Elsevier

World Neurosurgery

Volume 159, March 2022, Pages e303-e310
World Neurosurgery

Original Article
Benefits of the Enhanced Recovery After Surgery Program in Short-Segment Posterior Lumbar Interbody Fusion Surgery

https://doi.org/10.1016/j.wneu.2021.12.046Get rights and content

Objective

Enhanced recovery after surgery (ERAS) is a multimodal, evidence-based approach to perioperative care that aims to reduce physiological and psychological stress, improve the quality of rehabilitation, and speed up the recovery of patients. Our study aims to investigate the benefits of perioperative use of ERAS for a short-segment posterior lumbar interbody fusion.

Methods

We selected two 1-year periods: the first from before the establishment of the multidisciplinary ERAS team in January 2017 (pre-ERAS year 2016) and the second period when ERAS was applied widely in our hospital (ERAS year 2019). Data were collected from the electronic medical records of patients who had undergone a short-level posterior lumbar interbody fusion during these 2 periods. The primary outcomes were postoperative complications, length of hospital stay, and off-bed time.

Results

A total of 207 patients were included; 95 patients in the pre-ERAS group were compared with 112 patients in the ERAS group. There was no significant difference between the 2 groups in baseline demographic. Patients in the ERAS group had significantly shorter length of hospital stay, off-bed time, and earlier drainage tube and catheter removal time. The rate of postoperative complications differed significantly between the pre-ERAS and ERAS groups. Patients in the ERAS group had significantly less intraoperative blood loss, financial cost, and opioid consumption than patients in the pre-ERAS group. The visual analog scale and Oswestry Disability Index scores, similar at baseline, were significantly lower in the ERAS group at postoperative day 3.

Conclusions

The benefits of our ERAS protocol for patients undergoing short-level posterior lumbar fusion are evident in terms of reduced hospital stay and time to get out of bed, reduced incidence of postoperative complications, intraoperative blood loss, opioid use and hospital costs, and improved early postoperative pain and dysfunction.

Introduction

Henri Kehlet first proposed the concept of enhanced recovery after surgery (ERAS) in 1997.1,2 ERAS is a multidisciplinary approach based on evidence-based medical evidence that accelerates recovery by enhancing perioperative care to reduce physical and psychological stress. It was initially used in elderly patients undergoing colon surgery and has since been widely used in other surgical fields, whereas applications in spine surgery have yet to be developed.3 Recently, a study confirmed that the ERAS program could bring many benefits to patients who underwent short-segment lumbar fusion.4,5

It is difficult to develop a uniform, standardized ERAS pathway for spinal fusion surgery because of its heterogeneity. Therefore, different ERAS protocols might be suitable for different lumbar fusion procedures. At present, there are many studies on the application of ERAS in minimally invasive lumbar fusion because it has many advantages, such as causing fewer iatrogenic injuries, shorter hospital stays, and faster postoperative recovery, which are highly consistent with the original concept of ERAS.6, 7, 8 In addition, these studies have demonstrated that perioperative application of ERAS in minimally invasive lumbar fusion surgery can shorten the length of hospital stay, reduce postoperative complications, and improve patient satisfaction.2,9,10

Currently, because of the high equipment requirements and long learning curve associated with minimally invasive spinal fusion surgery, traditional posterior lumbar interbody fusion (PLIF) surgery is still used in most regions to treat lumbar diseases. Therefore, it is of high clinical significance to confirm the effectiveness of ERAS in traditional PLIF surgery. The aim of our study was to demonstrate whether our ERAS program is appropriate for traditional PLIF surgery and what benefits it may bring to patients undergoing short-segment lumbar fusion.

Section snippets

Study Design

Prospective data gathered by our hospital were retrospectively analyzed. The data contained the records of all patients who underwent spinal fusion in 2016 and 2019. All the data came from the hospital’s electronic medical record.

We selected two 1-year periods: the first from before the establishment of the multidisciplinary ERAS team in January 2017 (pre-ERAS year 2016) and the second period when the ERAS was applied widely in our hospital (post-ERAS year 2019). Data were collected from the

Baseline Characteristics

A total of 207 patients were included in our study, 95 of whom were in the pre-ERAS group and 112 of whom were in the ERAS group. All patients were diagnosed with lumbar disc herniation, lumbar stenosis, or spondylolisthesis and underwent a short-level (1- or 2-level) PLIF. The demographic characteristics of the population are shown in Table 2. There was no significant difference between the pre-ERAS group and the ERAS group in age, gender, comorbidities diagnosis, and the number of levels

The Importance of the ERAS Protocol

Patients who are about to undergo surgery suffer from multiple factors such as the disease itself, surgical injury, psychological, and physical stress. ERAS was originally outlined to speed up bed turnover and reduce complications and hospital costs. Although originally designed primarily for colorectal surgery patients, its basic principles have been applied to other surgical disciplines. These basic principles included: 1) shift from a disease-centered approach to a patient-centered approach;

Conclusions

Overall, a traditional open short-segment PLIF with an ERAS protocol performed better in reducing LOS, off-bed time, bleeding, complications, postoperative drainage volume, postoperative pain, drainage tube, and catheter removal time. Importantly, patients were more satisfied with ERAS management than with conventional care. Taken together, we established that a traditional open short-segment PLIF combined with ERAS might bring about more benefits to patients.

CRediT authorship contribution statement

Jinlei Chen: Conceptualization, Methodology, Writing – original draft. Dongliang Li: Conceptualization, Data curation. Ruirui Wang: Conceptualization, Sources. Shuang Wang: Software, Validation, Data curation, Writing – review & editing. Zhizhong Shang: Conceptualization, Methodology. Mingchuan Wang: Conceptualization, Data curation. Xin Wang: Writing – review & editing, Supervision, Project administration, Conceptualization.

Acknowledgments

The authors thank all investigators and supporters involved in this study. Especially, they would like to thank Professor Jinhui Tian (Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou City 730000, China) for their valuable suggestions and inputs during the entire project.

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  • Conflict of interest statement: This work was supported by Gansu Natural Science Foundation (No. 21JR7RA362), the China Postdoctoral Science Foundation (No. 2017M613342), Lanzhou Chengguan Science and Technology Bureau (No. 2017SHFZ0036), Gansu Natural Science Foundation (No. 18JR3RA353), and the First Hospital of Lanzhou University Foundation (No. ldyyyn2017-26).

    Availability of data and material: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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