Enhanced recovery after surgery (ERAS)—Concepts, components, and application to spine surgery

Intradermal and Intramuscular Bupivacaine Reduces Opioid Use Following Noninstrumented Spine Surgery

OBJECTIVE

To evaluate the efficacy of intraoperative bupivacaine hydrochloride wound infiltration as an adjunct means of pain relief following noninstrumented posterior spine surgery.

METHODS

A retrospective cohort analysis was performed of all patients who underwent posterior spinal decompression surgery at the University of California, San Diego, and at the San Diego VA Medical Center between June 2020 and July 2021, following a change in practice to including bupivacaine infiltration at the end of the surgery. Patients were stratified into groups based on whether they received intrawound bupivacaine during surgery. Demographic and clinical data were extracted from the electronic health record. Postoperative opioid use, visual analog pain scores, heart rate, and blood pressure were compared.

RESULTS

The analysis included 43 patients; 21 received bupivacaine infiltration, and 22 did not. No complications were encountered in the perioperative period. Patients who received bupivacaine consumed significantly less opioids over the 72 hours following surgery, had slightly lower pain scores, and experienced slightly lower heart rates. No significant difference was found between groups with respect to systolic blood pressure, operative time, or length of hospital stay.

CONCLUSIONS

Intraoperative infiltration of the exposed paraspinous musculature and peri-incisional subdermal layer with bupivacaine significantly reduced postoperative opioid consumption for 72 hours after surgery and slightly reduced pain ratings and conferred superior heart rate control. This low-cost intervention produced significant patient benefit with minimal risk and no significant increase in surgical time or hospital stay.

Fast-track protocols for patients undergoing spine surgery: a systematic review

BACKGROUND CONTEXT

Fast-track is an evidence-based multidisciplinary strategy for pre-, intra-, and postoperative management of patients during major surgery. To date, fast-track has not been recognized or accepted in all surgical areas, particularly in orthopedic spine surgery where it still represents a relatively new paradigm.

PURPOSE

The aim of this review was provided an evidenced-based assessment of specific interventions, measurement, and associated outcomes linked to enhanced recovery pathways in spine surgery field.

METHODS

We conducted a systematic review in three databases from February 2012 to August 2022 to assess the pre-, intra-, and postoperative key elements and the clinical evidence of fast-track protocols as well as specific interventions and associated outcomes, in patients undergoing to spine surgery.

RESULTS

We included 57 full-text articles of which most were retrospective. Most common fast-track elements included patient's education, multimodal analgesia, thrombo- and antibiotic prophylaxis, tranexamic acid use, urinary catheter and drainage removal within 24 hours after surgery, and early mobilization and nutrition. All studies demonstrated that these interventions were able to reduce patients' length of stay (LOS) and opioid use. Comparative studies between fast-track and non-fast-track protocols also showed improved pain scores without increasing complication or readmission rates, thus improving patient's satisfaction and functional recovery.

CONCLUSIONS

According to the review results, fast-track seems to be a successful tool to reduce LOS, accelerate return of function, minimize postoperative pain, and save costs in spine surgery. However, current studies are mainly on degenerative spine diseases and largely restricted to retrospective studies with non-randomized data, thus multicenter randomized trials comparing fast-track outcomes and implementation are mandatory to confirm its benefit in spine surgery.

Awake spinal surgery: simplifying the learning curve with a patient selection algorithm

OBJECTIVE

There is a learning curve for surgeons performing "awake" spinal surgery. No comprehensive guidelines have been proposed for the selection of ideal candidates for awake spinal fusion or decompression. The authors sought to formulate an algorithm to aid in patient selection for surgeons who are in the startup phase of awake spinal surgery.

METHODS

The authors developed an algorithm for selecting patients appropriate for awake spinal fusion or decompression using spinal anesthesia supplemented with mild sedation and local analgesia. The anesthetic protocol that was used has previously been reported in the literature. This algorithm was formulated based on a multidisciplinary team meeting and used in the first 15 patients who underwent awake lumbar surgery at a single institution.

