Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

Oral ketamine for acute postoperative analgesia (OKAPA) trial: A randomized controlled, single center pilot study

STUDY OBJECTIVE

Although opioids represent the mainstay of treating surgical pain, their use is associated with significant side effects. There is an urgent need to find new pain relievers with safer side effect profiles. One drug that has been receiving increasing attention is ketamine. By using the oral route of administration, ketamine could potentially be used by patients in a less resource-intensive manner with similar efficacy. This study aims to examine the role of oral ketamine in improving recovery after major spine surgery.

DESIGN

A prospective, single-center, double blinded parallel arm, placebo controlled randomized feasibility trial.

SETTING

Toronto Western Hospital (TWH), UHN, Toronto, Canada.

PATIENTS

Adult patients (aged 18-75) undergoing multi-level lumbar spine decompression and fusion with planned overnight admission in hospital.

INTERVENTIONS

Study treatment (oral ketamine 30 mg) or matching placebo for three days (nine doses total) or until hospital discharge.

MEASUREMENTS

The primary outcome was the patient-reported Quality of Recovery-15 score (QoR-15). Secondary outcomes were opioid use, pain intensity, pain interference (PROMIS-pain interference questionnaire), mood (PHQ-9) and, side-effects (Generic Assessment of Side Effects Scale).

MAIN RESULTS

Data from 35 patients were analyzed, of which 18 patients in the ketamine group and 17 patients in the placebo group. There were no significant differences identified in QoR-15 scores at postoperative days 1,3,7, and 30. There were also no significant differences found in pain intensity scale scores at postoperative days 1, 3, 7, and 30, and PROMIS and PHQ-9 scores at postoperative days 7 and 30. Significantly less oral opioids were used in the ketamine group compared to the placebo group on postoperative day 3 and by postoperative day 7. In addition, patients in the ketamine group spent significantly less days on oral opioids and trended to be discharged from hospital earlier.

CONCLUSION

This pilot study demonstrated that low dose oral ketamine can be safely used as an adjunct in postoperative pain treatment to help reduce opioid consumption after major spine surgery.

Advancing the timing of drainage removal: a comprehensive analysis of different drainage removal criteria in patients undergoing short-level lumbar fusion surgery

OBJECTIVE

To specifically evaluate the safety and benefit of different drainage removal criteria (50 ml and 100 ml per 24 h) in patients undergoing short-level lumbar fusion surgery.

METHODS

Patients with degenerative lumbar diseases who underwent short level lumbar fusion with instrumentation between January 2021 and January 2023 were retrospectively recruited in the study. Based on the different criteria for drainage removal, the patients were divided into 2 groups (group A and group B). To control for confounding factors, a 1:1 nearest propensity score matching of significant variation, especially age, gender, BMI, number of fused levels, intraoperative blood loss, and surgical duration, were performed between groups. Perioperative outcomes were compared between groups. Multivariate logistic regression was performed to determine the risk factors for overall complications.

RESULTS

A total of 1004 eligible patients were reviewed in this study with 676 patients in group A and 328 patients in group B. After propensity score matching, 616 patients, 308 in each group were included in the final analysis. There were significantly more patients getting drainage removed on POD 2 (23.1% vs. 32.1%, p = 0.012) and POD 3 (37.0% vs., 45.1%, p = 0.041) in group B. In addition, patients in group B had earlier postoperative timing of ambulation (3.87 ± 1.12 vs. 2.41 ± 1.34, p = 0.012). No significant difference in symptomatic hematoma and surgical site infection was observed, but there were significant fewer overall complications (10.39% vs. 5.19%, p = 0.016) in the group B. Multivariate logistic regression indicated that postoperative timing of ambulation (OR 2.38, 95% CI 1.19-3.97, p < 0.001) was independently associated with overall complications.

CONCLUSION

In this study, we found that the relaxation of the criteria for drainage removal could significantly shorten the length of stay, in addition, it could promote early postoperative ambulation of patients and thus reduce the occurrence of perioperative overall complications.

Enhanced recovery after surgery protocols for minimally invasive treatment of Achilles tendon rupture: Prospective single-center randomized study

BACKGROUND

Achilles tendon rupture is a common orthopedic injury, with an annual incidence of 11-37 per 100000 people, significantly impacting daily life. Minimally invasive surgery, increasingly favored for its reduced risks and comparable fixation strength to open surgery, addresses these challenges. Despite advantages like accelerated recovery, perioperative care poses emotional support, pain management, and rehabilitation challenges, impacting treatment efficacy and patient experience. To address these gaps, this study investigated the efficacy of a rapid rehabilitation protocol in enhancing recovery outcomes for minimally invasive Achilles tendon surgery, aiming to develop personalized, standardized care guidelines for broader implementation.

AIM

To evaluate a nursing-led rapid rehabilitation program for minimally invasive Achilles tendon repair surgery, providing evidence-based early recovery indicators.

METHODS

This study enrolled 160 patients undergoing channel-assisted minimally invasive Achilles tendon repair randomized into experimental and control groups. The experimental group received perioperative rapid rehabilitation nursing care, while the control group received standard care. The primary outcome measure was the Oswestry disability index score, with secondary outcomes including quality of life, Barthel index, patient satisfaction with nursing, incidence of complications, and rehabilitation adherence. Statistical analysis included appropriate methods to compare outcomes between groups. The study was conducted in a specific setting, utilizing a randomized controlled trial design.

RESULTS

All 160 patients completed the follow-up. The experimental group showed significantly greater improvements in key efficacy indicators: Postoperative Oswestry disability index score (8.688 vs 18.88, P < 0.0001), quality of life score (53.25 vs 38.99, P < 0.0001), and Barthel index (70.44 vs 51.63, P < 0.0001). The experimental group had a lower incidence of deep vein thrombosis (1.25% vs 10.00%, P = 0.0339) with a relative risk of 0.1250 (95% confidence interval: 0.02050-0.7421). Infection rates were lower in the experimental group (2.50% vs 11.25%, P = 0.0564). Hospital stay (5.40 days vs 7.26 days, P < 0.0001) and postoperative bed rest (3.34 days vs 5.42 days, P < 0.0001) were significantly shorter. Patient satisfaction was 100% in the experimental group vs 87.50% in the control group (P = 0.0031).

CONCLUSION

The rapid rehabilitation intervention significantly reduced pain, shortened hospital stays, and lowered complication rates, improving joint function and patient satisfaction.

Enhanced recovery after surgery pathway reduces back pain, hospitalization costs, length of stay, and satisfaction rate of lumbar tubular microdiscectomy: A retrospective cohort study

Tubular microdiscectomy is one of the most commonly performed surgical procedures for lumbar disc herniation (LDH). This study aimed to investigate the effectiveness of the enhanced recovery after surgery (ERAS) pathway for microdiscectomy in improving perioperative clinical outcomes in patients with LDH. This study retrospectively analyzed the prospectively collected perioperative outcomes of patients in pre-ERAS (January 2020 to December 2021) and post-ERAS (January 2022 to September 2023) groups. Length of stay was the primary outcome measure, while secondary outcome measures included operative time, estimated blood loss (EBL), postoperative first ambulation time, postoperative drainage volume, drainage tube removal time, complication rate, hospitalization cost, perioperative visual analog scale (VAS) scores for leg pain and low back pain (LBP), readmission rate within 30 days, and patient satisfaction rate. No significant differences in baseline parameters, including sex, age, body mass index, preoperative VAS scores for leg pain and LBP, and comorbidities, were observed between the groups. Additionally, operative time, complication rates, and 30-day readmission rates did not differ significantly between the groups. However, the post-ERAS group exhibited significantly lower length of stay compared to the pre-ERAS group (5.1 ± 1.2 vs 6.2 ± 1.6, P < .001). Additionally, the estimated blood loss (P < .001), drainage tube removal time (P < .001), postoperative drainage volume (P = .002), postoperative first ambulation time (P < .001), and hospitalization costs (P = .032) in the post-ERAS group were significantly lower in the pre-ERAS group. Furthermore, the LBP VAS score was significantly lower on the first day (P = .001) and third days (P = .002) postoperatively in the post-ERAS group, whereas the patient satisfaction rate on the first day (P = .036) postoperatively was significantly higher in the pre-ERAS group. Compared with the conventional pathway, the ERAS pathway in tubular microdiscectomy is associated with better perioperative clinical outcomes in patients with LDH.

Reducing costs and improving patient recovery through a nurse-driven centralized spinal orthoses program on a post-surgical unit: A quality improvement initiative

Background

An external vendor providing off-the-shelf spinal orthoses to inpatients created significant costs and barriers to quality care for spinal surgery patients. A nursing leadership team initiated a quality improvement project to reduce the cost of providing off-the-shelf spinal orthoses and improve the care provided to spinal patients.

Objective

To develop and evaluate a nursing-led process for providing off-the-shelf orthoses to spinal surgery patients and eliminate high costs.

Design

Quality improvement project evaluated as a retrospective interrupted time-series.

Setting

Post Surgery Inpatient Unit Level II Trauma Center in a United States hospital located in Florida.

Participants

Vendor Program: 134 patients; Centralized Program: 155 patients.

Methods

The nursing leadership team developed a centralized spinal orthoses program where the bedside nurse fitted the patient with a spinal orthosis, eliminating the need for an external orthotist. The study quantifies changes in study metrics by comparing patients identified through chart review who received care in the vendor program to those who received care in the centralized program utilizing nonparametric statistical techniques.

Results

The centralized nursing-led spinal orthosis program allowed the unit to mobilize patients more quickly than patients managed under the vendor program (3.85 hr. [95 % CI: 1.27 to 7.26 hrs] reduction; p = 0.004). The overall length of stay was reduced by 0.78 days ([1.34 - 0.02 days]; p = 0.063) or 18.72 h. While the statistical test did not indicate significance, the 18.72-hour reduction in length of stay represents a potential clinically relevant finding. Evaluating patients that suffered a primary spinal injury and no complications (vendor program: 54 patients; centralized program: 86 patients) showed a similar reduction in time to mobilization (4.5 hr reduction [0.53 to 12.93 hrs]; p = 0.025), but the length of stay reduction increased to 1.02 days [0.12 to 1.97 days], a difference determined to be statistically significant (p = 0.014). Centralizing the process for providing off-the-shelf spinal orthoses reduced the cost of a thoracic-lumbar sacral orthosis by $1,483 and the price of a lumbar-sacral orthosis by $1,327. Throughout the study, the new program reduced the cost of providing spinal orthoses by $175,319.

Conclusions

The results demonstrate that the nursing-led centralized spinal orthosis program positively impacted the quality of care provided to our patients while also reducing the cost of delivering the orthoses.

