery” OR “laminectomy” OR “interbody fusion” OR “diskectomy” OR “discectomy” OR “spinal fusion”). Queried databases included PubMed/Medline, Web of Science, the Cochrane Reviews library, Embase, CINAHL, and OVID Medline. Additionally, we queried the bibliographies of included studies for additional relevant articles.

To be included, articles had to 1) describe the application of an ERAS protocol to 5 or more patients undergoing elective spine surgery, 2) report results for an adult population (≥ 18 years old), and 3) report results for at least one of the following outcomes: complication rate, postoperative quality of life/patient-reported outcomes (PROs), hospitalization/LOS, postoperative pain scores, and postoperative opioid use. To qualify as an ERAS protocol, we required that at least two interventions (e.g., multimodal analgesia and early mobilization) be applied; single interventions (e.g., early mobilization alone) were not classified as ERAS protocols. Articles were also excluded if they were abstracts only, did not provide primary data (i.e., were reviews, opinion pieces, commentaries, perspectives, or technical notes), described results for a pediatric population (age < 18 years old), or described data for fewer than 5 patients. We screened articles using Covidence, and studies were assigned levels of evidence based on the classification adopted by the North American Spine Society.34 Articles were independently screened by two reviewers (Z.P. and E.C.), with a third reviewer (J.E.) serving as referee in cases of disagreement. Data extracted included surgery type, use of a control protocol, ERAS protocol elements, number of patients treated under the ERAS and control protocols, length of LOS, intraoperative blood loss, operation duration, complication rate, wound infection rate, readmission rate, reoperation rate, and PROs.

Meta-Analysis

All included studies that directly compared outcomes between patients treated using ERAS protocols and conventional care pathways were included in the quantitative meta-analyses. Studies were split based on the types of patients enrolled. After performing a qualitative review, we deemed that there were sufficient data to perform quantitative meta-analyses for general ERAS protocols (those applied to all spine patients treated at the center) and lumbar spine surgery–specific protocols. All quantitative analyses were performed using RevMan 5.3 (Cochrane) using random-effects modeling. Endpoints examined in the meta-analysis were standard differences in LOS, and odds ratios for complication rate, wound infection rate, 30-day readmission rate, and ICU admission rate.

Results

Our search (Fig. 1) identified 950 unique articles, of which 67 underwent full-text review, yielding 27 articles for inclusion in the qualitative analysis7–33 and 14 articles for inclusion in the quantitative analysis.8–15,19,28–31,33 Reasons for exclusion were being abstracts only (n = 19), failing to present primary data (n = 12), describing results in a pediatric population (n = 7), failing to describe the ERAS protocol (n = 1), and lacking full-text English-language translation (n = 1). Of the included studies, 1 article was level II evidence,7 while the remainder were level III8–16,19,27–33 (n = 17) or level IV17,18,20–26 (n = 9) evidence. Nine studies described ERAS protocols applied to all elective spine patients,8,17–19,27–31 2 described protocols for cervical spine surgery patients,21,32 14 described lumbar-specific surgery protocols,9–15,20,22–26,33 and 2 described protocols for patients undergoing spine tumor surgery.7,16

FIG. 1.
FIG. 1.

PRISMA flow diagram for the results of the literature search. Figure is available in color online only.

General Spine Surgery ERAS Protocols

Nine studies8,17–19,27–31 described 6988 patients treated under 7 distinct general spine surgery protocols (Table 1). The most common elements in the described ERAS protocols were patient education (6 protocols [7 studies, with 2 from the same practice28,30]);8,17–19,28–30 smoking cessation (4 studies);8,18,19,27 multimodal opioid-sparing analgesia during the intraoperative or postoperative period (9 studies);8,17–19,27–31 tranexamic acid (TXA) use to reduce intraoperative blood loss (3 studies);27,28,30 goal-directed fluid replacement intraoperatively (2 studies);18,27 urinary catheter discontinuation within 24–48 hours postoperatively (4 studies);18,27,28,30 early drain removal (2 studies);18,31 mechanical venous thromboembolism (VTE) prophylaxis (2 studies);27,31 early resumption of enteral feeding (2 studies);18,30 and early postoperative mobilization (4 studies).17,18,29,31 Seven studies8,19,27–31 directly compared patients treated under ERAS protocols with historical controls treated under conventional care pathways. One study found that patients treated with ERAS had lower transfusion requirements,27 2 found decreased ICU admissions (range 1.4–2.6 days),28,30 1 found earlier urinary catheter discontinuation,19 4 found decreased LOS (range 0.5–3.5 days),8,28–30 2 found lower complication rates (range 0.7%–5.3%),29,31 1 showed lower wound infection rates,27 1 showed lower postoperative narcotic use,8 and 1 found earlier mobilization.8 No studies reported significant differences in 30-day readmission rates; however, Debono et al.29 found that ERAS implementation led to lower 90-day reoperation rates among patients undergoing posterior lumbar fusion. Three studies also collected PRO data, with Angus et al. finding ERAS patients to have higher satisfaction scores19 and two independent groups finding that ERAS and traditional pathway patients experience similar improvements in terms of pain and disability.8,31 Two studies performed economic analyses and found ERAS to lower total costs. Carr et al.28 performed a component analysis and found that the cost savings were driven by a combination of reduced indirect costs and nonimplant direct costs. Similar reductions in indirect costs and nonimplant direct costs were reported in a subsequent analysis by the same group.30

TABLE 1.

Summary of generalized ERAS protocols for elective surgeries to address degenerative disease or deformity

