1
|
Magableh HM, Ibrahim S, Pennington Z, Nathani KR, Johnson SE, Katsos K, Freedman BA, Bydon M. Transforming Outcomes of Spine Surgery-Exploring the Power of Enhanced Recovery After Surgery Protocol: A Systematic Review and Meta-Analyses of 15 198 Patients. Neurosurgery 2024:00006123-990000000-01058. [PMID: 38358272 DOI: 10.1227/neu.0000000000002865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/05/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Enhanced recovery after surgery (ERAS) protocols aim to optimize patient outcomes by reducing the surgical stress response, expediting recovery, and reducing care costs. We aimed to evaluate the impact of implementing ERAS protocols on the perioperative surgical outcomes and financial implications associated with spine surgeries. METHODS A systematic review and meta-analysis of peer-reviewed studies directly comparing outcome differences between spine surgeries performed with and without utilization of ERAS pathways was conducted along Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Of 676 unique articles identified, 59 with 15 198 aggregate patients (7748 ERAS; 7450 non-ERAS) were included. ERAS-treated patients had shorter operative times (mean difference [MD]: 10.2 mins; P < .01), shorter hospitalizations (MD: 1.41 days, P < .01), fewer perioperative complications (relative risk [RR] = 0.64, P < .01), lower postoperative opioid use (MD of morphine equivalent dose: 164.36 mg; P < .01), and more rapid mobilization/time to first out-of-bed ambulation (MD: 0.92 days; P < .01). Spine surgeries employing ERAS were also associated with lower total costs (MD: $1140.26/patient; P < .01), especially in the United States (MD: $2869.11/patient, P < .01) and lower postoperative visual analog pain scores (MD = 0.56, P < .01), without any change in odds of 30-day readmission (RR: 0.80, P = .13) or reoperation (RR: 0.88, P = .60). Subanalyses based on the region of spine showed significantly lower length of stay in both cervical and lumbar surgeries implementing ERAS. Type of procedure showed a significantly lesser time-to-initiate mobilization in fusion surgeries using ERAS protocols compared with decompression. CONCLUSION The present meta-analysis indicates that current literature supports ERAS implementation as a means of reducing care costs and safely accelerating hospital discharge for patients undergoing spine surgery.
Collapse
Affiliation(s)
- Hamzah M Magableh
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Sufyan Ibrahim
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachary Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Karim Rizwan Nathani
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah E Johnson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Konstantinos Katsos
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
2
|
Heo DH, Jang JW, Park CK. Enhanced recovery after surgery pathway with modified biportal endoscopic transforaminal lumbar interbody fusion using a large cage. Comparative study with minimally invasive microscopic transforaminal lumbar interbody fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2853-2862. [PMID: 37211555 DOI: 10.1007/s00586-023-07747-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE Studies about the clinical efficacy of endoscopic lumbar interbody fusion using an enhanced recovery after surgery (ERAS) pathway are insufficient. Thus, the purpose of this study was to investigate clinical usefulness of biportal endoscopic transforaminal lumbar interbody fusion (TLIF) using an ERAS compared with microscopic TLIF. METHODS Prospectively collected data were retrospectively analyzed. Patients who received modified biportal endoscopic TLIF with ERAS were grouped into an endoscopic TLIF group. Those who received microscopic TLIF without ERAS were grouped into a microscopic TLIF group. Clinical and radiologic parameters were compared between two groups. Fusion rate was evaluated using sagittal reconstruction images of postoperative computed tomographic (CT) scan. RESULTS There were 32 patients in the endoscopic TLIF group with ERAS and 41 patients in the microscopic TLIF group without ERAS. Visual analog scale (VAS) scores for back pain preoperatively at day one and day two were significantly (p < 0.05) higher in the non-ERAS microscopic TLIF group than in the ERAS endoscopic TLIF group. Preoperative Oswestry Disability Index were significantly improved at the last follow-up in both groups. The fusion rate at postoperative one year was 87.5% in the endoscopic TLIF group and 85.4% in the microscopic TLIF group. CONCLUSION Biportal endoscopic TLIF with ERAS pathway may have good aspect to accelerate recovery after surgery. There was no inferiority of fusion rate of endoscopic TLIF comparing to microscopic TLIF. Biportal endoscopic TLIF using a large cage with ERAS pathway may be a good alternative treatment for lumbar degenerative disease.