Tweetable abstract

A nursing-led centralized spinal orthosis program reduces the cost of care while reducing time to mobilization and length of stay.

Implementing enhanced recovery after surgery protocol in elderly patients following multi-level posterior lumbar or thoracolumbar instrumented fusion for degenerative diseases

PURPOSE

Enhanced recovery after surgery (ERAS) is an evidence-based multimodal perioperative management strategy. The aim of the present study was to analyze the clinical efficacy of ERAS in elderly patients (> 70 years old) undergoing multi-level posterior lumbar or thoracolumbar instrumented fusion for degenerative diseases.

METHODS

Patients older than 70 years undergoing multi-level lumbar or thoracolumbar instrumented fusion for degenerative disk diseases or spinal stenosis from January 2017 to December 2018 (non-ERAS group) and from January 2020 to December 2021 (ERAS group) were enrolled in present study. Patient-specific and procedure-specific clinical characteristics were collected. Univariate and multivariate regression were performed to determine the risk factors related to length of stay (LOS) and complications.

RESULTS

A total of 233 patients were enrolled in this study, 70 in non-ERAS group and 163 in ERAS group. There were comparable baseline characteristics between groups. Further there were no significant differences in 90-day readmission rates and complication rates. However, we observed a significant reduction in LOS (14.89 ± 7.78 days in non-ERAS group versus 11.67 ± 7.26 days in ERAS group, p = 0.002) and overall number of complications (38 in non-ERAS group versus 58 in ERAS group, p = 0.008). Univariate linear regression denoted that operation time (p < 0.001), intraoperative blood loss (p < 0.001), intraoperative blood transfusion (p < 0.001), fusion number ≥ 5 (p < 0.001), spinal surgery including the thoracic spine (p < 0.001), CCI > 2 (p = 0.018), ERAS (p = 0.003) and spinal surgery including lumbar (p = 0.030) were associated with LOS. Furthermore, multivariate linear regression showed that ERAS (p = 0.001), CCI > 2 (p = 0.014), and Fusion number ≥ 5 (p = 0.002) were independent risk factors for LOS. Analogously, univariate logistic regression revealed that longer operation time (p = 0.005), more intraoperative blood loss (p < 0.001), more intraoperative blood transfusion (p = 0.001), fusion number ≥ 5 (p = 0.001), ERAS (p = 0.004) and spinal surgery including thoracic spine (p = 0.002) were related to complications, while implementing ERAS was associated with less complications. Multivariate logistic regression denoted that implementation of ERAS (p = 0.003), Intraoperative blood loss (p = 0.003) and Fusion number ≥ 5 (p = 0.008) were independent risk factors for postoperative complications.

CONCLUSIONS

In conclusion, the present study reported the first ERAS principles performed in multi-level lumbar or thoracolumbar instrumented fusion for degenerative conditions. Our outcomes shown that the implementation of ERAS in these populations is favorable for reducing LOS and decreasing overall number of complications though the comparable complication rates between two groups. Totally, our ERAS protocols were safe and feasible in these populations.

Enhanced Recovery After Craniotomy: Global Practices, Challenges, and Perspectives

The global demand for hospital care, driven by population growth and medical advances, emphasizes the importance of optimized resource management. Enhanced Recovery After Surgery (ERAS) protocols aim to expedite patient recovery and reduce health care costs without compromising patient safety or satisfaction. Its principles have been adopted in various surgical specialties but have not fully encompassed all areas of neurosurgery, including craniotomy. ERAS for craniotomy has been shown to reduce the length of hospital stay and costs without increasing complications. ERAS protocols may also reduce postoperative nausea and vomiting and perioperative opioid requirements, highlighting their potential to enhance patient outcomes and health care efficiency. Despite these benefits, guidelines, and strategies for ERAS in craniotomy remain limited. This narrative review explores the current global landscape of ERAS for craniotomy, assessing existing literature and highlighting knowledge gaps. Experts from 26 countries with diverse cultural and socioeconomic backgrounds contributed to this review, offering insights about current ERAS protocol applications, implementation challenges, and future perspectives, and providing a comprehensive global overview of ERAS for craniotomy. Representatives from all 6 World Health Organization geographical world areas reported that barriers to the implementation of ERAS for craniotomy include the absence of standardized protocols, provider resistance to change, resource constraints, insufficient education, and research scarcity. This review emphasizes the necessity of tailored ERAS protocols for low and middle-income countries, addressing differences in available resources. Acknowledging limitations in subjectivity and article selection, this review provides a comprehensive overview of ERAS for craniotomy from a global perspective and underscores the need for adaptable ERAS protocols tailored to specific health care systems and countries.

Effect of saline irrigation temperature difference on postoperative acute pain and hypothermia during biportal endoscopic spine surgery

BACKGROUND

Recently, enhanced recovery after surgery (ERAS) protocols have attracted attention; they emphasize on avoiding intraoperative hypothermia while performing lumbar fusion surgery. However, none of the studies have reported the protocol for determining the temperature of saline irrigation during biportal endoscopic spine surgery (BESS) procedure. This study evaluated the effectiveness of warm saline irrigation during BESS in acute postoperative pain and inflammatory reactions.

MATERIALS AND METHODS

Fifty-five patients who underwent BESS procedure were retrospectively analyzed for the incidence of perioperative hypothermia (< 36oC), postoperative inflammatory factors (white blood cells (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin-6 (IL-6), serum amyloid A (SAA)), and clinical outcomes (back visual analog scale (VAS) score, postoperative shivering). The patients were divided into the warm and cold saline irrigation groups.

RESULTS

Hemoglobin, WBC, ESR, creatine kinase, and creatine kinase-muscle brain levels did not significantly differ between the warm and cold saline groups. The mean CRP, IL-6, and SAA levels were significantly higher in the cold saline group than in the warm saline group (p = 0.0058, 0.0028, and 0.0246, respectively); back VAS scores were also higher with a statistically significant difference until two days postoperatively (p < 0.001). During the entire procedure, the body temperature was significantly lower in the cold saline irrigation group, but the hypothermia incidence rate significantly differed 30 min after the operation was started.

CONCLUSIONS

Using warm saline irrigation during BESS is beneficial for early recovery after surgery, as it is associated with reduced postoperative pain and complication rates.

Minimally Invasive Spine Surgery for Lumbar Decompression or Disc Herniation

Many people experience low back pain caused by degenerative disease of the lumbar spine; this includes spinal stenosis, spondylolisthesis, disc degeneration, and disc herniation. Conservative management of degenerative disease, which includes physical therapy, lifestyle modifications, and medications, is the initial approach. If this approach fails, a surgical procedure may be the next step. Previously, open lumbar surgery would have been the planned procedure; today, minimally invasive spine surgery gives patients another choice. Perioperative nurses should understand how minimally invasive spine surgery differs from the open procedure, the steps involved during a minimally invasive procedure, the benefits of this type of procedure, and nursing considerations for patients undergoing minimally invasive spinal procedures.

Association between underweight status or low body mass index and the risk of developing superior mesenteric artery syndrome following scoliosis corrective surgery in pediatric patients: a review of the literature

Superior mesenteric artery (SMA) syndrome is the compression of the third portion of the duodenum between the abdominal aorta and the superior mesenteric artery. Although multifactorial, the most frequent cause of SMA syndrome is significant weight loss and cachexia often induced by catabolic stress. SMA syndrome resulting from scoliosis surgery is caused by a reduction of the aortomesenteric angle and distance. Risk factors include rapid weight loss, malnutrition, and a rapid reduction in the mesenteric fat pad and are the most common causes of a decrease in the aortomesenteric angle and distance. Surgically lengthening the vertebral column can also lead to a reduction of the aortomesenteric distance, therefore, has been identified as a risk factor unique to spinal surgery. Despite a reported decline in SMA syndrome cases due to improved surgical techniques, duodenal compression is still a risk and remains a life-threatening complication of scoliosis surgery. This article is a cumulative review of the evidence of being underweight or having a low body mass index as risk factors for developing SMA syndrome following surgical scoliosis instrumentation and correction.

Application of enhanced recovery after surgery for oral dryness prevention after endoscopic sinus surgery

OBJECTIVE

To investigate the efficacy of cluster nursing intervention based on Enhanced Recovery After Surgery (ERAS) for xerostomia in chronic rhinosinusitis after nasal endoscopic surgery.

METHODS

A total of 80 patients with chronic rhinosinusitis who underwent functional nasal endoscopic surgery between January 2020 and December 2021 were selected and randomly divided into a control group (n = 40) and an experimental group (n = 40). Patients in the control group were treated with general nursing, while ERAS-based cluster nursing intervention was adopted for the experimental group, in addition to general nursing. Xerostomia stage and comfort level were observed at 2 h, 6 h, 24 h and 48 h after surgery; negative emotions before and after nursing were also observed.

RESULTS

After the intervention, the xerostomia stage and comfort level at 6, 24 and 48 after surgery were higher in the experimental group (p < 0.05). Negative emotions in the experimental group were lower after nursing (p < 0.001). The self-rating depression scale and self-rating anxiety scale scores increased after nursing in both two groups (p < 0.05).

CONCLUSION

Enhanced recovery after surgery-based cluster nursing intervention can alleviate xerostomia, improve patients' comfort levels, reduce their negative emotions and accelerate postoperative recovery.

LEVEL OF EVIDENCE: 2

Enhanced recovery after surgery (ERAS) improves outcomes in elderly patients undergoing short-level lumbar fusion surgery: a retrospective study of 333 cases

BACKGROUND

Degenerative lumbar disease significantly impairs the quality of life in elderly individuals, with short-segment lumbar degenerative disease being particularly prevalent. When conservative treatment proves ineffective, surgical intervention becomes the optimal choice for managing lumbar disease. The implementation of Enhanced Recovery After Surgery (ERAS) in spinal surgery has been progressively refined, leading to greater patient benefits. However, age and the associated decline in physiological function remain critical factors influencing surgical decision-making. Currently, there is a paucity of research focused on elderly patients undergoing lumbar fusion surgery to substantiate that advanced age does not diminish the benefits derived from ERAS in this demographic.

METHODS

This is a retrospective cohort study of prospectively collected data. Patients who underwent short-segment (1 or 2 segments) transforaminal lumbar interbody fusion (TLIF) under the care of the same surgical team at our institution were recruited, and divided into no-ERAS-elder, ERAS-elder, and ERAS-younger groups. Subsequently, time to physiological function recovery and other outcomes were compared.