Authors & Year (LOE)No. of PtsSurgery TypePopulation DetailsProtocolResults
Ali et al., 20198 (III)201Spine or peripheral nerve surgeryComparison of 201 ERAS pts w/ 74 historical controlsPreop: pt education; nutrition optimization & DM2 + OSA management; opioid & smoking cessation counselingLOS: 3.6 ± 2.4 vs 4.0 ± 3.2 days, NS
95 laminectomy/discectomy/foraminotomySimilar in terms of smoking percentage, age, sex, & prevalence of DM2, COPD, & OSAIntraop: metabolism management w/ periop carbohydrate loading; multimodal opioid-sparing analgesiaICU: ↔ in ICU time
51 thoracolumbosacral fusionPostop: early mobilization; wound care management w/ daily chlorhexidine skin bath; “triage pathway” including primary physician FU w/in 2 wksCR: 10.9 vs 16.2%, NS
27 cervicothoracic laminectomy w/ or w/o fusionFoley discont’d: 35.8 vs 12.2% on POD0, p < 0.001
26 ACDFPT: ↑ odds of mobilization & ambulation on POD0 & POD1
15 otherAnalgesia: ↓ postop PCA use; ↓ narcotic use @ 1-mo FU (38.8 vs 52.7%, p = 0.04)
30-day readmit: 3.0 vs 5.4%, NS
↔ in POD0–3 pain scores
↓ postop PCA use
↓ narcotic use @ 1-mo FU (38.8 vs 52.7%, p = 0.04)
PROs: ↔ Δ in EQ-5D, ODI, NDI, & overall health rating @ 1-mo FU
Angus et al., 201919 (III)214“Complex spine surgery” including PLIF & scoliosis correctionComparison of 214 ERAS pts w/ 412 historical controlsPreop: pt education; prehabilitation therapy; vitamin D check; smoking cessation; anesthesia assessment; preop carbohydrate loadingLOS: 8.7 vs 12.2 days, no stats
Populations similar in sex, ASA status, spine surgery history, baseline core outcome measure indexIntraop: noneCR: intraop 6.1 vs 6.8%, NS; postop 3.3 vs 4.9%, NS
ERAS pts slightly older, higher mean BMI, worse preop leg painPostop: multimodal analgesia; “care pathway”30-day readmit: 1.9 vs 2.1%, NS
PRO: ↑ postop satisfaction
Most staff endorse ERAS as better for providers & for pt care
Chakravarthy et al., 201927 (III)799All surgeries for degenerative disease eligibleComparison of 799 pts treated under ERAS protocol w/ 971 historical controlsPreop: smoking cessation; correction of anemia (target Hgb >13 g/dL); DM2, BMI optimization (no elective surgery if BMI >40); frailty assessment for pts >75 yrsCR: ↔, no specifics
Intraop: goal-directed fluid management w/ balanced crystalloids; TXA (1 g), cell saver to ↓ EBLWnd infx: 2 vs 4%, p = 0.02
Postop: multimodal, opioid-sparing analgesia; epidural analgesia; discont’d Foley POD1; mobilization ≤8 hrs postop; mechanical VTE prophylaxis↓ transfusion rate: 7.7 vs 20.1%, p = 0.004
Carr et al., 201928 (III)620“Major spine surgery”Comparison of 620 pts treated w/ ERAS pathway w/ 183 historical controls & 129 nonpathway, contemporary controls identified by similar CPT & ICD-9 codesPreop: pt education; multimodal analgesia; carbohydrate loading (300 mL solution 2 hrs preop); active OR warmingOR time: 439 ± 164 vs 436 ± 139 mins, NS
Anterior-posterior surgeryPopulations similar in age, sex, ASA status, case-mix indexIntraop: 4 mg IV ondansetron for nausea/emesis prophylaxis; TXA (1 g)LOS: 5.4 vs 8.0 days, p < 0.02
≥4-level index caseERAS had more comorbidities than contemporary controls (CCI)Postop: full diet POD1; discont’d Foley POD2; multimodal, opioid-sparing analgesia including ketamineICU time: 1.8 vs 2.5 days, p < 0.02
≥3-level revision↓ total cost by $5889, p < 0.01
Anterior revision↓ indirect cost by $2839, p < 0.01
Expected duration ≥6 hrs↓ nonimplant direct cost by $4102, p < 0.01
Expected EBL ≥1 L↓ costs for periop services, bed & nursing, lab medicine, clinical services, transfusion services, imaging; all p < 0.01
Staged surgery
Corpectomy, PSO
Dagal et al., 201930 (III)267Major spine surgeryComparison of 267 pts undergoing surgery w/ ERAS protocol to 183 historic controls & 108 nonprotocol contemporary controls identified by similar CPT & ICD-9 codesPreop: pt education; multimodal analgesia; carbohydrate loading (300-mL solution 2 hrs preop); active OR warmingLOS: 6.1 ± 3.6 vs 7.6 ± 5.1 days, p = 0.006
Anterior-posterior surgeryPopulations similar in age, sex, comorbidities, case-mix indexIntraop: 4 mg IV ondansetron for nausea/emesis prophylaxis; TXA (1 g)ICU time: 1.9 ± 1.4 vs 3.3 ± 2.8 days, p = 0.001
≥4-level index caseASA status higher in ERAS vs contemporary controls (p < 0.001)Postop: full diet POD1; discont’d Foley POD2; multimodal, opioid-sparing analgesia including ketamineCR: 10.5 vs 7.4%, NS
≥3-level revisionWnd infx: 8.2 vs 6.5%, NS
Anterior revision30-day readmit: 9.7 vs 9.3%, NS
Expected duration ≥6 hrs↔ total cost by $4572, NS
Expected EBL ≥1 L↓ indirect cost by $2224, p = 0.03
Staged surgery; corpectomy, PSO↓ nonimplant direct cost by $3555, p = 0.01
Debono et al., 201929 (III)1920202 ALIFComparison of 1920 ERAS pts w/ 1563 historical controls treated w/ standard of carePreop: anesthesia consultation; pt education; OR disinfection; allowed to eat until 6 hrs preop, clear liquids until 2 hrs preopLOS: ALIF (3.3 ± 0.8 vs 6.1 ± 1.1 days), ACDF (1.3 ± 0.7 vs 3.1 ± 0.9 days), posterior fusion (4.8 ± 2.3 vs 6.7 ± 4.8 days); all p < 0.001
612 ACDFCohorts were similar in terms of age, sex, BMI, & tobacco useIntraop: no routine drain placedCR: ALIF (11.4 vs 11.9%, NS), ACDF (8.2 vs 6.0%, NS), posterior fusion (10.9 vs 14.8%, p = 0.03)
1106 posterior lumbar fusionPostop: multimodal, opioid-sparing analgesia; early mobilizationWnd infx: ALIF (3.5 vs 3.1%), ACDF (0.5 vs 0.5%), posterior fusion (2.5 vs 3.8%); all NS
90-day readmit: ALIF (3.0 vs 3.1%), ACDF (1.5 vs 2.1%), posterior fusion (6.1 vs 8.1%); all NS
90-day reop: ALIF (1.5 vs 1.9%, NS), ACDF (0.8 vs 1.3%, NS), posterior fusion (3.7 vs 6.1%, p = 0.03)
Pts report high overall levels of satisfaction
Sivaganesan et al., 201931 (III)151106 lumbar surgeryComparison of 151 pts treated under ERAS protocol to 1596 historical controls treated w/ conventional carePreop: organize d/c planningEBL: 265 ± 309 vs 333 ± 373 mL, p = 0.01
45 cervical surgeryGroups comparable in terms of age, race, sex, BMI, tobacco use, comorbidities, ASA grade, & diagnosisIntraop: addition of gram-negative antibiotic coverage, if pt has risk factorsOR time: 182.8 ± 69.9 vs 179.2 ± 83.9 mins, NS
ERAS group had longer average symptom duration, shorter preop opioid use, & higher prevalence of COPDPostop: immediate mobilization unless durotomy w/ poor primary repair (24-hr rest); multimodal, opioid-sparing analgesia; discont’d drain POD2 or if output <100 mL/8 hrs; mechanical DVT prophylaxis, pharmacological if staged surgery or indication is trauma/tumorLOS: 2.3 ± 1.7 vs 2.6 ± 2.1 days, p = 0.07; ↓ for L-spine, p < 0.05
ERAS had lower baseline disability on ODI (not clinically significant)CR: 4.6 vs 11.3%, p = 0.009
90-day readmit: 3.3 vs 4.7%, NS
↔ overall satisfaction, satisfaction w/ provider, or satisfaction w/ nursing staff
↔ in 90-day outcomes for pain, ODI, or EQ-5D in C- or L-spine pts
Staartjes et al., 201918 (IV)257961 MIS ALIFNo comparison groupPreop: smoking & EtOH cessation ≥3 mos preop; anesthesia screening; weight loss to BMI ≤30; pt education; heparin VTE prophylaxisOR time: 32.2 ± 29.7 mins
87 MIS TLIFEvaluation of outcomes in 2579 pts treated under ERAS protocol; comparison of outcomes in different surgical typesIntraop: local analgesia w/ ropivacaine; prioritize MIS techniques; limited muscle relaxant; normothermia, normovolemia maintenance; avoid drain when possibleLOS: 1.1 ± 1.2 days
51 MIS robot-assisted PLIFIndications: disc herniation (74%), stenosis (17%), degenerative disc disease (4%), spondylolisthesis (4%), facet joint cyst (1%)Postop: early discont’d drain & Foley; mobilization ≤2 hrs postop; multimodal, opioid-sparing analgesia; early oral intake; target d/c POD1CR: 4%
1929 tubular lumbar microdiscectomy30-day readmit: 1%
451 mini-open lumbar decompressionReop (all): 8%
On average, all groups had good improvement in EQ-5D, ODI, pain scores at 6 wks & 1 yr postop
Significant ↓ in surgery length (p < 0.001) & complication rate (p = 0.03) w/ increasing experience under ERAS protocol
NS trend toward ↓ LOS; significant ↓ LOS among fusion pts (p < 0.001)
Venkata & van Dellen, 201817 (IV)237187 lumbar decompression or discectomyNo comparison groupPreop: in-depth preop counseling/pt education; coordination of post-d/c wound care & FULOS: 95% POD1 (53.2% ≤24 hrs postop)
145 1-levelEvaluation of outcomes in 237 pts treated under enhanced recovery pathwayIntraop: no monopolar cautery; low opioid analgesiaCR: 2.1%
30 2-levelPostop: early postop mobilization; regular wound checks; close coordination w/ primary care team30-day readmit: 2.5%
12 3-levelReop (all): 2.9%
50 cervical surgery
20 anterior
30 posterior