RESULTS

A total of 15 patients who underwent decompression or lumbar fusion using the awake protocol were reviewed. The mean patient age was 61 ± 12 years, with a median BMI of 25.3 (IQR 2.7) and a mean Charlson Comorbidity Index of 2.1 ± 1.7; 7 patients (47%) were female. Key patient inclusion criteria were no history of anxiety, 1 to 2 levels of lumbar pathology, moderate stenosis and/or grade I spondylolisthesis, and no prior lumbar surgery at the level where the needle is introduced for anesthesia. Key exclusion criteria included severe and critical central canal stenosis or patients who did not meet the inclusion criteria. Using the novel algorithm, 14 patients (93%) successfully underwent awake spinal surgery without conversion to general anesthesia. One patient (7%) was converted to general anesthesia due to insufficient analgesia from spinal anesthesia. Overall, 93% (n = 14) of the patients were assessed as American Society of Anesthesiologists class II, with 1 patient (7%) as class III. The mean operative time was 115 minutes (± 60 minutes) with a mean estimated blood loss of 46 ± 39 mL. The median hospital length of stay was 1.3 days (IQR 0.1 days). No patients developed postoperative complications and only 1 patient (7%) required reoperation. The mean Oswestry Disability Index score decreased following operative intervention by 5.1 ± 10.8.

CONCLUSIONS

The authors propose an easy-to-use patient selection algorithm with the aim of assisting surgeons with patient selection for awake spinal surgery while considering BMI, patient anxiety, levels of surgery, and the extent of stenosis. The algorithm is specifically intended to assist surgeons who are in the learning curve of their first awake spinal surgery cases.

Enhanced Recovery After Surgery Protocol for Lumbar Spinal Surgery With Regional Anesthesia: A Retrospective Review

Background

In the USA, spinal fusion surgery incurs the highest hospital cost. Despite the recent advances in the application of enhanced recovery after surgery (ERAS) protocols in these surgeries, the efficacy of these protocols in improving the perioperative outcomes remains unclear. We conducted a retrospective review as a quality improvement (QI) project to analyze the efficacy of the ERAS protocol with intraoperative modified thoracolumbar interfascial plane (mTLIP) block to determine whether these interventions reduce the length of stay (LOS) and opioid requirements during the postoperative period.

Methods

Retrospective reviews of adult patients (>18 yrs) who underwent elective lumbar spinal fusion or laminectomy at our institute were reviewed. Patients were administered oral gabapentin and acetaminophen preoperatively. Prior to incision, an mTLIP block was performed using liposomal bupivacaine. Intraoperatively, ketamine, ketorolac, and tranexamic acid were administered. Postoperative, pain control was treated with scheduled acetaminophen, ketorolac, and low-dose ketamine infusion. Hydromorphone and oxycodone were administered for breakthrough pain. Patients who underwent a similar procedure without ERAS protocol were chosen as controls to assess the efficacy of ERAS protocol. Data pertaining to patient demographics, operative and perioperative use of analgesics, LOS, 90-day readmissions, and morbidity were collected. Patients who underwent laminectomy and spinal fusion surgery were analyzed separately

Results

A total of 65 patients were identified; laminectomy (n- 24), spinal fusion surgery (n-41). In the laminectomy patients, treatment group (n-12) and the control group (n-12). Treatment group receiving the ERAS protocol with the regional anesthesia via the mTLIP (n= 12) opioid requirement was reduced by 51.42% [P = 0.03], and LOS was reduced by 2.04 days [P = 0.01] [0.75 days vs. 2.79 days]). In the spinal fusion patients, treatment group (n-15) and control group (n-26). Treatment group receiving the ERAS protocol with the use of regional anesthesia via the mTLIP group (n= 15), opioid requirement was reduced by 38.33% [P = 0.04]. No difference in LOS was observed at 5.4 days vs. 4.88 days (P = 0.28).

Conclusion

ERAS protocol in patients undergoing lumbar spinal surgery incorporated the use of regional anesthesia via the mTLIP block, we observed there is a statistically significant reduction in the LOS for lumbar laminectomy and a significant reduction in opioid administration for lumbar laminectomies and spinal fusion surgery.

Minimizing the need for high dependency unit support in adolescent idiopathic scoliosis surgery. Is enhanced recovery and the multidisciplinary team key?