RESULTS

The outcomes of the ERAS-elder group (n = 113) and the no-ERAS-elder group (n = 120) were compared. The overall physiological function recovery was significantly faster (6.71 ± 2.6 days vs. 8.6 ± 2.67 days, p = 0.01) in the ERAS-elder group. Next, the outcomes of the ERAS-elder group (n = 113) were compared with those of the ERAS-younger group (n = 100), and no significant difference in total physiological function recovery was found between the two groups (6.71 ± 2.6 days vs. 6.14 ± 1.63 days, p = 0.252).

CONCLUSIONS

This study shows that the implementation of the ERAS program can effectively shorten the recovery time of physiological function in elderly patients after short-segment lumbar surgery, reduce the incidence of some complications, alleviate pain, and significantly shorten the length of hospital stay. ERAS enables elderly patients to achieve outcomes comparable to those of younger patients.

New protocol for early robot-assisted gait training after spinal surgery

Introduction

Early rehabilitation post-spinal surgery is vital for patients' recovery. Robot-assisted gait training (RAGT) shows promise but requires further study to establish a specific protocol and gauge its effects on both patients and physical therapists. This study aimed to determine the impact of a newly developed protocol for early RAGT on patients' functional enhancement and satisfaction levels after spinal surgery, as well as on the physical therapists who implemented the therapy.

Methods

First, we developed the protocol in collaboration with three physiatrists and two physical therapists with extensive experience in musculoskeletal rehabilitation. The protocol was updated three times, each after three rounds of face-to-face meetings. Afterward, we conducted a cross-sectional study involving five physical therapists and 32 post-spinal surgery patients at a tertiary hospital rehabilitation center. The intervention consisted of five sessions of RAGT. Main outcome measures included the Functional Ambulation Category (FAC), the ambulation item of the Modified Barthel Index (MBI ambulation), and satisfaction surveys for both patients and physical therapists.

Results

RAGT typically started 17.91 ± 9.76 days postoperatively and was successfully applied with no remarkable adverse effects. The FAC scores increased from 2.65 ± 1.21 to 3.78 ± 0.71 (p = 0.006), and MBI ambulation increased from 7.69 ± 2.71 to 10.66 ± 2.90 (p < 0.001) between transfer and discharge. Satisfaction with the robot, RAGT, and treatment, assessed using a 5-point Likert scale, were 3.30 ± 0.79, 3.72 ± 0.85, and 3.08 ± 0.84, respectively. Satisfaction was notably the highest for alleviating fear of falling, whereas managing pain and discomfort during position changes scored the lowest. Physical therapists rated RAGT satisfaction, impact on the working environment, and treatment stability at 3.0 ± 0.65, 2.80 ± 0.67, and 3.50 ± 0.61, respectively.

Conclusion

Early spinal surgery rehabilitation with RAGT improved patients' functionality and gait satisfaction. While physical therapists considered RAGT safe, its impact on their work environment was limited. Integrating RAGT into post-spinal surgery rehabilitation demands ongoing protocol refinement, custom robot development, and efficacy evaluations.

Enhanced Recovery After Surgery Protocols in One- or Two-Level Posterior Lumbar Fusion: Improving Postoperative Outcomes

Background/Objectives: Enhanced recovery after surgery (ERAS) protocols optimize perioperative care and improve recovery. This study evaluated the effectiveness of ERAS in one- or two-level posterior lumbar fusion surgeries, focusing on perioperative medication use, pain management, and functional outcomes. Methods: Eighty-eight patients undergoing lumbar fusion surgery between March 2021 and February 2022 were allocated into pre-ERAS (n = 41) and post-ERAS (n = 47) groups. Outcomes included opioid and antiemetic consumption, pain scores (numerical rating scale (NRS)), functional recovery (Oswestry Disability Index (ODI) and EuroQol 5 Dimension (EQ-5D)), and complication rates. Pain was assessed daily for the first four postoperative days and at 6 months. Linear Mixed Effects Model analysis evaluated pain trajectories. Results: The post-ERAS group showed significantly lower opioid (p = 0.005) and antiemetic (p < 0.001) use. No significant differences were observed in NRS pain scores in the first 4 postoperative days. At 6 months, the post-ERAS group reported significantly lower leg pain (p = 0.002). The time:group interaction was not significant for back (p = 0.848) or leg (p = 0.503) pain. Functional outcomes at 6 months, particularly ODI and EQ-5D scores, showed significant improvement in the post-ERAS group. Complication rates were lower in the post-ERAS group (4.3% vs. 19.5%, p = 0.024), while hospital stay and fusion rates remained similar. Conclusions: The ERAS protocol significantly reduced opioid and antiemetic use, improved long-term pain management and functional recovery, and lowered complication rates in lumbar fusion patients. These findings support the implementation of ERAS protocols in spinal surgery, emphasizing their role in enhancing postoperative care.

Effectiveness of accelerated rehabilitation surgical nursing on perioperative outcomes in patients with calcaneal fractures

This study aims to evaluate the impact of accelerated rehabilitation nursing on perioperative outcomes in patients with calcaneal fractures. A total of 101 patients with calcaneal fractures admitted from December 2020 to December 2022 were included in this study. Patients were randomly assigned to an observation group (OG) of 51 patients receiving accelerated rehabilitation surgical nursing and a control group (CG) of 50 patients receiving conventional surgical nursing. Outcomes assessed included patient satisfaction, visual analog scale (VAS) scores before and after surgery, swelling reduction time, and complication rates. The satisfaction rate in the OG was 96.07%, significantly higher than the 80.00% observed in the CG. Post-operative VAS scores at day 4 and 6 were significantly lower in the OG compared to the CG. Swelling reduction time was shorter in the OG (152.56 ± 25.22 hours) compared to the CG (170.76 ± 22.51 hours). Additionally, the complication rate in the OG was significantly lower at 7.84% compared to 24.00% in the CG (P < .05).the implementation of accelerated rehabilitation nursing significantly shortened the average length of hospital stay for patients in the observation group. In contrast, patients in the control group, who received conventional nursing care, had a relatively longer hospital stay. In the perioperative treatment of calcaneal fractures, accelerated rehabilitation surgical nursing can significantly improve patient satisfaction, reduce pain, shorten the time for swelling to subside, and lower the incidence of complications. Additionally, it can shorten the hospital stay for patients, demonstrating its efficacy and potential for broader clinical application.

[Translated article] Management of spinal deformities caused by osteoporotic vertebral fractures

Osteoporosis and fragility play a significant role in the treatment and planning of patients with deformity secondary to osteoporotic vertebral fracture (OVF). The resulting deformity can present significant challenges for its management, both from a medical and surgical perspective. The need for a specific classification for these deformities, including the potential for the development of artificial intelligence and machine learning in predictive analysis, is emerging as a key point in the coming years. Relevant aspects in preoperative optimisation and management of these patients are addressed. A classification with therapeutic guidance for the management of spinal deformity secondary to OVF is developed, emphasising the importance of personalised treatment. Flexibility and sagittal balance are considered key aspects. On the other hand, we recommend, especially with these fragile patients, management with minimally invasive techniques to promote rapid recovery and reduce the number of complications.

Enhanced Recovery After Surgery Pathways in Pediatric Spinal Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Pediatric spinal fusion surgery is a complex procedure that poses challenges in perioperative management. The enhanced recovery after surgery (ERAS) approach is an evidence-based, multidisciplinary strategy to optimize patient care in an individualized, multidisciplinary way. Despite the benefits of ERAS protocol implementation, the role of ERAS in pediatric spine surgery remains understudied. This systematic review and meta-analysis aims to evaluate the current literature regarding pediatric spinal surgery ERAS protocols and their ability to decrease the length of stay, pain, time-to-stand, and complications.

METHODS

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Statistical analyses were performed using Cochrane's RevMan (version 5.4).

RESULTS

Seventeen studies totaling 2733 patients were included in this analysis. Patients treated in an ERAS protocol had significant reductions in length of stay (P < 0.001), time-to-stand (P < 0.001), total complications (P = 0.02), and estimated blood loss (P = 0.001).

CONCLUSIONS

ERAS protocol implementation can significantly enhance outcomes for pediatric patients receiving spinal surgery. Consequently, ERAS protocols have the potential to lower healthcare expenses, increase access, and set a new standard of care. Future research should be conducted to expand pediatric ERAS protocols to a diverse range of spinal pathologies and assess the long-term advantages of this practice.

Evaluation of ERAS protocol implementation on complex spine surgery complications and length of stay: a single institution study

BACKGROUND CONTEXT

With the goal of improving patient outcomes, the Integrated Spine Center at UT Southwestern Medical Center implemented an enhanced recovery after surgery (ERAS) protocol which includes pre- and postsurgery guidelines. Numerous studies have shown benefit of implementation of ERAS protocols to standardize perioperative care in line with best practices; however, the literature on complication rates, LOS, and readmissions shows mixed results.

PURPOSE

The goal of this study was to investigate the impact of the ERAS protocol implementation on complication rates in the perioperative period, as well as hospital and ICU length of stay and hospital re-admission rates.

STUDY DESIGN/SETTING

A retrospective cohort study was performed on all patients who underwent spine surgery between September 2016 and September 2021 at a single institution. Patients who met inclusion criteria were divided into non-ERAS and ERAS groups, and comparative statistics were used to evaluate ERAS protocol effectiveness.

PATIENT SAMPLE

All patients who underwent spine surgery at UT Southwestern between September 2016 and September 2021 were evaluated for inclusion in the study. The patient sample was further refined to include only complex patient cases which were able to receive the full ERAS protocol (nonemergent admissions).

OUTCOME MEASURES

Presence of absence of postoperative complications including surgical site infection, AKI, DVT, MI, sepsis, pneumonia, PE, stroke, shock, and other complications were compared between groups, as were hospital and ICU length of stay, and 7, 30, and 90 day readmissions. Self-reported or functional measures were not used in outcome evaluation.

METHODS

A database of patient and surgery characteristics was built using an EMR query tool with spot checks performed by the authors. Control and treatment groups were matched for gender, age, BMI, ASA score, and surgery type. Total number of complication rates was compared between ERAS and non-ERAS groups, and comparative statistics were used to determine significance.

RESULTS

Significant differences between ERAS versus non-ERAS groups were found in rates of UTI (6.8% vs 3.1%, respectively; p=.031), constipation (20.6% vs 11.4%, respectively; p=.001), and any complications (31.4% vs 19.4%, respectively; p<.001). There was no significant difference in the rates of other complications, in length of hospital or ICU stay, or readmissions at 7, 30, and 90 days.