ACDF = anterior cervical discectomy and fusion; ALIF = anterior lumbar interbody fusion; ASA = American Society of Anesthesiologists; C-spine = cervical spine; CCI = Charlson Comorbidity Index; COPD = chronic obstructive pulmonary disease; CPT = Current Procedural Terminology; CR = complication rate; d/c = discharge; discont’d = discontinued; DM2 = diabetes mellitus type 2; DVT = deep venous thrombosis; EBL = estimated blood loss; EtOH = alcohol; FU = follow-up; Hgb = hemoglobin; IV = intravenous; L-spine = lumbar spine; LOE = level of evidence; NDI = Neck Disability Index; NS = not significant; ODI = Oswestry Disability Index; OR = operating room; OSA = obstructive sleep apnea; PCA = patient-controlled analgesia; PLIF = posterior lumbar interbody fusion; PSO = pedicle subtraction osteotomy; PT = physical therapy; pt = patient; readmit = readmission; wnd infx = wound infection rate; ↑ = increase; ↓ = decrease; ↔ = no change.

Six studies8,19,28–31 were included in one or more outcomes of the quantitative meta-analysis. ERAS protocols were associated with decreased LOS (mean difference −1.22 days, p = 0.002 [Fig. 2A]). No differences were noted in complication rate (Fig. 2B), wound infection rate (Fig. 2C), 30-day readmission rate (Fig. 2D), or ICU admission rate (Fig. 2E). Insufficient data were available to perform analyses of 30-day reoperation rate, costs, or narcotics usage. When considering only those studies employing contemporary controls, significant differences were noted in LOS (mean difference −2.14 days [95% CI −3.20 to −1.08 days], p < 0.001). There were insufficient data using contemporary controls to evaluate any of the other outcomes.

FIG. 2.
FIG. 2.

Forest plots showing the results of the quantitative meta-analysis for general spine surgery ERAS protocols. ERAS protocols were found to be associated with a decrease in LOS/hospitalization (A), no change in complication rate (B), no change in wound infection rate (C), no change in 30-day readmission rate (D), and no change in ICU admission rate (E). Figure is available in color online only.

ERAS Protocols for Cervical Spine Surgery

We identified 2 studies21,32 describing 147 patients treated under two distinct cervical spine surgery–specific protocols (Table 2). Both protocols included preoperative patient education and fasting (no intake within 6 hours of surgery), perioperative antiemetic prophylaxis, early resumption of enteral intake, and multimodal analgesia. Li et al.32 compared 114 patients undergoing unilateral open-door laminoplasty using an ERAS pathway with 110 historical controls. ERAS-treated patients had significantly shorter LOS, early urinary catheter discontinuation, and shorter times to ambulation. No differences were noted in complication rates, wound infection rates, or 30-day reoperation rates. ERAS-treated patients also had lower pain scores on postoperative day (POD) 3. Soffin et al.21 described ERAS protocol implementation in 33 patients undergoing same-day cervical spine surgery—25 underwent anterior cervical discectomy and fusion, and 8 underwent cervical disc arthroplasty. No comparison group was included.

TABLE 2.

Summary of ERAS protocols in cervical spine surgery for degenerative pathologies and deformity

Authors & Year (LOE)No. of PtsSurgery TypePopulation DetailsProtocolResults
Li et al., 201832 (III)114Unilat open-door cervical laminoplasty (Hirabayashi technique)Comparison of 114 pts undergoing cervical laminoplasty for stenosis w/ ERAS pathway w/ 110 historical controls treated w/ conventional carePreop: pt education; fasting starting 6 hrs preop, allow water up to 2 hrs preopEBL: 102.02 ± 48.83 vs 108.09 ± 53.18 mL, NS
Groups comparable in age, sex, ASA status, BMI, tobacco use, prevalence of DM2 & cardiovascular disease, & preop pain & disability (JOA score)Intraop: ropivacaine injection of incisionOR time: 111.20 ± 27.54 vs 117.36 ± 25.93 mins, NS
Postop: antiemetic prophylaxis; regular diet POD0; restrict IV fluid repletion; multimodal analgesia; ambulation POD1; discont’d Foley POD1; discont’d wound drain POD2; VTE prophylaxis w/ serial compression devicesLOS: 5.75 ± 2.46 vs 7.67 ± 3.45 days, p < 0.001
CR: 21.1 vs 20.9%, NS
Foley discont’d: 24.76 ± 12.34 vs 53.61 ± 18.16 hrs, p < 0.001
Time to ambulation: 30.79 ± 14.45 vs 65.24 ± 25.34 hrs, p < 0.001
Wnd infx: 4.4 vs 6.4%, NS
30-day reop: 0.8 vs 0%, NS
↓ mean & max pain scores on POD3, p < 0.001
Good compliance w/ ERAS protocol; ≥85% for all elements
Soffin et al., 201921 (IV)3325 ACDFNo comparison group undergoing conventional care pathwayPreop: pt education & expectation management; stop solid oral intake 6 hrs preop & liquid 4 hrs preop, carbohydrate loading 4 hrs preop; nonopioid analgesia; scopolamine patch for nausea prophylaxisEBL: median 25 mL
12 1-levelCohort of 33 pts undergoing cervical surgery according to ERAS pathwayIntraop: dual antiemetic therapy w/ 4–8 mg dexamethasone + 4–8 mg ondansetron; no N2O anesthetic; minimal inhaled anesthetic; normothermia maintenance (36–37°C); goal-directed fluid repletion; local analgesia w/ Marcaine; no Foley catheterOR time: 69.8 ± 19.5 mins
12 2-levelComparison of pts undergoing ACDF or CDA using pathwayPostop: mobilization ≤2 hrs postop; swallow evaluation; early oral intake following successful evaluation; multimodal opioid-sparing analgesiaLOS: median 416 mins
1 3-level↑ LOS, ↑ opioid use in PACU for pts who were opioid tolerant at baseline, NS
8 CDA (single-level)

CDA = cervical disc arthroplasty; JOA = Japanese Orthopaedic Association; PACU = postanesthesia care unit.

