Enhanced Recovery After Surgery (ERAS) Protocol Reduces Opioid Use After Spinal Surgery

Peer Reviewed

An enhanced recovery after surgery (ERAS) protocol for elective spine surgery and peripheral nerve surgery was associated with reduced opioid use at one month post-operatively, according to a prospective cohort study published online ahead of print in the Journal of Neurosurgery: Spine.

A key finding from the study is the feasibility of the ERAS protocol at a tertiary care academic medical center in which multiple surgeons and providers are involved in patient care for spine surgery, explained lead author Zarina S. Ali, MD, MS, Assistant Professor of Neurosurgery at Pennsylvania Hospital in Philadelphia. In addition, “We are really excited about the clinical implications of the findings in terms of reduced opioid use perioperatively and post-operatively.”

“This study is well-designed, and the authors are credited in recognizing the need to individualize patient care while simultaneously creating a common patient care pathway,” commented SpineUniverse Editorial Board member James S. Harrop, MD, Professor in the Departments of Neurological and Orthopedic Surgery at Thomas Jefferson University in Philadelphia, PA.
Patient in post-op using a walker with nursing assistant.Addressing fear of movement immediately in the post-operative period by encouraging timely post-operative mobility and ambulation reduces immobility. Photo Source: 123RF.com.

ERAS Protocol Based on Best Practices

The ERAS protocol was developed at the University of Pennsylvania and uses a multimodal, opioid-sparing approach to spine surgery pain management (see Neurosurgery ERAS Protocol). Of note, the ERAS protocol includes opioid-sparing multimodal analgesia (eg, gabapentin, acetaminophen, and local bupivacaine) as well as strict parameters for early ambulation (3-5 times per day) beginning on post-operative day one to help avoid the potential for post-operative fear of movement.

“We based the principles of our ERAS program on what we considered best practice within the literature,” Dr. Ali told SpineUniverse. “We believe that addressing the fear of movement immediately in the post-operative period by encouraging timely post-operative mobility and ambulation reduces immobility and enhances recovery,” the researchers wrote.

Neurosurgery ERAS Protocol at Pennsylvania Hospital

Neurosurgery ERAS Protocol at Pennsylvania HospitalNeurosurgery ERAS Protocol at Pennsylvania Hospital. Source: Ali ZS, et al. J Neurosurg Spine. 2019 Jan 25:1-9. doi: 10.3171/2018.9.SPINE18681. [Epub ahead of print]

The researchers prospectively followed patients who underwent elective spine or peripheral nerve surgery by the same team of neurosurgeons at the University of Pennsylvania. The patients were treated using an ERAS pain management protocol (n=201) between April and June 2017 or received traditional surgical care (n=74) between September and December 2016.

The traditional surgical care group (control) received routine care including post-operative pain management with patient-controlled analgesia (PCA) post-operatively (ie, post-operative day 0–1), among other routine parameters.

ERAS Reduces Opioid Use Immediately After Surgery

A greater proportion of the ERAS group received a combination of at least 3 or 4 nonopioid agents compared to control patients (P<0.001). The ERAS group had nearly complete elimination of PCA use (0.5%) compared to the control group (54.1%; P<0.001). Importantly, this reduction in opioid medication in the perioperative period did not lead to an increase in pain, as the authors found that maximum pain scores on post-operative days 0-3 were not significantly different between the two groups.

At one month post-operatively, the ERAS group had a lower rate of opioid use (38%) compared to the control group (53%; P=0.041).

Given that the approximately three-quarters of the institution’s spinal and peripheral nerve surgical population is opioid naïve, and with research indicating that between 3% and 7% opioid naïve patients undergoing surgery will continue to take opioids at one year post-operatively, the lower rate of opioid use in the ERAS group has “profound implications in helping to limit the chronic opioid dependency in patients following spine surgery,” according to the researchers. However, further studies are needed to assess the durability of these findings, they noted.

Evolution of the ERAS Program

“ERAS is an iterative process,” Dr. Ali said. “There are some things that we are doing much more effectively than when we first started the program. For example, currently there is increased attention to developing a consistent multimodal regimen. I think we are more cognizant about what nonopioid regimens offer patients so as to reduce their opioid consumption perioperatively.”

Several follow-up studies on the ERAS protocol are currently ongoing. For example, Dr. Ali and colleagues are conducting a randomized controlled trial of the ERAS program versus standard of care, and are also examining cost-effectiveness and qualitative data to determine the effects of ERAS from a patient experience standpoint.

“ERAS implicitly involves more intensive patient education pre-operatively, and outcomes are driven by patient expectations,” Dr. Ali explained. “While pain control was a very important component of our study, it was something that we were studying along with multiple other endpoints, the most important of which are patient-reported outcomes.”

ERAS Encompasses All Phases of Patient Care in Spine Surgery

“As the authors note, numerous surgical specialties have utilized and recognized the patient benefit to having structured patient care pathways,” Dr. Harrop said. “This article is extremely well done and illustrates the advantages of ERAS in the spine community. The importance of these pathways is to incorporate all phases of patient care for spine surgery. These authors did an excellent job recognizing and treating patients not only during their operative care put also pre- and post-operatively.”

“We have also developed an ERAS pathway at Jefferson Hospitals and have incorporated pre-operative medications, screening, and referral for higher-risk patients (also including those with anemia),” Dr. Harrop explained. “In addition, we have designed and built a comprehensive spine unit such that similar nursing support and education can be maximized.”

Disclosures
Dr. Ali and Dr. Harrop have no relevant disclosures.

Updated on: 03/13/19
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Paradigm Shift to Outpatient Spine Surgery Centers
Zarina S. Ali, MD, MS
Assistant Professor of Neurosurgery
Pennsylvania Hospital
Philadelphia, PA
James S. Harrop, MD, FACS
Professor, Departments of Neurological and Orthopedic Surgery
Thomas Jefferson University
Philadelphia, PA
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