CONCLUSIONS

Implementation of the ERAS protocol did not decrease complication rates or length of stay, and ERAS patients had significantly higher rates of UTI, constipation, and any complications. There may have been confounding factors due to the impact of COVID-19 on delivery of care, as well as misalignment between ERAS goals and outcome measures.

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review

PURPOSE OF REVIEW

To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures.

RECENT FINDINGS

Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Effects of liposomal bupivacaine on opioid use and healthcare resource utilization after outpatient spine surgery: a real-world assessment

BACKGROUND CONTEXT

Perioperative pain management affects cost and outcomes in elective spine surgery.

PURPOSE

This study investigated the association between liposomal bupivacaine (LB) and outpatient spine surgery outcomes, including perioperative, postoperative, and postdischarge opioid use and healthcare resource utilization.

STUDY DESIGN

This was a retrospective comparative study.

PATIENT SAMPLE

Eligibility criteria included adults with ≥6 months of continuous data before and after outpatient spine procedures including discectomy, laminectomy, or lumbar fusion. Patients receiving LB were matched 1:3 to patients receiving non-LB analgesia by propensity scores.

OUTCOME MEASURES

Outcomes included (1) opioid use in morphine milligram equivalents (MMEs) during the perioperative and postdischarge periods and (2) postdischarge readmission and emergency department (ED) visits up to 3 months after surgery. Generalized linear mixed-effects modeling with appropriate distributions was used for analysis.

METHODS

Deidentified data from the IQVIA linkage claims databases (2016-2019) were used for the analysis. This study was funded by Pacira BioSciences, Inc.

RESULTS

In total, 381 patients received LB and 1143 patients received non-LB analgesia. Baseline characteristics were well balanced after propensity score matching. The LB cohort used fewer MMEs versus the non-LB cohort before discharge (80 vs 132 MMEs [mean difference, -52 MMEs; p=.0041]). Following discharge, there was a nonsignificant reduction in opioid use in the LB cohort versus the non-LB cohort within 90 days (429 vs 480 MMEs [mean difference, -50 MMEs; p=.289]) and from >90 days to 180 days (349 vs 381 MMEs [mean difference, -31 MMEs; p=.507]). The LB cohort had significantly lower rates of ED visits at 2 months after discharge versus the non-LB cohort (3.9% vs 7.6% [odds ratio, 0.50; p=.015]). Postdischarge readmission rates did not differ between cohorts.

CONCLUSIONS

Use of LB for outpatient spine surgery was associated with reduced opioid use at the hospital and nonsignificant reduction in opioid use at all postoperative timepoints examined through 90 days after surgery versus non-LB analgesia. ED visit rates were significantly lower at 60 days after discharge. These findings support reduced cost and improved quality metrics in patients treated with LB versus non-LB analgesia for outpatient spine surgery.

Effect of enhanced recovery after surgery on postoperative outcomes in children undergoing robot-assisted laparoscopic pyeloplasty

OBJECTIVE

To assess the effects of the enhanced recovery after surgery (ERAS) perioperative protocol on the outcomes of robot-assisted laparoscopic pyeloplasty (RALP) in pediatric patients.

METHODS

A total of 57 children who underwent RALP at our center between November 2021 and December 2023 were included in the study. They were randomly assigned to either the ERAS (intervention) group or the non-ERAS (control) group. The analysis focused on comparing the length of hospital stay, recovery of gastrointestinal function, incidence of complications within 90 days post-surgery, postoperative extubation time (urinary tube and double-J tube), postoperative auxiliary examinations, and readmission rates within 30 days. Additionally, the patients were divided into two age groups: <4 years old and ≥4 years old, to assess pain severity.

RESULTS

There were no significant differences in preoperative general information, preoperative auxiliary examination findings, or intraoperative conditions between the ERAS and non-ERAS groups. The ERAS group had a significantly shorter postoperative hospital stay compared to the non-ERAS group. Furthermore, the time to the first postoperative bowel movement was shorter, and the incidence of postoperative complications was significantly lower in the ERAS group. Among children <4 years old, there was no significant difference in pain severity between the two groups. However, in children ≥4 years old, the ERAS group experienced significantly lower pain levels at 6 and 24 h post-surgery compared to the non-ERAS group.

DISCUSSION

The findings of this prospective randomized controlled trial should determine if ERAS is superior to traditional perioperative management in children undergoing RALP, particularly regarding postoperative hospital stay, intestinal function recovery, pain response, and complication rates. We anticipate that our data will offer valuable clinical insights and guidance for the implementation of ERAS in pediatric robotic surgery for urinary diseases.

CONCLUSION

The ERAS protocol can reduce the length of hospital stay, aid in the recovery of gastrointestinal function, and lower postoperative complication rates. It also has the potential to lessen postoperative pain to varying degrees in certain pediatric patients. ERAS is a safe and effective protocol for pediatric patients undergoing RALP.

Effectiveness of tramadol-including multimodal analgesia in spinal surgery: a single-center, retrospective cohort study

BACKGROUND

Multimodal analgesia (MMA) is recommended for postoperative pain management; however, studies evaluating the effect of tramadol-including MMA on numerical rating scale (NRS)-based postoperative pain levels and the length of stay (LOS) in the hospital are limited. Therefore, this study aimed to compare the before and after effects of tramadol-including MMA application, and assess its effect on postoperative NRS scores and LOS.

METHODS

Patients who underwent spinal surgery under general anesthesia at the Rakuwakai Marutamachi Hospital in fiscal years 2020 and 2022 were included in this study. The outcomes between the pre- and post-intervention groups were compared through propensity score matching.

RESULTS

Following propensity score matching, 249 patients were included in each group. MMA application significantly decreased the median LOS from 10 to 9 days (p < 0.001). Additionally, the median NRS scores exhibited a significant decrease from 4 to 3 on postoperative day (POD) 3 (p = 0.0109) and from 3 to 2 on POD 5 (p = 0.0087). Following MMA application, the number of patients receiving additional analgesics decreased significantly, from 38 to 6 (p < 0.001).

CONCLUSIONS

The introduction of tramadol-including MMA can effectively reduce postoperative pain and decrease the LOS for patients undergoing spinal surgery.

The Implementation of Enhanced Recovery After Spine Surgery in High and Low/Middle-income Countries: A Systematic Review and Meta-Analysis

In this review article, we explore the implementation and outcomes of enhanced recovery after spine surgery (spine ERAS) across different World Bank country-income levels. A systematic literature search was conducted through PubMed, Embase, Scopus, and CINAHL databases for articles on the implementation of spine ERAS in both adult and pediatric populations. Study characteristics, ERAS elements, and outcomes were analyzed and meta-analyses were performed for length of stay (LOS) and cost outcomes. The number of spine ERAS studies from low-middle-income countries (LMICs) increased since 2017, when the first spine ERAS implementation study was published. LMICs were more likely than high-income countries (HICs) to conduct studies on patients aged ≥18 years (odds ratio [OR], 6.00; 95% CI, 1.58-42.80), with sample sizes 51 to 100 (OR, 4.50; 95% CI, 1.21-22.90), and randomized controlled trials (OR, 7.25; 95% CI, 1.77-53.50). Preoperative optimization was more frequently implemented in LMICs than in HICs (OR, 2.14; 95% CI, 1.06-4.41), and operation time was more often studied in LMICs (OR 3.78; 95% CI, 1.77-8.35). Implementation of spine ERAS resulted in reductions in LOS in both LMIC (-2.06; 95% CI, -2.47 to -1.64 d) and HIC (-0.99; 95% CI, -1.28 to -0.70 d) hospitals. However, spine ERAS implementation did result in a significant reduction in costs. This review highlights the global landscape of ERAS implementation in spine surgery, demonstrating its effectiveness in reducing LOS across diverse settings. Further research with standardized reporting of ERAS elements and outcomes is warranted to explore the impact of spine ERAS on cost-effectiveness and other patient-centered outcomes.

Intraoperative fluid management in adult spinal deformity surgery: variation analysis and association with outcomes

PURPOSE

To evaluate the variability in intraoperative fluid management during adult spinal deformity (ASD) surgery, and analyze the association with complications, intensive care unit (ICU) requirement, and length of hospital stay (LOS).

METHODS

Multicenter comparative cohort study. Patients ≥ 18 years old and with ASD were included. Intraoperative intravenous (IV) fluid data were collected including: crystalloids, colloids, crystalloid/colloid ratio (C/C), total IV fluid (tIVF, ml), normalized total IV fluid (nIVF, ml/kg/h), input/output ratio (IOR), input-output difference (IOD), and normalized input-output difference (nIOD, ml/kg/h). Data from different centers were compared for variability analysis, and fluid parameters were analyzed for possible associations with the outcomes.

RESULTS

Seven hundred ninety-eight patients with a median age of 65.2 were included. Among different surgical centers, tIVF, nIVF, and C/C showed significant variation (p < 0.001 for each) with differences of 4.8-fold, 3.7-fold, and 4.9-fold, respectively. Two hundred ninety-two (36.6%) patients experienced at least one in-hospital complication, and ninety-two (11.5%) were IV fluid related. Univariate analysis showed significant relations for: LOS and tIVF (ρ = 0.221, p < 0.001), IOD (ρ = 0.115, p = 0.001) and IOR (ρ = -0.138, p < 0.001); IV fluid-related complications and tIVF (p = 0.049); ICU stay and tIVF, nIVF, IOD and nIOD (p < 0.001 each); extended ICU stay and tIVF (p < 0.001), nIVF (p = 0.010) and IOD (p < 0.001). Multivariate analysis controlling for confounders showed significant relations for: LOS and tIVF (p < 0.001) and nIVF (p = 0.003); ICU stay and IOR (p = 0.002), extended ICU stay and tIVF (p = 0.004).

CONCLUSION

Significant variability and lack of standardization in intraoperative IV fluid management exists between different surgical centers. Excessive fluid administration was found to be correlated with negative outcomes.

LEVEL OF EVIDENCE

III.

Management of Spinal Deformities Caused by Osteoporotic Vertebral Fractures

Osteoporosis and fragility play a significant role in the treatment and planning of patients with deformity secondary to osteoporotic vertebral fracture (OVF). The resulting deformity can present significant challenges for its management, both from a medical and surgical perspective. The need for a specific classification for these deformities, including the potential for the development of artificial intelligence and machine learning in predictive analysis, is emerging as a key point in the coming years. Relevant aspects in preoperative optimization and management of these patients are addressed. A classification with therapeutic guidance for the management of spinal deformity secondary to OVF is developed, emphasizing the importance of personalized treatment. Flexibility and sagittal balance are considered key aspects. On the other hand, we recommend, especially with these fragile patients, management with minimally invasive techniques to promote rapid recovery and reduce the number of complications.