ERAS Protocols for Lumbar Spine Surgery

Fourteen studies9–15,20,22–26,33 were identified that used lumbar spine–specific protocols, describing a total of 970 patients treated with 13 distinct protocols (Table 3). In the described protocols, the most commonly included elements were patient education (8 studies);10,14,15,22–26 preoperative carbohydrate loading (6 studies);10,14,23–26 multimodal, opioid-sparing analgesia during the intraoperative or postoperative period (11 studies);9–11,13–15,23–26,33 goal-directed fluid replacement intraoperatively (4 studies);10,14,25,26 local analgesia with an amino-amide sodium channel blocker (e.g., bupivacaine and ropivacaine) (9 studies);10,12,14,15,20,23–26 use of minimally invasive surgery (MIS) techniques (4 studies);10,23,24,33 urinary catheter avoidance or discontinuation within 48 hours of placement (8 studies);9,10,13,20,23–26 perioperative antiemetic prophylaxis (4 studies);13,15,25,26 early resumption of enteral feeding (9 studies);10,11,13,14,23–26,33 and early postoperative mobilization (11 studies).10–15,23–26,33 Less commonly included items were preoperative nutrition optimization (3 studies),9,10,23 preoperative smoking cessation (1 study),9 TXA administration to reduce intraoperative blood loss (2 studies),14,15 early surgical drain removal (1 study),13 mechanical VTE prophylaxis (3 studies),10,11,23 and minimization of postoperative intravenous fluid repletion (2 studies).11,24 Of the included studies, 7 studies compared patients treated under an ERAS protocol with those treated with conventional care.9,11–15,33 In comparative studies, ERAS was found to have the following benefits: decreased LOS (range 0.4–4.7 days),9–12,14,33 earlier urinary catheter discontinuation,11 earlier ambulation (reduced indwelling time by an average of 46.2 hours),11,12 increased odds of discharge home versus to an inpatient facility,9 decreased complication rates,11 greater improvement in postoperative pain scores (range 27%–30% decrease),11,12,33 earlier discontinuation of patient-controlled analgesia,13 decreased postoperative narcotics usage,12 and greater improvement in PRO measures of disability.33 No studies reported differences in readmission or reoperation rates. Other studies looking at PROs found no difference in pain9 or disability score10,15 improvements between patients treated under ERAS and normal care protocols. Two studies10,14 compared costs between patients treated under an ERAS protocol and conventional care protocols. Wang et al.10 found that the decrease in total costs is driven by reduction in hospitalization costs.

TABLE 3.

Summary of ERAS protocols in lumbar/lumbosacral spine surgery for degenerative pathologies and deformity

