ERAS Post-Surgical Protocols Continue to Reshape Spine Surgery

Improving the functional outcomes of spine surgeries should ideally bring better patient experiences. Toward that end, the Enhanced Recovery After Surgery (ERAS) protocols are collectively designed to decrease each surgery’s adverse effects and enable faster, smoother patient recoveries. Certain spine surgeons have utilized the ERAS protocols for years and are playing a key role in their wider adoption.

Evolution of ERAS Spine Surgery Protocols

Spine surgery was initially thought to be too complex for the application of ERAS. However, that has not been the case. The Journal of Clinical Orthopaedics and Trauma’s July 9, 2022, edition contained a narrative review profiling the expansion of ERAS protocols to diverse spine surgeries.¹Initial ERAS spine surgery studies focused solely on lumbar spine procedures. In 2022, ERAS-linked surgeries include spinal deformity, anterior cervical, spinal tumor, and geriatric spinal procedures.

Collectively, ERAS protocols’ application has been linked to reduced length of hospital stays and lower hospital costs. Less patient opioid consumption and decreased spine surgery complication rates are two additional benefits.

Each anesthesia-surgical team utilizes its preferred version of the ERAS spine surgery protocols. Currently, there is no universal standard for these protocols. From this perspective, the Anaesthesiology Intensive Therapy’s March 16, 2022, edition contained a literature review of currently used ERAS protocols for spine surgery.²

The Postoperative Component of ERAS Protocols

The general postoperative component for ERAS includes expedited nutrition intake, physical therapy and early ambulation, pain management, and wound care.

Most ERAS-practicing spine surgeons stress aggressive nutrition resumption and fast-tracked ambulation. Multimodal pain management is also a key ERAS spine surgery component. Although most surgeons prioritize reduced perioperative opioid usage, they vary widely in medication choice and dosage instructions.

ERAS Protocols Benefits for Two Sample Spine Surgeries

In 2022, each hospital and spine surgeon interprets the ERAS protocols differently. With that said, it is useful to highlight ERAS protocols’ benefits in two types of spine surgeries, with particular focus on post-surgical recovery.

Anterior Cervical Spine Surgery

BMC Musculoskeletal Disorders published a study on March 15, 2022 evaluating the effects of 21 ERAS protocols on patients who underwent an anterior cervical discectomy and fusion (or ACDF) procedure.³ The ERAS-treated patients were compared against another patient cohort who underwent ACDF surgeries before the adoption of ERAS protocols.

Compared to the conventional ACDF surgery group, the ERAS cohort experienced a shorter length of stay, a reduced overall cost, and fewer complications. The ERAS-treated patients also had higher patient postoperative satisfaction rates.

Open Transforaminal Lumbar Interbody Fusion

The Spine Journal published a retrospective cohort study also in March 2022 on ERAS protocols’ use in open transforaminal lumbar interbody fusion (or TLIF) surgeries.4 The study profiled one surgeon’s experiences with degenerative disease patients who underwent a 1- or 2-level open TLIF procedure.

The conventional surgical and ERAS surgical cohorts each included 57 patients with similar propensity-matched characteristics. The surgeon performed the second group of surgeries after implementing the ERAS post-surgical protocols.

The study showed that the ERAS protocols resulted in decreased operative times and patients’ length of stay. Other functional post-surgery factors also improved.⁴

Spine Surgeons Are Helping to Reshape ERAS Protocols

Forward-thinking spine surgeons are not waiting for adoption of universal ERAS post-surgical standards. Instead, they are modifying (and often expanding) the ERAS protocols to facilitate more impactful outcomes for the individuals in their care.

Aaron J. Greenberg, MD

Aaron J. Greenberg, MD, is an orthopedic spine surgeon at Redefine Healthcare, a New Jersey-based Premier Brain and Spine practice. Since 2015, Dr. Greenberg has utilized ERAS spine surgery protocols in more than 500 surgeries. These procedures include anterior/posterior lumbar fusions (both traditional and open). Dr. Greenberg has also performed minimally invasive lumbar decompressions along with anterior/posterior multilevel cervical decompression and fusions.

Expansion of ERAS Protocols

Dr. Greenberg has gradually expanded his use of the ERAS protocols, both in procedural scope and modalities. Initially, his ERAS focus was limited to postoperative medications and strategies. Today, Dr. Greenberg utilizes preoperative, intraoperative, and postoperative ERAS protocols.