Collapse
Affiliation(s)
- Dong Hwa Heo
- Endoscopic Spine Surgery Center, Neurosurgery, Champodonamu Spine Hospital, Seoul, Republic of Korea
| | - Jae Won Jang
- Spine Center, Department of Neurosurgery, Suwon Leon Wiltse Memorial Hospital, 437, Gyeongsu-dearo, Paldal-gu, Suwon-Si, Gyeonggi-do, 16480, Republic of Korea.
| | - Choon Keun Park
- Spine Center, Department of Neurosurgery, Suwon Leon Wiltse Memorial Hospital, 437, Gyeongsu-dearo, Paldal-gu, Suwon-Si, Gyeonggi-do, 16480, Republic of Korea
| |
Collapse
|
3
|
Contartese D, Salamanna F, Brogini S, Martikos K, Griffoni C, Ricci A, Visani A, Fini M, Gasbarrini A. Fast-track protocols for patients undergoing spine surgery: a systematic review. BMC Musculoskelet Disord 2023; 24:57. [PMID: 36683022 PMCID: PMC9869597 DOI: 10.1186/s12891-022-06123-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 12/29/2022] [Indexed: 01/24/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Deyanira Contartese
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Francesca Salamanna
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Silvia Brogini
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Konstantinos Martikos
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Cristiana Griffoni
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Ricci
- grid.419038.70000 0001 2154 6641Anesthesia-resuscitation and Intensive care, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Andrea Visani
- grid.419038.70000 0001 2154 6641Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Milena Fini
- grid.419038.70000 0001 2154 6641Scientific Direction, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Gasbarrini
- grid.419038.70000 0001 2154 6641Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| |
Collapse
|
4
|
Cui P, Wang S, Wang P, Yang L, Kong C, Lu S. Comparison of perioperative outcomes in frail patients following multilevel lumbar fusion surgery with and without the implementation of the enhanced recovery after surgery protocol. Front Surg 2022; 9:997657. [PMID: 36406376 PMCID: PMC9666399 DOI: 10.3389/fsurg.2022.997657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/05/2022] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is an evidence-based multimodal perioperative management designed to reduce the length of stay (LOS) and complications. The purpose of the present study is to evaluate the recovery of physiological function, LOS, complications, pain score, and clinical efficacy in frail elderly patients undergoing multisegment fusion surgery after the implementation of the ERAS protocol. METHODS Frail patients older than 75 years undergoing multilevel lumbar fusion surgery for degenerative discogenic conditions, lumbar spinal stenosis, and lumbar spondylolisthesis from January 2017 to December 2018 (non-ERAS frail group) and from January 2020 to December 2021 (ERAS frail group) were enrolled in the present study. Propensity score matching for age, sex, body mass index, and smoking status was performed to keep comparable characteristics between the two groups. Further recovery of physiological function, LOS, complications, pain score, and clinical efficacy were compared between the groups. RESULTS There were 64 pairs of well-balanced patients, and the clinical baseline data were comparable between the two groups. There was significant improvement in terms of recovery of physiological function (10.65 ± 3.51 days vs. 8.31 ± 3.98 days, p = 0.011) and LOS (12.18 ± 4.69 days vs. 10.44 ± 4.60 days, p = 0.035), while no statistical discrepancy was observed with regard to complications between the groups, which indicated favorable outcomes after the implementation of the ERAS protocol. Further analysis indicated that more patients were meeting a minimally clinical important difference for the visual analog score for the legs and the Oswestry Disability Index in the ERAS frail group. With regard to postoperative pain, the score was higher in the ERAS frail group than in the non-ERAS frail group on postoperative day (POD) 1 (4.88 ± 1.90 in the ERAS frail group vs. 4.27 ± 1.42 in the non-ERAS frail group, p = 0.042), while there was no significant discrepancy on POD 2 (3.77 ± 0.88 in the ERAS frail group vs. 3.64 ± 1.07 in the non-ERAS frail group, p = 0.470) and POD 3 (3.83 ± 1.89 in the ERAS frail group vs. 3.47 ± 1.75 in the non-ERAS frail group, p = 0.266). CONCLUSIONS In this retrospective cohort study, we found a significant improvement in terms of LOS, recovery of physiological function, and clinical efficacy after the implementation of the ERAS protocol in elderly and frail patients undergoing multilevel lumbar fusion surgery, while there was no significant discrepancy with regard to complications, 90-day readmission, and postoperative pain.
Collapse
Affiliation(s)
- Peng Cui
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Shuaikang Wang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Peng Wang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Lijuan Yang
- Department of Pathology, West China Hospital, Sichuan University, Sichuan, China
| | - Chao Kong
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Shibao Lu
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Beijing, China
| |
Collapse
|