Authors & Year (LOE)No. of PtsSurgery TypePopulation DetailsProtocolResults
Bradywood et al., 20179 (III)244≤5-level lateral or posterior lumbar fusionComparison of 244 pts treated under ERAS w/ 214 historical controlsPreop: weaning of opioids; smoking cessation (≥8 wks prior to surgery); nutrition optimization; chlorhexidine showersOR time: 156 ± 61 vs 151 ± 57 mins, NS
110 posteriorPopulations similar in age, comorbidities, indication for surgery (ICD-9), surgery typeIntraop: noneLOS: 3.5 ± 1.5 vs 3.9 ± 1.5 days, p < 0.001
88 lateralPostop: electronic order sets, including bracing, PT orders, medications, radiology orders; multimodal analgesia w/ “early” PCA discont’d; discont’d Foley POD1Foley discont’d: 87 vs 77% by POD2, p = 0.003
46 other30-day readmit: 2 vs 5%, NS
↑ odds of d/c home: 75 vs 64%, p = 0.002
↔ in pain control or likelihood of recommending hospital
Brusko et al., 201912 (III)571- to 3-level open or MIS lumbar fusionComparison of 57 ERAS pts w/ historical cohort of 41 pts receiving conventional care pathwayPreop: noneLOS: 2.9 ± 1.9 vs 3.8 ± 1.8 days, p = 0.01
Populations similar in age, sex, BMI, surgical invasivenessIntraop: local analgesia w/ liposomal bupivacaineTime to oral analgesia: 1.6 ± 1.2 vs 2.0 ± 1.1 days, p = 0.06
Postop: early mobilization; IV acetaminophen infusion↓ narcotic usage on POD0, POD1, & POD3; all p < 0.05
↓ pain score on POD1: 4.2 ± 3.2 vs 6.0 ± 3.2, p = 0.006
↓ ondansetron use, p = 0.02
↑ distance ambulated on POD0 & POD1; both p < 0.01
Feng et al., 201914 (III)441-level MIS TLIFComparison of 44 pts undergoing 1-level MIS TLIF w/ ERAS protocol & 30 historical controlsPreop: pt education; fasting 8 hrs for solid food, 6 hrs for liquids except carbohydrate-rich liquids 2–8 hrs preop; COX2 inhibitorsEBL: 100 vs 150 mL, p = 0.02
39 L4–5Groups similar in terms of age, sex distribution, BMI, & prevalence of DM2, COPD, & cardiovascular diseaseIntraop: normothermia, normovolemia maintenance; local analgesia w/ ropivacaine; TXAOR time: 206 vs 228 mins, p = 0.04
4 L5–S1Postop: multimodal, opioid-sparing analgesia; clear liquids POD0, early return of regular diet; mobilization POD1LOS: median 5 vs 7 days, p = 0.001
1 L3–4CR: 2 vs 4%, NS
30-day readmit: 0 vs 3%, NS
30-day reop: 2.2 vs 6.7%, NS
Compliance lowest w/ intraop ERAS components
↓ intraop fluid requirements (p = 0.03), ↓ surgical drainage POD1–3 (p = 0.003)
↓ total cost by median 959 yuan, p = 0.01
Fleege et al., 201422 (IV)1711- to 2-level lumbar fusionNo details on comparison groupPreop: pt education via 4-hr pt schoolLOS: 6.2 vs 10.9 days, no stats
171 total pts undergoing 1- or 2- level fusion for degenerative pathologiesIntraop: none
Postop: “structured d/c management”
Hawasli et al., 202020 (IV)10MIS lumbar decompression w/ or w/o fusionNo comparison groupPreop: coordination of post-OR disposition w/ ward teamLOS: 18.0 ± 7.2 hrs
Evaluation of ERAS protocol in pts undergoing MIS lumbar surgery (plan for 10 w/ & 10 w/o fusion; only 10 total enrollees)Intraop: local anesthetic; discont’d FoleyTime to ambulation: 1.0 ± 0.7 hrs
Postop: noneCR: 17% (0% after excluding 2 pts)
Return to work: 5.8 ± 2.3 wks
Heo & Park, 201915 (III)23Biportal endoscopic TLIFComparison of 23 pts undergoing 1-level MIS biportal endoscopic TLIF w/ ERAS w/ 46 historical controls undergoing microscopic TLIF w/ normal care pathwayPreop: pt education; preemptive analgesia w/ pregabalin or gabapentin; TXA loading; prophylactic antiemetic & antibiotic injectionEBL: 190.3 ± 31.0 vs 289.3 ± 58.5 mL, p < 0.05
3 L3–4Groups similar in sex, age, preop painIntraop: TXA to reduce bleeding; local vancomycin dosing; local anesthetic infiltrationOR time: 152.4 ± 9.6 vs 122.4 ± 13.1 mins, p < 0.05
17 L4–5Postop: PCA & oral analgesia w/ pregabalin & gabapentin; early ambulation & mechanical VTE prophylaxisCR: 4.3 vs 13.0%, NS
3 L5–S1Wnd infx: 0 vs 2.2%, NS
30-day readmit: 0 vs 4.6%, NS
↓ postop back pain score on POD1–2; equivalent outcomes at 12 mos for pain & ODI scores
Nazarenko et al., 201633 (III)23Lumbosacral microdiscectomyComparison of 23 pts treated w/ ERAS protocol & 25 historical controls treated w/ conventional carePreop: noneLOS: 2.3 vs 3.8 days, p < 0.05
1 L1–2Group similar in age, sexIntraop: prioritize MIS techniqueWnd infx: 4.3 vs 4%, NS
7 L3–4ERAS group more likely to self-pay vs have compulsory insurancePostop: early oral nutrition resumption; multimodal analgesia; mobilization POD1–2; postdischarge exercise regimen↑ pt report of adequate pain control
8 L4–5↓ pain scores, ↑ ODI scores, ↑ Roland-Morris disability scores at discharge & 1-mo FU; all p < 0.05
11 L5–S1
Ren et al., 201911 (III)73PLDFComparison of 73 pts treated under ERAS protocol & 82 historical controls treated using conventional carePreop: use of ASA fasting program; preop DVT screeningEBL: 113.24 ± 49.1 vs 113.98 ± 53.7 mL, NS
30 L4–5Groups comparable for age, sex, diagnosis (disc herniation vs spondylolisthesis vs stenosis), operative segmentIntraop: noneOR time: 85.68 ± 11.54 vs 88.27 ± 16 mins, NS
43 L5–S1Postop: minimization of IV vol repletion; early resumption of regular diet; multimodal, opioid-sparing analgesia; early mobilization; mechanical VTE prophylaxisLOS: 3.80 ± 1.04 vs 7.29 ± 1.62 days, p < 0.01
CR: 23.2 vs 41.5%, p = 0.02
Foley discont’d: 36.31 ± 8.42 vs 71.48 ± 13.75 hrs, p < 0.01
Time to ambulation: 23.41 ± 7.05 vs 69.63 ± 13.05 hrs, p < 0.01
Wnd infx: 1.4 vs 1.2%, NS
↓ mean & max pain scores POD1–3
Early 1st defecation time, earlier resumption of oral intake
Smith et al., 201913 (III)961- or 2-level lumbar fusionComparison of 96 pts undergoing treatment using the ERAS protocol w/ 123 historic controls treated using conventional care pathwayPreop: scheduling of postop FU & dissemination of education materials; anesthesia consult; pain liaison consultation if high-risk pt; analgesia & antiemeticEBL: 34.4 vs 19.5% w/ EBL >300 mL, p = 0.02
54 1-levelGroups comparable in age, sex, BMI, comorbidities (DM2, cardiovascular disease, COPD), baseline anxiety/depression, tobacco/substance use, ASA class, & preop pain medication regimenIntraop: 8 mg dexamethasone; ketamine infusion for high-risk pain ptsOR time: 212.4 ± 140.4 vs 184.7 ± 85.4 mins, NS
42 2-levelOSA less common in ERAS groupPostop: POD0—advance diet as tolerated, bowel regimen, incentive spirometry; POD1—discont’d Foley, multimodal oral opioid-sparing analgesia, mobilization, PT evaluation; POD2—discont’d drain, d/c from hospital, if possibleLOS: 92.3 ± 36.9 vs 96.2 ± 32.0 hrs, NS
CR: 7.9 vs 1.7%, p = 0.04
Discont’d PCA: POD0 in 0 vs 7.3%, p = 0.01
Wnd infx: 2.1 vs 1.6%, NS
Compliance w/ ERAS ∼80% for most parameters
↓ crystalloid given in OR
↓ long-acting opioid use POD1–3
↔ max pain scores POD0–3
Soffin et al., 201925 (IV)6134 MIS single-level lumbar microdiscectomyNo comparison groupPreop: pt education & expectation management; stop solid oral intake 6 hrs preop & liquid 4 hrs preop, carbohydrate loading 4 hrs preop; nonopioid analgesia; scopolamine patch for nausea prophylaxisEBL: median 20 mL
27 MIS lumbar decompressionSeries of 61 pts treated w/ ERAS protocolIntraop: dual antiemetic therapy w/ 4–8 mg dexamethasone + 4–8 mg ondansetron; no N2O anesthetic; normothermia maintenance (36°C); goal-directed fluid repletion; local analgesia w/ Marcaine; no Foley catheterOR time: 55.6 ± 21.2 mins
17 1-levelPostop: mobilization ≤2 hrs postop; early oral intake; multimodal opioid-sparing analgesiaLOS: median 279 mins
9 2-levelVariable compliance (53–100%) for different ERAS components
1 3-level
Soffin et al., 201926 (IV)3622 lumbar microdiscectomyCohort of 36 pts treated under ERAS protocol w/ comparison of 18 pts treated using opioid-free anesthesia (midazolam, propofol, lidocaine, vecuronium only) w/ 18 pts treated using opioid-containing anesthesia (adds fentanyl or hydromorphone)Preop: pt education & expectation management; stop solid oral intake 6 hrs preop & liquid 4 hrs preop, carbohydrate loading 4 hrs preop; opioid analgesia; scopolamine patch for nausea prophylaxisOR time: 58.95 ± 12.88 mins
14 lumbar decompressionCohorts similar in age, sex, BMI, ASA status, tobacco use, baseline opioid tolerance, medical comorbiditiesIntraop: dual antiemetic therapy w/ 4–8 mg dexamethasone + 4–8 mg ondansetron; no N2O anesthetic; normothermia maintenance (36°C); goal-directed fluid repletion w/ balanced crystalloid; local analgesia w/ Marcaine; no Foley catheterLOS: median 237–274 mins
Postop: mobilization ≤2 hrs postop; early oral intake; multimodal opioid-sparing analgesia worst pain scores in PACU
↔ postop opioid consumption in PACU
↓ overall opioid usage, p < 0.001
High overall compliance w/ ERAS pathway (91.4%); compliance for intraop > preop > postop
Wang et al., 201723 (IV)421- or 2-level endoscope-assisted unilateral MIS TLIF w/ percutaneous screwsNo comparison groupPreop: pt education & expectation management; nutrition optimization, stop oral intake 12 hrs preop (solids) & 8 hrs preop (liquids), carbohydrate loading preopEBL: 66 ± 30 mL
37 1-levelEvaluation of outcomes in series of pts undergoing endoscopic MIS TLIF w/ ERAS protocolIntraop: local analgesia w/ bupivacaine; use MIS technique; use osteobiologics to ↑ fusion odds (e.g., rhBMP-2); no general anesthesia → moderate sedation; avoid surgical drain, Foley; normothermia & goal-directed fluid repletionOR time: 94.6 ± 22.4 mins
5 2-levelLevelsPostop: mechanical VTE prophylaxis; multimodal, opioid-sparing analgesia; early mobilization; early oral intakeLOS: 1.3 ± 0.9 days
1 L1–2CR: 11.9%
1 L2–3Reop (all): 7.1%
6 L3–4Clinical & statistical ↓ in ODI
36 L4–5Stress iterative nature of ERAS implementation
Wang et al., 201810 (III)381- or 2-level endoscope-assisted unilateral MIS TLIF w/ percutaneous screwsComparison of 38 pts treated w/ endoscopic MIS TLIF under ERAS protocol w/ 15 historical controls treated w/ tubular MIS TLIF under conventional care pathwayPreop: pt education & expectation management; nutrition optimization; stop oral intake 12 hrs preop (solids) & 8 hrs preop (liquids), carbohydrate loading preopEBL: 68 ± 31 vs 231 ± 73 mL, p < 0.001
34 1-levelGroups comparable in BMI, comorbiditiesIntraop: local analgesia w/ bupivacaine; use MIS technique; use osteobiologics to ↑ fusion odds (e.g., rhBMP-2); no general anesthesia → moderate sedation; avoid surgical drain, Foley; normothermia & goal-directed fluid repletionOR time: 96 ± 22 vs 129 ± 14 mins, p = 0.003
4 2-levelERAS pts older, higher proportion male, shorter FUPostop: mechanical VTE prophylaxis; multimodal, opioid-sparing analgesia; early mobilization; early oral intakeLOS: 1.2 ± 0.8 vs 3.9 ± 1.1 days, p = 0.009
CR: 12 vs 21%, NS
Wnd infx: 0 vs 0%, NS
↓ total costs by $3444, p < 0.001; main savings in hospitalization costs
↔ rates of clinical improvement on ODI
Zhang et al., 201724 (IV)521-level endoscope-assisted MIS TLIFNo comparison groupPreop: pt education & expectation management; d/c coordination; preemptive analgesia w/ NSAIDs; nothing by mouth 6 hrs preop; carbohydrate loading 3 hrs preopEBL: 100 ± 35 mL
3 L2–3Evaluation of outcomes in 52 pts treated under ERAS pathway for degenerative or isthmic spondylolisthesisIntraop: normothermia; no general anesthesia, moderate sedation only; local analgesia w/ bupivacaine; MIS technique; controlled hypotension to ↓ EBL; no drain or Foley placedOR time: 115 ± 30 mins
11 L3–4FU 12 ± 4 mosPostop: multimodal, opioid-sparing analgesia; early oral intake w/ liquids 2 hrs postop & regular diet POD2; IV fluid minimization; ambulation POD1LOS: 4.9 ± 1.3 days
28 L4–5CR: 7.7%
10 L5–S1Wnd infx: 3.8%
Significant ↓ pain @ 24 hrs, 3 mos, & last FU; significant ↓ in disability on ODI