Poor postoperative pain control is associated with poor long-term patient-reported outcomes after elective spine surgery: an observational cohort study

BACKGROUND CONTEXT

A significant proportion of patients experience poorly controlled surgical pain and fail to achieve satisfactory clinical improvement after spine surgery. However, a direct association between these variables has not been previously demonstrated.

PURPOSE

To investigate the association between poor postoperative pain control and patient-reported outcomes after spine surgery.

STUDY DESIGN

Ambispective cohort study.

PATIENT SAMPLE

Consecutive adult patients (≥18-years old) undergoing inpatient elective cervical or thoracolumbar spine surgery.

OUTCOME MEASURE

Poor surgical outcome was defined as failure to achieve a minimal clinically important difference (MCID) of 30% improvement on the Oswestry Disability Index or Neck Disability Index at follow-up (3-months, 1-year, and 2-years).

METHODS

Poor pain control was defined as a mean numeric rating scale score of >4 during the first 24-hours after surgery. Multivariable mixed-effects regression was used to investigate the relationship between poor pain control and changes in surgical outcomes while adjusting for known confounders. Secondarily, the Calgary Postoperative Pain After Spine Surgery (CAPPS) Score was investigated for its ability to predict poor surgical outcome.

RESULTS

Of 1294 patients, 47.8%, 37.3%, and 39.8% failed to achieve the MCID at 3-months, 1-year, and 2-years, respectively. The incidence of poor pain control was 56.9%. Multivariable analyses showed poor pain control after spine surgery was independently associated with failure to achieve the MCID (OR 2.35 [95% CI=1.59-3.46], p<.001) after adjusting for age (p=.18), female sex (p=.57), any nicotine products (p=.041), ASA physical status >2 (p<.001), ≥3 motion segment surgery (p=.008), revision surgery (p=.001), follow-up time (p<.001), and thoracolumbar surgery compared to cervical surgery (p=.004). The CAPPS score was also found to be independently predictive of poor surgical outcome.

CONCLUSION

Poor pain control in the first 24-hours after elective spine surgery was an independent risk factor for poor surgical outcome. Perioperative treatment strategies to improve postoperative pain control may lead to improved patient-reported surgical outcomes.

Impact of Gender-Specific Physiological activities on Bone Density and Spinal Alignment Post-Spinal Stabilization Surgery Affecting Quality of Life

Background: The rate of spinal stabilization surgery has increased in recent years among both males and females due to ineffective activities impacting their quality of life, work-disability, and social-disability. Aim: This study aimed to determine the impact of such activities on bone density and spinal alignment after spinal stabilization surgery within the context of Bursa, Turkey. Method: A sample of 450 patients, who had undergone spinal surgery, was included, 210 of which were females and 240 were males. These patients had suffered from different ailments including spinal stenosis, degenerative spondylolisthesis and disc herniation. In order to attain the required outcomes, Core Outcome Measures Index (COMI) was measured before and after (one year) operation. This test measured various positive and negative outcomes post-spinal stabilization surgery including improvement in degree of pain and back function, quality of life, degree of work-disability and social-disability, over a period of 12-months. Patients' satisfaction level with therapy was also measured using a 5-point Likert scale while parametric statistics provided the relationship among variables. Results: The results obtained show that females with all pathologies had worse COMI scores significantly (p < 0.05) as compared to males. However, no significant differences were observed after the operation within the context of gender (p > 0.05). However, 72% of females and 71% of males received minimal clinically important change (MCIC) score of 2.2 for COMI. Hence, gender showed insignificant relationship with MCIC, since females did not show any significant satisfaction level as compared to males concerning their post-operative health outcomes. Conclusion: The study recommends to emphasize on improving therapeutic and surgical measures aiming at attaining significant satisfaction levels after surgery.

Enhanced recovery after surgery from 1997 to 2022: a bibliometric and visual analysis

Enhanced recovery after surgery (ERAS) is a multimodal perioperative management concept, but there is no article to comprehensively review the collaboration and impact of countries, institutions, authors, journals, references, and keywords on ERAS from a bibliometric perspective. This study assessed the evolution of clustering of knowledge structures and identified hot trends and emerging topics. Articles and reviews related to ERAS were retrieved through subject search from the Web of Science Core Collection. We used the following strategy: "TS = Enhanced recovery after surgery" OR "Enhanced Postsurgical Recovery" OR "Postsurgical Recoveries, Enhanced" OR "Postsurgical Recovery, Enhanced" OR "Recovery, Enhanced Postsurgical" OR "Fast track surgery" OR "improve surgical outcome". Bibliometric analyses were conducted on Excel 365, CiteSpace, VOSviewer, and Bibliometrics (R-Tool of R-Studio). Totally 3242 articles and reviews from 1997 to 2022 were included. These publications were mainly from 684 journals in 78 countries, led by the United States and China. Kehlet H published the most papers and had the largest number of co-citations. Analysis of the journals with the most outputs showed that most journals mainly cover Surgery and Oncology. The hottest keyword is "enhanced recovery after surgery". Later appearing topics and keywords indicate that the hotspots and future research trends include ERAS protocols for other types of surgery and improving perioperative status, including "bariatric surgery", "thoracic surgery", and "prehabilitation". This study reviewed the research on ERAS using bibliometric and visualization methods, which can help scholars better understand the dynamic evolution of ERAS and provide directions for future research.

Erector spinae plane block level does not impact analgesic efficacy in enhanced recovery for lumbar spine surgery

BACKGROUND CONTEXT

Postoperative pain control following spine surgery can be difficult. The Enhanced Recovery After Surgery (ERAS) programs use multimodal approaches to manage postoperative pain. While an erector spinae plane block (ESPB) is commonly utilized, the ideal distance for injection from the incision, referred to as the ES (ESPB to mid-surgical level) distance, remains undetermined.

PURPOSE

We evaluated the impact of varying ES distances for ESPB on Numerical Rating Scale (NRS) measures of postoperative pain within the ERAS protocol.

STUDY DESIGN/SETTING

Retrospective observational study.

PATIENT SAMPLE

Adult patients who underwent elective lumbar spine fusion surgery.

OUTCOME MEASURES

Primary outcome measures include the comparative postoperative NRS scores across groups at immediate (T1), 24 (T2), 48 (T3), and 72 (T4) hours postsurgery. For secondary outcomes, a propensity matching analysis compared these outcomes between the ERAS and non-ERAS groups, with opioid-related recovery metrics also assessed.

METHODS

All included patients were assigned to one of three ERAS groups according to the ES distance: Group 1 (G1, ES > 3 segments), Group 2 (G2, ES = 2-3 segments), and Group 3 (G3, ES<2 segments). Each patient underwent a bilateral ultrasound-guided ESPB with 60 mL of diluted ropivacaine or bupivacaine.

RESULTS

Patients within the ERAS cohort reported mild pain (NRS < 3), with no significant NRS variation across G1 to G3 at any time. Sixty-five patients were matched across ERAS and non-ERAS groups. The ERAS group exhibited significantly lower NRS scores from T1 to T3 than the non-ERAS group. Total morphine consumption during hospitalization was 26.7 mg for ERAS and 41.5 mg for non-ERAS patients. The ERAS group resumed water and food intake sooner and had less postoperative nausea and vomiting.

CONCLUSIONS

ESPBs can be effectively administered at or near the mid-surgical level to the low thoracic region for lumbar spine surgeries. Given challenges with sonovisualization, a lumbar ESPB may be preferred to minimize the risk of inadvertent pleural injury.

Bispectral Index Monitoring Effect on Delirium Occurrence and Nursing Quality Improvement in Post-anesthesia Care Unit Patients Recovering From General Anesthesia: A Randomized Controlled Trial

BACKGROUND

The effect of intraoperative anesthesia depth monitoring on delirium occurrence and improvement of nursing quality in the post-anesthesia care unit (PACU) remains unclear. We aimed to explore the effect of intraoperative anesthesia bispectral index (BIS) monitoring on delirium occurrence and improvement of nursing quality in the PACU for patients recovering from general anesthesia.

METHODS

 This randomized controlled trial included 120 patients, aged 20-80 years, classified as grades I-III according to the American Society of Anesthesiologists. The BIS-guided group (group B) underwent intraoperative monitoring of BIS anesthesia depth (maintained within the anesthetic range (40-60)). The depth of anesthesia was not monitored in the non-BIS-guided group (group C). The patient's vital signs were recorded at the beginning of the operation (T0), upon entering the PACU (T1), 15 min after extubation (T2), and after leaving the PACU (T3). Delirium score, emergence period (extubation and PACU observation times), and adverse events in the PACU were monitored. The nursing activity score (NAS) was used to evaluate the quality of care.

RESULTS

Group B exhibited significantly lower heart rate and mean arterial pressure at T1 and T2, shorter time to extubation and PACU observation time, and a significantly lower incidence of adverse events than group C. Group B had significantly lower Ricker sedation-agitation scores and a lower incidence of delirium than group C. The NAS was significantly lower for group B than for group C. Patients aged 60-80 years in group C experienced agitation, requiring 30% more frequent assistance from one or two nurses than those in group B.

CONCLUSION

Intraoperative BIS monitoring can reduce the incidence of adverse events in the PACU, diminish the incidence of delirium during the recovery period in elderly patients, lessen the nursing workload, improve nursing quality, and promote patient rehabilitation, thus meriting clinical application.

Efficacy and Safety of Enhanced Recovery After Surgery (ERAS) Protocols for Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the efficacy and safety of enhanced recovery after surgery (ERAS) in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for lumbar degenerative disease (LDD).

METHODS

Electronic databases including PubMed, Embase, the Cochrane Library, Web of Science, Clinical Trials.gov, etc. were searched from inception to October 2023. Randomized controlled trials (RCTs) and cohort studies (CSs) comparing ERAS program with traditional protocol of MIS-TLIF for LDD were included.

RESULTS

A total of 11 studies were included for final analysis. The pooled results of RCTs showed that compared with MIS-TLIF, the ERAS program used in MIS-TLIF could reduce the length of hospital stay, operation time, intraoperative blood loss and incidence of postoperative complications, decrease visual analog scale and Oswestry Disability Index (ODI) score, and improve patient satisfaction (P < 0.05). However, the pooled results of CSs revealed no statistical difference in the ODI score, fusion rate, operation time, and incidence of complications between the two groups (P > 0.05).

