ERAS vs non-ERAS: Protocol implementation resulted in significant outcomes improvement in patients undergoing lumbar spine fusion.

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The Spine Journal



Effective management of common adverse events (AE) immediately after lumbar fusion, ie, uncontrolled pain, nausea and vomiting, and urinary retention, is imperative to facilitate discharge. Persisting, intolerable symptoms prolong hospitalization. Enhanced Recovery After Surgery (ERAS) has shown improved outcomes across a variety of surgical population, results in spine surgery is limited.


To compare measurable outcomes before and after ERAS implementation.


Retrospective study.


Patients undergoing lumbar fusion.


Pain scores, opioid consumption, AEs and length of stay (LOS).


A comprehensive Spine ERAS clinical pathway was developed. Associated policies and order sets were established. Printed and electronic education resources were produced. The program was fully implemented after a 3-month trial. With IRB approval, a retrospective review of pre-post ERAS consecutive patients was completed. Pre-ERAS (Non-ERAS) patients received traditional care; ERAS patients were treated with evidence-based care pathways including preoperative optimization; screening and prophylaxis treatment of anemia, infection and postoperative nausea and vomiting (PONV); standardized anesthetic, pre-emptive multi-modal analgesia (MMA) and Tranexamic Acid (TXA) use; interventions to promote metabolic status and return to normal function i.e. early catheter removal, mobilization, and diet resumption. Supplemental opioid was changed from patient-controlled analgesia (PCA) with a short acting opioid ie, hydromorphone, to intraoperative intravenous methadone. The intermittent demand dosing from PCA causes significant fluctuation in serum opioid concentration resulting in either inadequate pain control or over sedation. Methadone was preferred due to its long duration and stable serum concentration. Demographics, surgical details, hospitalization, medications and AEs were compared. All opioids were converted to morphine milligram equivalents (MME). Data was analyzed with analysis of variance, Wilcoxon, chi-square, and/or Spearman correlation tests.


A total of 146 ERAS and 192 Non-ERAS (n-338) patients were included in this series. Patients during the trial period were excluded. Both groups were similar with regards to age, gender, BMI, ASA score, surgery and baseline opioid use (all p>0.05). Preoperative baseline pain scores were comparable between cohorts (ERAS 4.5 vs Non-ERAS 4.2, p=0.401). Comparing cohorts, significant reductions in pain scores were observed in the post-anesthesia care unit (p=0.004) and 24-48 hours post-operatively (p<0.001) and average total inpatient opioid consumption was significantly lower in ERAS (296.95 vs 534.18, p<0.001). PONV prophylaxis treatment has given rise to a higher proportion of antiemetics administered to ERAS (33% vs 26%, p<0.0001); laxative use was similar (ERAS 20% vs Non-ERAS 21%, p=0.399); ERAS had a lower incidence of postoperative hypotension (11% vs 22%, p<0.001); and urinary retention (4% vs 13%, p<0.001). No respiratory depression was reported in either group. Average pre/postoperative hemoglobin changes improved in TXA-treated patients (ERAS 13.9-11.5g/dL vs non-ERAS 14.0-10.8g/dL, p<0.001) and lower percentage received blood transfusion (2.9% vs 6.25%). ERAS had a significantly shorter LOS (p=0.007).


ERAS implementation in lumbar fusion resulted in significant reduction in pain scores, total opioid consumption, hypotension, urinary retention and LOS. A smaller percentage of patients received transfusion.




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