PLDF = posterior lumbar decompression and fusion; PT = physical therapy; rhBMP = recombinant human bone morphogenetic protein.

Eight studies9–15,33 were included in the quantitative meta-analysis. ERAS protocols were associated with decreased LOS (mean difference −1.53 days, p = 0.03 [Fig. 3A]). No differences were noted in complication rate (Fig. 3B) or wound infection rate (Fig. 3C). ERAS-treated patients also had a lower 30-day readmission rate (OR 0.37, p = 0.04 [Fig. 3D]). There were insufficient data to perform analyses of 30-day reoperation rate, ICU admission rates, costs, or narcotic usage.

FIG. 3.
FIG. 3.

Forest plots showing the results of the quantitative meta-analysis for lumbar spine surgery ERAS protocols. ERAS protocols were found to be associated with a decrease in LOS/hospitalization (A), no change in complication rate (B), no change in wound infection rate (C), and a decrease in 30-day readmission rate (D). Figure is available in color online only.

ERAS Protocols for Spine Tumor Surgery

Two studies7,16 describing 89 spine tumor patients treated under distinct ERAS protocols were identified (Table 4). Grasu and colleagues16 compared outcomes in 41 patients with vertebral column metastases treated under an ERAS pathway and 56 historical controls treated under conventional care. ERAS implementation was associated with moderate improvements in postoperative pain scores but produced no differences in hospital LOS, readmission rates, or postoperative narcotics use. Liu et al.7 subsequently performed a randomized controlled trial (RCT) comparing patients with intradural tumors treated under an ERAS pathway or a conventional care pathway. ERAS pathway care resulted in shorter hospital LOS, earlier urinary catheter removal, and earlier ambulation. They also saw increased patient satisfaction, lower narcotic use on POD1, and lower total care costs.

TABLE 4.

Summary of ERAS protocols in spine tumor surgery

Authors & Year (LOE)No. of PtsSurgery TypePopulation DetailsProtocolResults
Grasu et al., 201816 (III)41Surgery for spinal metastasesComparison of 41 pts undergoing surgical treatment for spinal metastases under ERAS pathway w/ 56 historical controls treated under conventional carePreop: pt education & expectation management; multidisciplinary anxiety management; multimodal pain management; allow clear liquids up to 2 hrs preop, carbohydrate loading preopOR time: 263.9 ± 128.0 vs 315.8 ± 142.1 mins, NS
Populations similar in terms of age, sex, preop pain, ASA class, tobacco use, & prevalence of DM2, cardiovascular disease, & COPD; surgical procedures similarIntraop: IV vs inhaled anesthesia; goal-directed fluid management; transfusion threshold of Hgb ≤9–10 g/dL; TXA to reduce blood loss; normothermia; prefer MIS technique; op site bupivacaine injection; plastic surgery reconstructionLOS: 6.3 ± 2.2 vs 6.8 ± 1.9 days, NS
Lower BMI in ERAS cohortPostop: ambulate POD1; incentive spirometry; multimodal analgesia w/ pain consult service; liquid diet POD0, resume regular diet as toleratedCR: 31.7 vs 17.9% @ 30 days, NS
30-day readmit: 14.6 vs 8.9%, NS
↓ average pain scores on POD2–3 (p < 0.05), lower average pain during hospitalization (p = 0.04)
↔ opioid use
Liu et al., 20207 (II)48Resection of intradural spine tumorRCT comparing 48 adult pts treated w/ ERAS pathway & 46 pts treated under traditional carePreop: pt education; smoking & EtOH cessation ≥2 wks preop; nutrition consultation if BMI <18.5 or >24 or albumin <3.5 g/dL; mechanical VTE prophylaxis; glycerin enema; carbohydrate loading 2 hrs preopEBL: 260 vs 300 mL, NS
Groups comparable in age, sex, BMI, ASA status, baseline medical comorbidities, tumor location & pathologies, performance status, preop pain, & baseline anxiety & depression levelsIntraop: local ropivacaine injection; prefer MIS techniques; normothermia; goal-directed fluid repletion w/ warmed fluids; intradermal suture; avoid surgical drain when possible; extubate in OROR time: 200 vs 240 mins, NS
Postop: multimodal, opioid-sparing analgesia; liquid diet POD0, staged solids diet POD0–2; discont’d Foley POD0; antiemetic prophylaxis; IV fluid restriction; mechanical VTE prophylaxis; ambulation POD1LOS: 5 vs 12 days, p < 0.0001
CR: 3.1 vs 4.3%, NS
Foley discont’d: d/c on POD0 in 87.5 vs 32.6%, p < 0.0001
Drain discont’d: POD0 in 44.4 vs 15.8%, NS
Ambulation: POD0 in 68.8 vs 17.4%, p < 0.0001
Wnd infx: 2.1 vs 0%, NS
30-day readmit: 0 vs 0%, NS
30-day reop: 0 vs 0%, NS
Similar transfusion rates & intraop IV fluid requirements
↓ costs by 13,313 yuan, p = 0.006
↑ pt satisfaction, p = 0.02
↓ postop pain on POD3
↓ opioid use on POD1, p = 0.04

Discussion

In our review, we found that a number of different ERAS protocols have been described in the adult spine literature, most commonly as general ERAS protocols or protocols specific to lumbar spine surgery patients. The overall quality of evidence is relatively low, with one level II study and mostly level III cohort studies. The most commonly described benefits were shorter LOS (12 studies),7–12,14,28–30,32,33 decreased complication rates (4 studies),11,13,29,31 and lower postoperative pain scores (6 studies).11,12,15,16,32,33 As many of these ERAS protocols emphasized MIS techniques10,18,23,33 (e.g., use of endoscopic or mini-open decompression, expandable cages, and percutaneous instrumentation), which have been independently associated with shorter LOS,35–37 lower complication rates,35,37,38 and reduced immediate postoperative pain,39 it is unclear whether these apparent benefits represent therapeutic differences or are simply the result of embracing newer surgical techniques. Regardless, we found sufficient data to perform meta-analyses for the general spine surgery–specific and lumbar surgery–specific protocols, which represents the first quantitative meta-analysis of the adult spine ERAS literature. We found that both of these ERAS protocol groups had a decreased LOS (1.22–1.53 days). Lumbar ERAS protocols alone were also associated with a decreased 30-day readmission rate. Neither general spine surgery nor lumbar-specific ERAS protocols were associated with a difference in complication rate or wound infection rate. Insufficient data were available for either protocol to analyze differences in costs or postoperative narcotics usage.