Current trends in the surgical treatment of patients with adolescent idiopathic scoliosis (AIS) involve the use of high dependency unit (HDU) in the postoperative period. The British Scoliosis Society also recommends the availability of HDU support in the postoperative period for these patients. However, this practice may lead to unexpected theatre cancellations due to lack of availability of HDU bed on the day of surgery. We also hypothesize that this practice may eventually lead to longer inpatient stay for the patients. All AIS patients at our unit are managed on a paediatric ward postoperatively, without HDU support. The primary aim of the study therefore is to evaluate whether operating on AIS patients without HDU support is well tolerated practice. Secondary aims were to evaluate patient related outcomes, including length of stay (LOS), and postoperative analgesia requirements. Adolescents aged 12-17 years with idiopathic scoliosis deformity who were treated with posterior instrumented scoliosis (PIS) correction were included in this prospective cohort study. The study period was between 12 November 2012 and 6 August 2018. Twenty-two patients were included in the HDU group and 33 patients in the non-HDU group. These were two matched cohort groups. Data were collected on complication rates, LOS, analgesic requirements, time to bowel opening, and attainment of physiotherapy goals in the immediate postoperative period. Statistical analysis was performed using statistical software R (3.4.3). There were no complications in the non-HDU group and one pneumothorax in the HDU group. There was a significant reduction in the LOS from 7.4 days (SD ±2.3, CI 0.012) days, to 5.8 (SD ±1.4, CI 0.01) days in the non-HDU group (P = 0.0001). There was no significant difference statistically or clinically in opiate usage between the HDU group, 115 mg (SD ±60.7, CI 0.8) and the non-HDU group 116 mg (SD ±55.8, CI 0.6) (P = 0.609). However, there was an improvement in pain scores in the non-HDU group where oral analgesics only were used (P = 0.002). A cost saving of £2038.80 per AIS case was made in the non-HDU group. AIS surgery can be performed safely without the need for HDU support in healthy adolescents. An oral analgesia-based enhanced recovery regime compares favourably to patient-controlled analgesia (PCA) and indicates these patients can be managed safely with strong multidisciplinary support on a paediatric ward.

Enhanced Recovery After Surgery Reduces Postoperative Opioid Use and 90-Day Readmission Rates After Open Thoracolumbar Fusion for Adult Degenerative Deformity

BACKGROUND

The role of enhanced recovery after surgery (ERAS) pathways implementation has not been previously explored in adult deformity patients.

OBJECTIVE

To determine the impact of ERAS pathways implementation in adult patients undergoing open thoraco-lumbar-pelvic fusion for degenerative scoliosis on postoperative outcome, opioid consumption, and unplanned readmission rates.

METHODS

In this retrospective single-center study, we included 124 consecutive patients who underwent open thoraco-lumbar-pelvic fusion from October 2016 to February 2019 for degenerative scoliosis. Primary outcomes consisted of postoperative supplementary opioid consumption in morphine equivalent dose (MED), postoperative complications, and readmission rates within the postoperative 90-d window.

RESULTS

There were 67 patients in the ERAS group, and 57 patients served as pre-ERAS controls. Average patient age was 69 yr. The groups had comparable demographic and intraoperative variables. ERAS patients had a significantly lower rate of postoperative supplemental opioid consumption (248.05 vs 314.05 MED, P = .04), a lower rate of urinary retention requiring catheterization (5.97% vs 19.3%, P = .024) and of severe constipation (1.49% vs 31.57%, P < .0001), and fewer readmissions after their surgery (2.98% vs 28.07%, P = .0001).

CONCLUSION

A comprehensive multidisciplinary approach to complex spine surgery can reduce opioid intake, postoperative urinary retention and severe constipation, and unplanned 90-d readmissions in the elderly adult population.

Readmission following complex spine surgery in a prospective cohort of 679 patients - 2-years follow-up using the Spine AdVerse Event Severity (SAVES) system

BACKGROUND CONTEXT

Recent studies suggest that prospective registration more accurately reflects the true incidence of adverse events (AEs). To our knowledge, no previous study has investigated prospectively registered AEs' influence on hospital readmission following spine surgery.

PURPOSE

To determine the frequency and type of unplanned readmissions after complex spine surgery, and to investigate if prospectively registered AEs can predict readmissions.

DESIGN

This is a prospective, consecutive cohort study.

PATIENT SAMPLE

We conducted a single-center study of 679 consecutive patients who underwent complex spine surgery defined as conditions deemed too complicated for surgery at a secondary institute, or patients with severe comorbidities requiring multidisciplinary observation and treatment.

OUTCOME MEASURES

The outcomes in this study were (1) readmission to any hospital department within 30 days of discharge and (2) readmission to a surgical spine center at any time in follow-up.

METHODS

All patients undergoing complex spine surgery, at our tertiary referral center, were consecutively, and prospectively, included from January 1 to December 31, 2013. Demographics and perioperative AEs were registered using the Spine AdVerse Events Severity (SAVES) system. Patients were followed for a minimum of two years. A competing risk survival model was used to estimate rates of readmissions with death as a competing risk. Patient characteristics, surgical parameters and perioperative AEs were analyzed to identify factors associated with readmission. Analyses of 30-day readmission were performed using logistic regression models. A proportional odds model, with death as competing risk, was used for readmissions to a spine center at any time in follow-up. Results were reported as odds ratios with 95% confidence intervals (95% CI).