CONCLUSIONS

Compared with MIS-TLIF, the ERAS program used in MIS-TLIF could effectively shorten the length of hospital stay, operation time, decrease intraoperative blood loss, and incidence of postoperative complications, promote postoperative pain relief, functional recovery, and patient satisfaction. This study confirmed the value of ERAS in MIS-TLIF surgery and provided evidence for the standardization of ERAS in the future. Considering that the pooled results of RCTs and CSs are not completely consistent, more high-quality studies are needed to confirm these conclusions.

Differences in Perioperative Management of Patients Undergoing Complex Spine Surgery: A Global Perspective

BACKGROUND

The aim of this survey was to understand institutional spine surgery practices and their concordance with published best practices/recommendations.

METHODS

Using a global internet-based survey examining perioperative spine surgery practice, reported institutional spine pathway elements (n=139) were compared with the level of evidence published in guideline recommendations. The concordance of clinical practice with guidelines was categorized as poor (≤20%), fair (21%-40%), moderate (41%-60%), good (61%-80%), or very good (81%-100%).

RESULTS

Seventy-two of 409 (17.6%) institutional contacts started the survey, of which 31 (7.6%) completed the survey. Six (19.4%) of the completed surveys were from respondents in low/middle-income countries, and 25 (80.6%) were from respondents in high-income countries. Forty-one incomplete surveys were not included in the final analysis, as most were less than 40% complete. Five of 139 (3.6%) reported elements had very good concordance for the entire cohort; hospitals with spine surgery pathways reported 18 elements with very good concordance, whereas institutions without spine surgery pathways reported only 1 element with very good concordance. Reported spine pathways included between 7 and 47 separate pathway elements. There were 87 unique elements in the reviewed pathways. Only 3 of 87 (3.4%) elements with high-quality evidence demonstrated very good practice concordance.

CONCLUSIONS

This global survey-based study identified practice variation and low adoption rates of high-quality evidence in the care of patients undergoing complex spine surgery.

Effect of Topical Application of an NSAID Lateral to the Incision on Postoperative Pain Following Unicompartmental Knee Arthroplasty: A Double-Blind Randomized Controlled Trial

OBJECTIVE

How to minimize postoperative pain following knee replacement surgery has been a great challenge. This study was performed to evaluate the effect of applying a topical nonsteroidal anti-inflammatory drug (NSAID) lateral to the incision for postoperative pain following unicompartmental knee arthroplasty (UKA).

METHODS

The randomized controlled trial enrolled 100 patients from August 2023 to January 2024. One hundred patients who underwent UKA were randomized into two groups. The intervention group received a topical NSAID lateral to the incision postoperatively, and the control group received a placebo lateral to the incision postoperatively. The primary outcome measures were the amount of opioid consumption and the visual analogue scale (VAS) score (12, 24, 36, 48, and 72 h after operation) for pain. The secondary outcome measures were the American Knee Society Score (AKSS, preoperation and 1-month follow-up after operation), the time of first analgesic demand, side effects of opioids, operation time, postoperative stay, surgery-related complications, and postoperative incision healing grade. Independent sample t test and paired sample t test were used to compare continuous data. Chi-square test and Fisher's precision probability tests were used to analyze the categorical data.

RESULTS

Ninety-eight patients (intervention group, 48 patients; control group, 50 patients) were analyzed. Opioid consumption was significantly lower in the intervention group than in the control group during the first 12 h, 12 to 24 h, and 24 to 48 h postoperatively (p < 0.05). The VAS score for pain within 72 h postoperatively was significantly lower in the intervention group than in the control group (p < 0.05). There was no significant difference in the AKSS, operation time, postoperative stay, complications, or postoperative incision healing grade between the two groups. The time of first analgesic demand for patient-controlled analgesia was significantly later in the intervention group than in the control group (p < 0.05). There were fewer side effects of opioids in the intervention group (8.3%) than in the control group (18.0%).

CONCLUSION

Postoperative application of topical NSAIDs lateral to the incision is an effective and safe method for pain management after UKA, helping to decrease the pain score and reduce opioid consumption postoperatively with no increase in side effects.

The impact of enhanced recovery after surgery (ERAS) on opioid consumption and postoperative pain levels in elective spine surgery

OBJECTIVE

Enhanced Recovery after Surgery (ERAS) protocols were developed to counteract the adverse effects of the surgical stress response, aiming for quicker postoperative recovery. Initially applied in abdominal surgeries, ERAS principles have extended to orthopedic spine surgery, but research in this area is still in its infancy. The current study investigated the impact of ERAS on postoperative pain and opioid consumption in elective spine surgeries.

METHODS

A single-center retrospective study of patients undergoing elective spine surgery from May 2019 to July 2020. Patients were categorized into two groups: those enrolled in the ERAS pathway and those adhering to traditional surgical protocols. Data on demographics, comorbidities, length of stay (LOS), surgical procedures, and postoperative outcomes were collected. Postoperative pain was evaluated using the Numerical Rating Scale (NRS), while opioid utilization was quantified in morphine milligram equivalents (MME). NRS and MME were averaged for each patient across all days under observation. Differences in outcomes between groups (ERAS vs. treatment as usual) were tested using the Wilcoxon rank sum test for continuous variables and Pearson's or Fisher's exact tests for categorical variables.

RESULTS

The median of patient's mean daily NRS scores for postoperative pain were not statistically significantly different between groups (median = 5.55 (ERAS) and 5.28 (non-ERAS), p=.2). Additionally, the median of patients' mean daily levels of MME were similar between groups (median = 17.24 (ERAS) and 16.44 (non-ERAS), p=.3) ERAS patients experienced notably shorter LOS (median=2 days) than their non-ERAS counterparts (median=3 days, p=.001). The effect of ERAS was moderated by whether the patient had ACDF surgery. ERAS (vs. non-ERAS) patients who had ACDF surgery had 1.64 lower average NRS (p=.006). ERAS (vs. non-ERAS) patients who had a different surgery had 0.72 higher average NRS (p=.02) but had almost half the length of stay, on average (p<.001).

CONCLUSIONS

The current study underscores the dynamic nature of ERAS protocols within the realm of spine surgery. While ERAS demonstrates advantages such as reduced LOS and improved patient-reported outcomes, it requires careful implementation and customization to address the specific demands of each surgical discipline. The potential to expedite recovery, optimize resource utilization, and enhance patient satisfaction cannot be overstated. However, the fine balance between achieving these benefits and ensuring comprehensive patient care, especially in the context of postoperative pain management, must be maintained. As ERAS continues to evolve and find its place in diverse surgical domains, it is crucial for healthcare providers to remain attentive to patient needs, adapting ERAS protocols to suit individual patient populations and surgical contexts.

Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review

Enhanced Recovery After Surgery (ERAS) protocols have revolutionized the approach to perioperative care in various surgical specialties. They reduce complications, improve patient outcomes, and shorten hospital lengths of stay. Implementation of ERAS protocols for neurosurgical procedures has been relatively underexplored and underutilized due to the unique challenges and complexities of neurosurgery. This narrative review explores the barriers to, and pioneering strategies of, standardized procedure-specific ERAS protocols, and the importance of multidisciplinary collaboration in neurosurgery and neuroanesthsia, patient-centered approaches, and continuous quality improvement initiatives, to achieve better patient outcomes. It also discusses initiatives to guide future clinical practice, research, and guideline creation, to foster the development of tailored ERAS protocols in neurosurgery.

Assessing the effects of prehabilitation protocols on post-operative outcomes in adult cervical deformity surgery: does early optimization lead to optimal clinical outcomes?

PURPOSE

To investigate the effect of a prehabilitation program on peri- and post-operative outcomes in adult cervical deformity (CD) surgery.

METHODS

Operative CD patients ≥ 18 years with complete baseline (BL) and 2-year (2Y) data were stratified by enrollment in a prehabilitation program beginning in 2019. Patients were stratified as having undergone prehabilitation (Prehab+) or not (Prehab-). Differences in pre and post-op factors were assessed via means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay-scales.

RESULTS

115 patients were included (age: 61 years, 70% female, BMI: 28 kg/m2). Of these patients, 57 (49%) were classified as Prehab+. At baseline, groups were comparable in age, gender, BMI, CCI, and frailty. Surgically, Prehab+ were able to undergo longer procedures (p = 0.017) with equivalent EBL (p = 0.627), and shorter SICU stay (p < 0.001). Post-operatively, Prehab+ patients reported greater reduction in pain scores and greater improvement in quality of life metrics at both 1Y and 2Y than Prehab- patients (all p < 0.05). Prehab+ patients reported significantly less complications overall, as well as less need for reoperation (all p < 0.05).

CONCLUSION

Introducing prehabilitation protocols in adult cervical deformity surgery may aid in improving patient physiological status, enabling patients to undergo longer surgeries with lessened risk of peri- and post-operative complications.

Alternative Therapies for Ankyloglossia-Associated Breastfeeding Challenges: A Systematic Review

Background: Ankyloglossia (AG) diagnoses are increasingly common, and management is not standardized. Nonsurgical alternative therapies are frequently recommended in conjunction with or instead of frenotomy, with uncertain evidence. Objective: To evaluate the efficacy of nonsurgical alternative therapies (chiropractic care, myofunctional therapy, and osteopathy) in improving breastfeeding for infants diagnosed with AG. Methods: PubMed, Embase, CINAHL, Scopus, Web of Science, Clinicaltrials.gov, and Google Scholar were searched (September-October 2023). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A librarian-designed search included the terms "Ankyloglossia," "Non-surgical," "myofunctional therapy," "chiropractic," "osteopathy," and related therapies, with no date restrictions. English language studies of infants <24 months with AG and alternative therapy were included. Risk-of-bias evaluation used Newcastle-Ottawa Scale (NOS). Results: Of 1,304 identified articles, four studies (2016-2022) met inclusion criteria (two cross-sectional, one case report, and one case series). All studies reported frenotomy in combination with alternative therapy yielded favorable outcomes for maternal pain, weight gain, feeding duration, and maintenance of latch. The risk of bias was moderate for two studies, low for the case series, and not calculated for the case report, which has an inherent high risk of bias. All studies lacked control or comparator groups preventing definitive conclusions about the role of alternative therapies in AG. Conclusion: Although some studies suggest the potential benefits of combining alternative therapies with surgery for AG-related breastfeeding issues, the lack of control groups renders the evidence inconclusive. Nonsurgical approaches alone currently lack sufficient evidence. As these alternative therapies gain popularity, rigorous research is crucial to determine their cost-effectiveness and role in managing AG.

A New Neuroanesthetic Protocol of Rendering Specialized Care in Treating Degenerative Lumbar Spine Diseases in High-Risk Patients: Prospective Analysis of the Results

The aim of the study is to assess the effectiveness of a new neuroanesthetic protocol for treating degenerative lumbar spine diseases in high-risk patients.