ERAS Protocols in Spine Surgery

The application of ERAS protocols to spine surgery was first discussed by Wainwright et al.,40 who noted that the application of protocols to other surgical fields had led to significant reduction in hospitalization duration without concomitant increases in readmission rates. Consequently, ERAS protocols were demonstrating the potential to reduce care costs by expediting safe patient discharge. As prolonged hospitalization has been demonstrated to be a key driver of spine surgery hospitalization costs,41 Wainwright et al. conjectured that the implementation of ERAS protocols might lead to similar savings in spine care.40

Subsequent to their publication, there has been a rapid increase in the number of publications on ERAS or accelerated recovery protocols for patients undergoing spine surgery. The results suggest that ERAS protocol implementation may lead to a reduction in cost of care; however, the evidence is too limited to support the implementation of ERAS protocols as standard of care. Of the identified studies, 3 studies10,28,30 directly compared costs between patients treated with ERAS pathway care and conventional care. Dagal et al.30 reported a mean reduction of $4572 per patient in their series of 267 patients treated under a general spine surgery ERAS protocol, approximately 8% of the total care costs. Analysis of the individual cost components revealed that these reductions were driven primarily by decreases in indirect costs (e.g., patient transport services and medical equipment maintenance) and nonimplant direct costs (e.g., perioperative services and laboratory medicine). The same group subsequently reported similar findings in a larger ERAS cohort of 620 patients, suggesting that the ERAS-associated cost reductions may be sustainable.28 Wang et al.10 reported similar cost reductions with their ERAS protocol for MIS transforaminal lumbar interbody fusion (TLIF) procedures. They observed a $3444 decrease in total costs (16%), which was again driven predominately by decreased hospitalization. Other groups have also reported cost savings, although the relative size of the savings is variable, with Feng et al. reporting 1.3% savings for their MIS TLIF protocol14 and Liu et al. reporting a 20% reduction in costs under their intradural tumor protocol.7 Given that much of these savings seem to stem from shortened hospital stays, our finding that ERAS implementation leads to a 1.2- to 1.5-day reduction in LOS suggests that ERAS implementation may be reasonably expected to reduce care costs. Using current estimates of hospitalization costs ($2093–$2653 per inpatient day),42 the savings are likely to be between $2500 and $3700 per patient treated. Extrapolated across the approximately 1 million patients hospitalized for spine surgery annually,43 this could lead to at least $2 billion in savings across the US healthcare system. Given that aggregate surgical and perioperative costs are estimated to cost $10–$22 billion,41,44 this could produce a relative cost reduction of 9%–20%.

Defining an ERAS Protocol

The present review, similar to recent qualitative reviews by Dietz et al.,45 Corniola et al.,46 and Elsarrag et al.,1 finds that there is not only extensive heterogeneity in the outcomes reported in ERAS studies but also significant heterogeneity in the protocols themselves. The elements that compose the protocols in the included studies are summarized in Table 5; the most common interventions were preoperative patient education and expectation management, postoperative multimodal analgesia, and early postoperative mobilization.

TABLE 5.

Summary of ERAS protocol elements in the analyzed studies

Protocol TypeGeneralCervicalLumbarTumor
Analyzed study*123456789101112131415161718192021222324252627
Preop phase
 Pt education & expectation management
 Smoking cessation assistance
 Preop carbohydrate loading w/ clear oral solution 2–3 hrs preop
Intraop
 TXA administration to reduce intraop blood loss
 Maintenance of normothermia (36–37°C) & goal-directed fluid replacement intraop
 Local analgesia w/ an amino-amide sodium channel blocker (e.g., bupivacaine, ropivacaine)
Postop
 Single- or dual-agent antiemetic prophylaxis
 Multimodal, opioid-sparing analgesia during the intraop or postop period
 Mechanical VTE prophylaxis
 Restrictive IV rehydration
 Early diet advancement
 Early postop mobilization
Catheter/drain management
 Avoid catheter placement, if possible
 Early discontinuation of urinary catheter (24–48 hrs postop)
 Surgical drain avoidance, if possible
 Early surgical drain removal

Cervical = cervical spine surgery ERAS protocol; general = general spine surgery ERAS protocol; lumbar = lumbar spine surgery ERAS protocol; tumor = spine tumor surgery ERAS protocol.

The numbers correspond to the references as follows: 1 = Ali et al., 20198; 2 = Angus et al., 201919; 3 = Chakravarthy et al., 201927; 4 = Carr et al., 201928; 5 = Dagal et al., 201930; 6 = Debono et al., 201929; 7 = Sivaganesan et al., 201931; 8 = Staartjes et al., 201918; 9 = Venkata & van Dellen, 201817; 10 = Li et al., 201832; 11 = Soffin et al., 201921; 12 = Bradywood et al., 20179; 13 = Brusko et al., 201912; 14 = Feng et al., 201914; 15 = Fleege et al., 201422; 16 = Hawasli et al., 202020; 17 = Heo & Park, 201915; 18 = Nazarenko et al., 201633; 19 = Ren et al., 201911; 20 = Smith et al., 201913; 21 = Soffin et al., 201925; 22 = Soffin et al., 201926; 23 = Wang et al., 201723; 24 = Wang et al., 201810; 25 = Zhang et al., 201724; 26 = Grasu et al., 201816; 27 = Liu et al., 20207.

Many of the interventions employed in the reviewed protocols, including TXA use,47 early drain discontinuation,48 and early postoperative mobilization,49 have been associated with reductions in hospital LOS, complication rates, and total care costs. However, as the included studies implemented these interventions as part of a coordinated care pathway, it is difficult to identify the significance of individual contributions. Nevertheless, their implementation in aggregate does appear to have benefits for patients as suggested by the present results, and therefore warrants additional investigation in the form of an RCT.

There are varying levels of evidence to support the interventions most commonly employed in the included protocols. Level II evidence has suggested that postoperative multimodal analgesia reduces postoperative pain and opioid usage in spine surgery patients. In a double-blind RCT of 25 patients undergoing lumbar decompression, Cassinelli et al.50 provided level II evidence that the addition of postoperative intravenous ketorolac to intravenous morphine significantly decreases pain scores and opioid usage. In another double-blind placebo-controlled RCT of 90 patients undergoing lumbar discectomy, Khurana et al.51 showed that preoperative gabapentin or pregabalin also reduces pain scores and opioid usage. Ozgencil et al.52 replicated these findings in their double-blind RCT of 90 patients undergoing lumbar laminectomy or discectomy. Patients treated with pregabalin or gabapentin used less opioid medication and were more satisfied with treatment. Of note, another double-blind RCT of 175 patients undergoing lumbar laminectomy found that outcomes were optimal using 900 or 1200 mg of gabapentin.53 However, benefits did not differ between patients receiving the medication pre- or postincision. Garcia et al.54 integrated these strategies into a multimodal pain regimen that was compared with intravenous morphine alone in an unblinded RCT of 22 patients undergoing multilevel lumbar decompression. Patients receiving multimodal analgesia had lower pain scores and opioid use at all time points. Similar findings have been reported in level III historically controlled cohort studies of patients undergoing multilevel fusion.55 Recently, Raja et al.56 published a double-blind RCT demonstrating that preoperative multimodal analgesia with paracetamol, ketorolac, and pregabalin reduces postoperative pain and opioid consumption following short-segment lumbar fusion.