Dr. Greenberg said his surgical patients have received multiple benefits from these ERAS-based surgeries. “[Patients have had] much better perioperative experiences as a whole due to a combination of improved pain control, improved early mobilization, and decreased opioid usage.”

Dr. Greenberg’s patients have also seen a decreased length of stay along with increased satisfaction with his services and with the facility. He has not seen any downsides to the ERAS protocols’ use and has recruited several colleagues to utilize them.

Looking ahead, Dr. Greenberg would like to see the ERAS protocols utilized in additional ways. “I would like to see more facilities have ERAS-driven order sets created and defaulted within the EMR for their spine service lines so that more surgeons are made aware of these protocols and consequently more patients can benefit from them,” he emphasized.

Patrick F. Doherty, MD

Patrick F. Doherty, MD, is a neurosurgeon at Connecticut’s Yale New Haven Hospital. Dr. Doherty has utilized ERAS protocols for his spinal surgeries since 2018. He has performed approximately 800 procedures including lumbar fusions, lumbar discectomies, and cervical fusions.

Multiple Patient Benefits

Dr. Doherty says his spine surgery patients have experienced several benefits from his usage of ERAS protocols. “In my experience, patients have benefited from quicker recovery in terms of length of stay, return to work, and less dependence on opioids despite better postop pain control. The multimodal nature of the ERAS protocol, in terms of pain control, has had significant impact on recovery.

“There has also been a reduction in surgical site infections in part due to the protocols… I have found no downsides to the protocol as it is hard to argue quicker recovery time with less dependence on opioids and less risk of infection,” Dr. Doherty remarked.

Yale New Haven Hospital has formed a multidisciplinary task force to drive system-wide implementation of ERAS protocols in spine surgery. The team has already begun to see positive trends from this initiative.

Hooman Melamed, MD, FAAOS

Hooman Melamed, MD, FAAOS, is a California-based orthopedic spine surgeon and orthopedic and sports medicine specialist. Dr. Melamed has performed more than 800 ERAS-based spine surgeries. These procedures include ultra-minimally invasive endoscopic spine surgeries, microscopic spine surgeries, and fully invasive major spinal deformity scoliosis kyphosis corrective operations.

Dr. Melamed is emphatic about the ERAS-based spine surgeries’ benefits. “It’s been an absolute game changer. Much faster recovery, less pain, less hospitalization, less post op complications, and faster return to normal life. Fewer issues with patients’ guts as well,” he concluded.

Modification of ERAS Protocols

Over time, Dr. Melamed has modified the ERAS post-spine surgery protocols. He says the changes have helped patients to achieve improved outcomes. Notably, he ceased the practice of post-surgical narcotics administration.

Dr. Melamed also recommends an anti-inflammatory diet and homeopathic medications to help reduce postoperative pain and swelling. Oxygen therapy, cryotherapy, and laser therapy are also part of Dr. Melamed’s postoperative patient regimen.

Adam Kanter, MD

Adam Kanter, MD, is chief of the neurosurgery division of the California-based Hoag Specialty Clinic. Dr. Kanter has utilized the ERAS protocols for 14 years. “I have employed ERAS protocols since I began practicing in 2008 due to my specialty focus in minimally invasive surgical (MIS) techniques, aimed at minimizing tissue trauma during surgery.

“Even highly complex, lengthy invasive operations such as circumferential deformity correction and post-traumatic stabilization surgery can employ ERAS conventions. In fact, several studies opine that ERAS protocols may be even more beneficial when employed in complex surgical interventions, more so than the simpler ones.

“One of the greatest benefits of ERAS protocol implementation is the improved communication and expectation it has provided for our patients, empowering them to be more involved with the surgical planning and recovery process…Several studies support the model that healthier pre-op patients have faster recoveries and better outcomes.”

Logistics of ERAS Implementation

Dr. Kanter continued, “Instituting these protocols has required we standardize many of the care steps along the inpatient continuum, so the patients and ancillary caregivers know exactly what to expect and when to expect it. It has also brought about improved collaboration and consensus among the providers as these protocols are derived.

“ERAS protocols require patients and social workers to consider where and when the patient will go following discharge. If acute rehabilitation is anticipated after surgery, our staff can pre-emptively work with rehab centers and plan accordingly for not only a more streamlined discharge, but often at preferred centers more convenient for them and their families,” Dr. Kanter concluded.

In the near term, universal adoption of ERAS protocols for spine surgery does not appear likely. However, individual spine surgeons are contributing to the ERAS practices’ evolution and forward progression.