Materials and Methods

Two groups of patients with a high risk of anesthesia and surgery determined by the authors' clinical decision support system (CDSS) have been prospectively studied. A new neuroanesthetic protocol was used in the experimental group (EG, n=25), while the control group (CG, n=25) underwent intravenous anesthesia based on propofol and fentanyl. Minimally invasive transforaminal lumbar interbody fusion was performed in all cases. Changes of the intraoperative mean arterial pressure and heart rate, intensity of the local pain syndrome, amount of the opiates used, presence of cognitive disorders, adverse effects of anesthesia, and surgical complications have been compared.

Results

The groups were representative (p>0.05) in terms of the age-gender parameters, anthropological data, comorbid background, involvement in smoking, preoperative characteristics of the lumbar spine, as well as the level of cognitive functions. No statistically significant changes of the mean arterial pressure (p=0.17) were registered in EG patients relative to the CG (p=0.0008). Intraoperative reduction of the heart rate in patients of the CG was not noted (p=0.49) in comparison with the EG (p=0.03). In the postoperative period, the best indicators of cognitive functions on the FAB test (p=0.02) and MoCA test (p=0.03) were revealed in EG. A significantly less amount of perioperative opiates (p=0.005) at a low level of the local pain syndrome was also noted (p=0.01). The intergroup analysis has shown fewer adverse effects of anesthesia in EG compared to CG (p=0.01) with a comparable number of postoperative surgical complications (p=0.42).

Conclusion

A new neuroanesthetic protocol of rendering a specialized care to patients with a high risk of anesthesia and surgery, assessed by the authors-developed CDSS, has resulted in effective elimination of the local postoperative pain syndrome, reduction of perioperative application of opioids, and stabilization of intraoperative indicators of cardiovascular activity. In addition, no postoperative cognitive disorders, anesthetic side-effects, adverse pharmacological consequences of the complex usage of non-steroidal anti-inflammatory drugs, prolonged local anesthetics, alpha-2-agonist, and non-narcotic analgesics have been registered.

Association between delayed ambulation and increased risk of adverse events after lumbar fusion surgery in elderly patients

PURPOSE

The relationship between delayed ambulation (DA) and postoperative adverse events (AEs) following transforaminal lumbar interbody fusion (TLIF) in elderly patients remains elusive. The aim of our study was to evaluate the effects of DA on the postoperative AEs including complications, readmission and prolonged length of hospital stay (LOS).

METHODS

This was a retrospective analysis of a prospectively established database of elderly patients (aged 65 years and older) who underwent TLIF surgery. The early ambulation (EA) group was defined as patients ambulated within 48 h after surgery, whereas the delayed ambulation (DA) group was patients ambulated at a minimum of 48 h postoperatively. The DA patients were 1:1 propensity-score matched to the EA patients based on age, gender and the number of fused segments. Univariate analysis was used to compare postoperative outcomes between the two groups, and multivariate logistic regression analysis was used to identify risk factors for adverse events and DA.

RESULTS

After excluding 125 patients for various reasons, 1025 patients (≤ 48 h: N = 659 and > 48 h: N = 366) were included in the final analysis. After propensity score matching, there were 326 matched patients in each group. There were no significant differences in the baseline data and the surgery-related variables between the two groups (p > 0.05). The patients in the DA group had a significant higher incidence of postoperative AEs (46.0% vs. 34.0%, p = 0.002) and longer LOS (p = 0.001). Multivariate logistic regression identified that age, operative time, diabetes, and DA were independently associated with postoperative AEs, whereas greater age, higher international normalized ratio, and intraoperative estimated blood loss were identified as independent risk factors for DA.

CONCLUSIONS

Delayed ambulation was an independent risk factor for postoperative AEs after TLIF in elderly patients. Older age, increased intraoperative blood loss and worse coagulation function were associated with delayed ambulation.

Timing of Resection of Spinal Meningiomas and Its Influence on Quality of Life and Treatment

BACKGROUND

The main treatment modality for spinal meningiomas (SM) is gross total resection (GTR). However, the optimal timing of surgery, especially in cases with absent or mild neurological symptoms, remains unclear. The aim of this study is to assess the impact of early-stage resection on neurological outcome, quality of life (QoL), and quality of care. The primary objective is a favorable neurological outcome (McCormick scale 1).

METHODS

We retrospectively analyzed data from patients who underwent operations for SM between 2011 and 2021. Patients with mild neurological symptoms preoperatively (McCormick scale 1 and 2) were compared to those with more severe neurological symptoms (McCormick scale 3-5). Disabilities and QoL were assessed according to validated questionnaires (SF-36, ODI, NDI).

RESULTS

Age, spinal cord edema, thoracic localization, and spinal canal occupancy ratio were associated with more severe neurological symptoms (all p < 0.05). Patients presenting with mild symptoms were associated with favorable neurological outcomes (OR: 14.778 (95%CI 3.918-55.746, p < 0.001)), which is associated with shorter hospitalization, better QoL, and fewer disabilities (p < 0.05). Quality of care was comparable in both cohorts.

CONCLUSIONS

Early surgical intervention for SM, before the development of severe neurological deficits, should be considered as it is associated with a favorable neurological outcome and quality of life.

Prospective same day discharge instrumented lumbar spine surgery - a forty patient consecutive series

PURPOSE

Outpatient lumbar decompression surgeries have been successfully performed in France for over twenty years, earning acceptance. However, outpatient instrumented lumbar spine procedures and arthroplasties are less documented. This study aimed to evaluate the feasibility, efficiency, and safety of outpatient lumbar instrumented surgery.

METHODS

A prospective single-center study involving three experienced surgeons was conducted from September 2020 to September 2021, with a minimum six-month postoperative follow-up. Inclusion criteria comprised patients aged 18 to 75 eligible for same-day discharge, undergoing single-level lumbar spinal fusion or arthroplasty via anterior or posterior Wiltse approach. The primary endpoint was assessing the percentage of successful outpatient discharges (within twelve hours), with secondary endpoints including perioperative/postoperative complications and discharge pain prescriptions in terms of frequency and severity.

RESULTS

Forty patients (mean age: 44 years; 16/24 male/female ratio) underwent surgery, including 18 lumbar arthroplasties, twelve ALIF, and ten TLIF procedures. The majority of surgeries were performed at L4-L5 (18 procedures) and L5-S1 levels (22 procedures). 95% (38/40) of patients were successfully discharged within twelve hours, with only two patients discharged the following day. No postoperative hematomas, serious adverse events, or revision surgeries were noted.

CONCLUSION

95% of patients were discharged successfully within twelve hours following outpatient lumbar fusion surgery, with a 100% patient satisfaction rate. Specific technical solutions were not necessary, and oral pain relief sufficed. Patient selection and education, including early pain management, played crucial roles in complication avoidance. This study underscores the safety of outpatient instrumented lumbar spine procedures, leading to cost reduction and expedited recovery.

Comparison of Postoperative Pain and Surgical Outcomes Between Three Types of Modified Muscle-Sparing Laminoplasty and Conventional Laminoplasty for Multilevel Degenerative Cervical Myelopathy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

This study aimed to compare postoperative pain and surgical outcomes of open-door laminoplasty (LP) and three types of muscle-sparing laminoplasties, namely unilateral muscle-preservation laminoplasty (UL), spinous process splitting double-door laminoplasty (DL) and intermuscular "raising roof" laminoplasty (RL) for multilevel degenerative cervical myelopathy (MDCM).

METHODS

Consecutive MDCM patients underwent LP or modified laminoplasties (UL, DL, RL) in 2022 were enrolled. Patients' preoperative baseline data and surgical characteristics were collected. Postoperative transient pain (TP), the axial pain and Japanese Orthopedic Association (JOA) score and neck disability index (NDI) at 6-month and 12-month follow-up were documented.

RESULTS

A total of 154 MDCM patients were included and a 12-month follow-up was completed for 148 patients (LP: 36, UL:39, DL: 37, RL:36). No significant difference was observed in the baseline data. Four groups presented favorable and comparable surgical outcome. The RL group reported significantly the least severe TP on the first three days following surgery. However, no significant difference was found in the axial pain and axial symptoms at both follow-ups. After regression analysis, RL group exhibited significantly better efficacy in alleviating Day-1 TP (P = 0.047) and 6-month axial pain (P = 0.040). However, this superiority was not observed at 12-month follow-up.

CONCLUSION

All the three muscle-sparing laminoplasty procedures showed similar short-term surgical outcomes compared to LP. The RL procedure demonstrated superiority in alleviating TP and 6-month axial pain compared to LP. The RL and DL groups showed less C5 palsy compared to LP.

Risk analysis index predicts mortality and non-home discharge following posterior lumbar interbody fusion: a nationwide inpatient sample analysis of 429,380 patients (2019-2020)

PURPOSE

Frailty is an independent risk factor for adverse postoperative outcomes following spine surgery. The ability of the Risk Analysis Index (RAI) to predict adverse outcomes following posterior lumbar interbody fusion (PLIF) has not been studied extensively and may improve preoperative risk stratification.

METHODS

Patients undergoing PLIF were queried from Nationwide Inpatient Sample (NIS) (2019-2020). The relationship between RAI-measured preoperative frailty and primary outcomes (mortality, non-home discharge (NHD)) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis.

RESULTS

A total of 429,380 PLIF patients (mean age = 61y) were identified, with frailty cohorts stratified by standard RAI convention: 0-20 "robust" (R)(38.3%), 21-30 "normal" (N)(54.3%), 31-40 "frail" (F)(6.1%) and 41+ "very frail" (VF)(1.3%). The incidence of primary and secondary outcomes increased as frailty thresholds increased: mortality (R 0.1%, N 0.1%, F 0.4%, VF 1.3%; p < 0.001), NHD (R 6.5%, N 18.1%, F 36.9%, VF 42.0%; p < 0.001), eLOS (R 18.0%, N 21.9%, F 31.6%, VF 43.8%; p < 0.001) and complication rates (R 6.6%, N 8.8%, F 11.1%, VF 12.2%; p < 0.001). The RAI demonstrated acceptable discrimination for NHD (C-statistic: 0.706) and mortality (C-statistic: 0.676) in AUROC curve analysis.

CONCLUSION

Increasing RAI-measured frailty is significantly associated with increased NHD, eLOS, complication rates, and mortality following PLIF. The RAI demonstrates acceptable discrimination for predicting NHD and mortality, and may be used to improve frailty-based risk assessment for spine surgeons.