Preoperative patient education is also supported by level II evidence. Bekelis et al.57 published a single-blind RCT showing that education with an immersive virtual reality experience lessened preoperative stress and improved postoperative satisfaction in neurosurgical patients. More extensive education has similarly been demonstrated to reduce preoperative anxiety in a double-blind RCT of patients undergoing lumbar decompression.58 Improved preoperative education is also linked by level II evidence to an increased likelihood of meeting patient expectations of surgery and reduced postoperative healthcare utilization.59 At present, there appears to be no single most-effective strategy, and, consequently, the strategies employed in current ERAS protocols are quite varied. These strategies include written materials,10,23 preoperative in-person courses,60 and use of an extended goal setting and information session during preoperative consultation.18,25 Given the cost differences associated with these interventions, prospective studies should be pursued to identify the most cost-effective strategy prior to integration in an ERAS protocol.

High-quality evidence supporting early postoperative ambulation is wanting, although large population-level retrospective studies have suggested that early ambulation lowers postoperative complications, reduces readmissions, and shortens hospitalizations.61 However, a single-blind RCT of 60 patients undergoing lumbar decompression failed to demonstrate differences in pain or functional outcomes between patients assigned to conventional care or a perioperative rehabilitation program emphasizing early postoperative ambulation.62 Early initiation of physical therapy postdischarge has additionally been found to not be cost-effective.63 Nevertheless, early ambulation has been linked to a lower VTE risk.64 It is also key to a patient’s ability to perform activities of daily living, which in turn define patient quality of life and determine postdischarge disposition.

Level II evidence is also available to support other interventions included in the studied protocols. Two recent meta-analyses found that TXA use, especially high-dose (> 20 mg/kg) TXA use, significantly reduces total and intraoperative blood loss.65,66 Additionally, when considering all open spine procedures, there is level II evidence that use of 15 mg/kg intravenous TXA or topical TXA reduces transfusion requirements.67 Level II evidence similarly supports the use of mechanical VTE prophylaxis in neurosurgical patients68 and the use of preoperative dexamethasone dosing in spine patients to reduce postoperative nausea and vomiting.69

Other interventions included in the ERAS protocols examined lack support from level I or II studies. Nevertheless, there is robust level III support in spine patients for smoking cessation, restrictive transfusion limits, intraoperative normothermia, goal-directed intraoperative fluid replacement, and expedited discontinuation of urinary catheters and surgical drains.27,70,71 Some of these interventions, such as smoking, rely heavily on patient adherence and may not be amenable to RCTs. However, transfusion strategies and drain removal policies are potential points of investigation and merit further exploration in prospective randomized trials.

By contrast, preoperative carbohydrate loading, intrawound topical vancomycin powder, and intraoperative cell salvage have less robust support. Currently, level II evidence finds no benefit to preoperative carbohydrate loading.72 Similarly, evidence for topical intrawound vancomycin is mixed. Many studies have suggested that it may reduce the risk of surgical site infections; however, all supportive studies to date are level III evidence.73 The only level II study, that of Tubaki et al.,74 found no difference in surgical site infections between controls and vancomycin-treated patients. Consequently, current evidence suggests that vancomycin is probably best reserved for patients at high risk for infection by antibiotic-resistant gram-positive organisms (e.g., patients with positive preoperative methicillin-resistant Staphylococcus aureus nasal swabs). Similarly, intraoperative cell salvage lacks level II support in the adult literature. Given its dependence on a minimum blood loss to reduce allogeneic transfusion requirements, it is unlikely to be beneficial in smaller surgeries.75 In single-level lumbar surgery, it is associated with increased costs,75 and it therefore may not be a valuable addition to standard ERAS protocols. Nevertheless, it may be useful in the right population (e.g., those undergoing adolescent idiopathic scoliosis surgery).

Study Limitations

There are several limitations to the present study. Most of the studies published are level III or IV evidence with moderate to significant potential for bias. Consequently, we are limited in our ability to reach generalizable conclusions. Additionally, several of the studies reported variability in the degree to which provider teams adhered to the ERAS pathway.13,25 For example, Smith et al.13 noted that some of the interventions in their ERAS pathway had only 40% provider adherence. The limited data quality also prevented us from performing a quantitative meta-analysis for total care costs and postoperative narcotic use, both of which are purported to be decreased by ERAS implementation. Lastly, although ERAS is broadly applied to many protocols in the literature, we find that there is significant heterogeneity in the definition of an ERAS protocol. Consequently, it is unclear if there are specific ERAS elements that mediate the benefits identified by this meta-analysis or if it is the implementation of the entire protocol that produces the superior outcomes. To reach generalizable conclusions about which elements should be included in a spine ERAS protocol, it will be necessary to investigate individual interventions in controlled trials of large populations. Alternatively, ERAS protocols composed of interventions supported by level I or II data may be compared with alternative protocols incorporating an additional intervention to assess the incremental benefit of that intervention. In so doing, all elements benefitting patient care can be identified and used to develop a standardized ERAS protocol for widespread implementation.

Conclusions

Here, we present the first quantitative meta-analysis of the literature on ERAS protocol implementation in adult spine surgery. General spine surgery ERAS protocols were associated with a 1.22-day reduction in LOS, but there were no differences in complications, wound infections, or 30-day readmission. Lumbar spine surgery ERAS protocols were associated with 1.53-day reduction in LOS and 63% lower odds of 30-day readmission; there were no differences in complications, wound infection, or ICU admission. Insufficient data were present to perform a quantitative analysis of cost savings or postoperative narcotics use; however, qualitative assessment suggests that ERAS protocols may result in reductions in both outcomes. Based on the data, it is clear that a more homogeneous definition of what defines an ERAS protocol is required, along with level I evidence from ERAS implementation in an RCT.

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.

Author Contributions

Conception and design: Pennington, Cottrill. Acquisition of data: Pennington, Cottrill. Analysis and interpretation of data: Pennington. Drafting the article: Pennington, Lubelski. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Sciubba. Statistical analysis: Pennington. Study supervision: Sciubba.

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Illustration by Nicole Wolf, MS, ©2019. Printed with permission. See the article by Bongers et al. (pp 283–292).
  • FIG. 1.

    PRISMA flow diagram for the results of the literature search. Figure is available in color online only.

  • FIG. 2.

    Forest plots showing the results of the quantitative meta-analysis for general spine surgery ERAS protocols. ERAS protocols were found to be associated with a decrease in LOS/hospitalization (A), no change in complication rate (B), no change in wound infection rate (C), no change in 30-day readmission rate (D), and no change in ICU admission rate (E). Figure is available in color online only.

  • FIG. 3.

    Forest plots showing the results of the quantitative meta-analysis for lumbar spine surgery ERAS protocols. ERAS protocols were found to be associated with a decrease in LOS/hospitalization (A), no change in complication rate (B), no change in wound infection rate (C), and a decrease in 30-day readmission rate (D). Figure is available in color online only.

  • 1

    Elsarrag M, Soldozy S, Patel P, et al. 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.

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