RESULTS

Within 2 years of index discharge, 443 (65%) were readmitted. Only 20% of readmissions were to a spine center. Cumulative incidence (95% CI) of readmission was estimated to 13% (10%-16%) at 30 days, 26% (23%-30%) at 90 days, 50% (46%-54%) at 1 year, and 59% (55%-63%) at 2 years following discharge. Rates were markedly lower for readmissions to a spine center. Increased odds of 30-day readmission were correlated to intraoperative hypotension (p=.02) and major intraoperative blood loss (p<.01). Readmission to a spine center was associated with the number of instrumented vertebrae (p=.047), major intraoperative AE (p=.01), and intraoperative hypotension (p<.01).

CONCLUSIONS

To the best of our knowledge, this is the first study to analyze prospectively registered AEs' association to readmission up to 2 years after complex spine surgery. We found that readmissions were more frequent than previously reported when including readmissions to any department or hospital. Factors related to major intraoperative blood loss were associated to increased odds of readmission. This should be considered during planning of postoperative observation and care.

Enhanced Recovery After Surgery: Concepts and Application to Total Shoulder Replacement

BACKGROUND

Enhanced Recovery After Surgery (ERAS) focuses on optimizing each element on a treatment pathway and encouraging the patient to actively engage in his or her recovery and rehabilitation. It requires collaboration across a multidisciplinary team and has been successful in improving patient outcomes, length of stay (LOS), and costs for a wide range of surgical procedures, including musculoskeletal surgeries such as total hip and total knee replacement.

PURPOSE

To examine the application of ERAS concepts to total shoulder replacement (TSR) surgery.

METHODS

Hospital Episode Statistics (HES) in England on LOS for TSR surgery were examined, and a review of literature on the use of ERAS concepts in TSR was undertaken.

RESULTS

Analysis of HES data suggested scope for improvement in reducing LOS. A review of the literature found some evidence of the use of ERAS concepts, particularly in multimodal pain management.

CONCLUSIONS

Future research is now required for ERAS procedure-specific components for TSR surgery.

Endoscopic transforaminal lumbar interbody fusion without general anesthesia: operative and clinical outcomes in 100 consecutive patients with a minimum 1-year follow-up

OBJECTIVE

Open spinal fusion surgery is often associated with significant blood loss, postoperative pain, and prolonged recovery times. Seeking to minimize surgical and perioperative morbidity, the authors adopted an endoscopic minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) technique performed without general anesthesia. In this report, they present data on the first 100 patients treated with this procedure.

METHODS

The authors conducted a retrospective review of the first 100 patients who underwent awake endoscopic MIS-TLIF at a single institution between 2014 and 2017. Surgery was performed while the patient was sedated but without intubation or the use of general anesthetic or narcotic agents. Long-lasting (liposomal) bupivacaine was used for local analgesia. The discectomy and placement of an expandable interbody graft were performed endoscopically, followed by percutaneous pedicle screw implantation. Inclusion criteria for the procedure consisted of diagnosis of degenerative disc disease with grade I or II spondylolisthesis and evidence of spinal stenosis or nerve impingement with intractable symptomatology.

RESULTS

Of the first 100 patients, 56 were female and 44 were male. Single-level fusion was performed in 84 patients and two-level fusion in 16 patients. The most commonly fused level was L4–5, representing 77% of all fused levels. The mean (± standard deviation) operative time was 84.5 ± 21.7 minutes for one-level fusions and 128.1 ± 48.6 minutes for two-level procedures. The mean intraoperative blood loss was 65.4 ± 76.6 ml for one-level fusions and 74.7 ± 33.6 ml for two-level fusions. The mean length of hospital stay was 1.4 ± 1.0 days. Four deaths occurred in the 100 patients; all four of those patients died from complications unrelated to surgery. In 82% of the surviving patients, 1-year follow-up Oswestry Disability Index (ODI) data were available. The mean preoperative ODI score was 29.6 ± 15.3 and the mean postoperative ODI score was 17.2 ± 16.9, which represents a significant mean reduction in the ODI score of −12.3 using a two-tailed paired t-test (p = 0.000001). In four cases, the surgical plan was revised to include general endotracheal anesthesia intraoperatively and was successfully completed. Other complications included two cases of cage migration, one case of osteomyelitis, and one case of endplate fracture; three of these complications occurred in the first 50 cases.

CONCLUSIONS

This series of the first 100 patients to undergo awake endoscopic MIS-TLIF demonstrates outcomes comparable to those reported in our earlier papers. This procedure can provide a safe and efficacious option for lumbar fusion with less morbidity than open surgery. Further refinements in surgical technique and technologies will allow for improved success.