Enhanced recovery after surgery protocols following emergency intra-abdominal surgery: a systematic review and meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to evaluate whether Enhanced Recovery After Surgery (ERAS) protocols for patients undergoing emergency intra-abdominal surgery improve postoperative outcomes as compared to conventional care.

METHODS

MEDLINE, EMBASE, WoS, CENTRAL, and Pubmed were searched from inception to December 2022. Articles were eligible if they were randomized controlled trials (RCT) or non-randomized studies comparing ERAS protocols to conventional care for patients undergoing emergency intra-abdominal surgery. The outcomes included postoperative length of stay (LOS), postoperative morbidity, prolonged postoperative ileus (PPOI), and readmission. An inverse variance random effects meta-analysis was performed. A risk of bias was assessed with Cochrane tools. Certainty of evidence was assessed with GRADE.

RESULTS

After screening 1018 citations, 20 studies with 1615 patients in ERAS programs and 1933 patients receiving conventional care were included. There was a reduction in postoperative LOS in the ERAS group for patients undergoing upper gastrointestinal (GI) surgery (MD3.35, 95% CI 2.52-4.17, p < 0.00001) and lower GI surgery (MD2.80, 95% CI 2.62-2.99, p < 0.00001). There was a reduction in postoperative morbidity in the ERAS group for patients undergoing upper GI surgery (RR0.56, 95% CI 0.30-1.02, p = 0.06) and lower GI surgery (RR 0.66, 95%CI 0.52-0.85, p = 0.001). In the upper and lower GI subgroup, there were nonsignificant reductions in PPOI in the ERAS groups (RR0.59, 95% CI 0.30-1.17, p = 0.13; RR0.49, 95% CI 0.21-1.14, p = 0.10). There was a nonsignificant increased risk of readmission in the ERAS group (RR1.60, 95% CI 0.57-4.50, p = 0.50).

CONCLUSION

There is low-to-very-low certainty evidence supporting the use ERAS protocols for patients undergoing emergency intra-abdominal surgery. The currently available data are limited by imprecision.

Clinical efficacy and complications of MIS-TLIF and TLIF in the treatment of upper lumbar disc herniation: a comparative study

BACKGROUND

The optimal treatment modality for upper lumbar disc herniation remains unclear. Herein, we compared the clinical efficacy and application value of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and transforaminal lumbar interbody fusion (TLIF) for upper lumbar disc herniation. We aimed to provide new evidence to guide surgical decisions for treating this condition.

METHODS

We retrospectively analyzed the clinical data of 81 patients with upper lumbar disc herniation admitted between January 2017 and July 2018, including 41 and 40 patients who underwent MIS-TLIF and TLIF, respectively. Demographic characteristics, preoperative functional scores, perioperative indicators, and postoperative complications were compared. We performed consecutive comparisons of visual analog scale (VAS) scores of the lumbar and leg regions, Oswestry disability index (ODI), Japanese Orthopaedic Association scores (JOA), and MacNab scores at the final follow-up, to assess clinical outcomes 5 years postoperatively.

RESULTS

VAS scores of the back and legs were significantly lower in the MIS-TLIF than the TLIF group at 3 months and 1 year postoperatively (P < 0.05). Intraoperative bleeding and postoperative hospitalization time were significantly lower, and the time to return to work/normal life was shorter in the MIS-TLIF than in the TLIF group (P < 0.05). The differences in JOA scores and ODI scores between the two groups at 3 months, 1 year, and 3 years postoperatively were statistically significant (P < 0.05).

CONCLUSION

The early clinical efficacy of MIS-TLIF was superior to that of TLIF, but no differences were found in mid-term clinical efficacy. Further, MIS-TLIF has the advantages of fewer medical injuries, shorter hospitalization times, and faster postoperative functional recovery.

Treatment of Ankylosing Spondylitis Patients with Cervical Spinal Injury with Anterior Single-Stage Fixation with Bone Cement Augmentation

Background/Objectives: Cervical spine fractures in ankylosing spondylitis (AS) are characterized as highly unstable fractures posing an elevated risk of neurological deficit and a significantly elevated mortality rate. This study assesses the efficacy and safety of single-stage plate stabilization with ventral cement augmentation in treating subaxial cervical spine fractures in patients with AS. Methods: Over 86 months, 38 patients diagnosed with AS received ventral plate stabilization with cement augmentation after suffering unstable subaxial cervical fractures. No additional dorsal stabilization was used in any of these surgeries. Results: There were no complications as a result of cement leakage. During the follow-up period, screw loosening and implant displacement were documented in two out of 38 cases. At the time of data analysis, 17 patients who had undergone treatment had died, representing 44.7% of the total cases. Seven patients died within 1 month, two patients died within 6 months, four patients died within 1 year, and four patients died after 1 year. Conclusions: Our study shows that a single-stage anterior screw and plate fixation of the cervical spine with cement augmentation could be a feasible and effective method to treat cervical spine fractures in patients with AS.

The impact of nursing interventions on the rehabilitation outcome of patients after lumbar spine surgery

BACKGROUND

This study aimed to investigate the impact of nursing interventions on the rehabilitation outcomes of patients after lumbar spine surgery and to provide effective references for future postoperative care for patients undergoing lumbar spine surgery.

METHODS

The study included two groups: a control group receiving routine care and an observation group receiving additional comprehensive nursing care. The comprehensive care encompassed postoperative rehabilitation, pain, psychological, dietary management, and discharge planning. The Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), Short-Form 36 (SF-36) Health Survey, self-rating depression scale (SDS) and self-rating anxiety scale(SAS) were used to assess physiological and psychological recovery. Blood albumin, haemoglobin, neutrophil counts, white blood cell counts, red blood cell counts, inflammatory markers (IL-6, IL-10, and IFN-γ) were measured, and the incidence of postoperative adverse reactions was also recorded.

RESULTS

Patients in the observation group exhibited significantly improved VAS, ODI, SF-36, SDS and SAS scores assessments post-intervention compared to the control group (P < 0.05). Moreover, levels of IL-6, IL-10, and IFN-γ were more favorable in the observation group post-intervention (P < 0.05), indicating a reduction in inflammatory response. There was no significant difference in the incidence of postoperative adverse reactions between the groups (P > 0.05), suggesting that the comprehensive nursing interventions did not increase the risk of adverse effects.

CONCLUSION

Comprehensive nursing interventions have a significant impact on the postoperative recovery outcomes of patients with LSS, alleviating pain, reducing inflammation levels, and improving the overall quality of patient recovery without increasing the patient burden. Therefore, in clinical practice, it is important to focus on comprehensive nursing interventions for patients with LSS to improve their recovery outcomes and quality of life.

Assessing the Economic Benefits of Enhanced Recovery After Surgery (ERAS) Protocols in Adult Cervical Deformity Patients: Is the Initial Additive Cost of Protocols Offset by Clinical Gains?

OBJECTIVE

To assess the financial impact of Enhanced Recovery After Surgery (ERAS) protocols and cost-effectiveness in cervical deformity corrective surgery.

STUDY DESIGN

Retrospective review of prospective CD database.

BACKGROUND

Enhanced Recovery After Surgery (ERAS) can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, the economic benefit of ERAS protocols, nor the heterogeneous components that make up such protocols, has not been established.

METHODS

Operative CD patients ≥18 y with complete pre-(BL) and up to 2-year(2Y) postop radiographic/HRQL data were stratified by enrollment in Standard-of-Care ERAS beginning in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay scales. QALY was calculated using NDI mapped to SF6D using validated methodology with a 3% discount rate to account for a residual decline in life expectancy.

RESULTS

In all, 127 patients were included (59.07±11.16 y, 54% female, 29.08±6.43 kg/m 2 ) in the analysis. Of these patients, 54 (20.0%) received the ERAS protocol. Per cost analysis, ERAS+ patients reported a lower mean total 2Y cost of 35049 USD compared with ERAS- patients at 37553 ( P <0.001). Furthermore, ERAS+ patients demonstrated lower cost of reoperation by 2Y ( P <0.001). Controlling for age, surgical invasiveness, and deformity per BL TS-CL, ERAS+ patients below 70 years old were significantly more likely to achieve a cost-effective outcome by 2Y compared with their ERAS- counterparts (OR: 1.011 [1.001-1.999, P =0.048].

CONCLUSIONS

Patients undergoing ERAS protocols experience improved cost-effectiveness and reduced total cost by 2Y post-operatively. Due to the potential economic benefit of ERAS for patients incorporation of ERAS into practice for eligible patients should be considered.

The Evolution of Enhanced Recovery After Surgery: Assessing the Clinical Benefits of Developments Within Enhanced Recovery After Surgery Protocols in Adult Cervical Deformity Surgery

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To investigate the impact of evolving Enhanced Recovery After Surgery (ERAS) protocols on outcomes after cervical deformity (CD) surgery.

BACKGROUND

ERAS can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, there remains a paucity of literature assessing how developments have impacted outcomes after adult CD surgery.

METHODS

Patients with operative CD 18 years or older with pre-baseline and 2 years (2Y) postoperative data, who underwent ERAS protocols, were stratified by increasing implantation of ERAS components: (1) early (multimodal pain program), (2) intermediate (early protocol + paraspinal blocks, early ambulation), and (3) late (early/intermediate protocols + comprehensive prehabilitation). Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through Bonferroni-adjusted means comparison analysis.

RESULTS

A total of 131 patients were included (59.4 ± 11.7 y, 45% females, 28.8 ± 6.0 kg/m 2 ). Of these patients, 38.9% were considered "early," 36.6% were "intermediate," and 24.4% were "late." Perioperatively, rates of intraoperative complications were lower in the late group ( P = 0.036). Postoperatively, discharge disposition differed significantly between cohorts, with late patients more likely to be discharged to home versus early or intermediate cohorts [χ 2 (2) = 37.973, P < 0.001]. In terms of postoperative disability recovery, intermediate and late patients demonstrated incrementally improved 6 W modified Japanese Orthopedic Association scores ( P = 0.004), and late patients maintained significantly higher mean Euro-QOL 5-Dimension Questionnaire and modified Japanese Orthopedic Association scores by 1 year ( P < 0.001, P = 0.026). By 2Y, cohorts demonstrated incrementally increasing SWAL-QOL scores (all domains P < 0.028) domain scores versus early or intermediate cohorts. By 2Y, incrementally decreasing reoperation was observed in early versus intermediate versus late cohorts ( P = 0.034).

CONCLUSIONS

The present study demonstrates that patients enrolled in an evolving ERAS program demonstrate incremental improvement in preoperative optimization and candidate selection, greater likelihood of discharge to home, decreased postoperative disability and dysphasia burden, and decreased likelihood of intraoperative complications and reoperation rates.