Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery

OBJECTIVESpine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate.METHODSUsing the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care.RESULTSOf 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference −1.22 days [95% CI −1.98 to −0.47]) and lumbar spine ERAS protocols (−1.53 days [95% CI −2.89 to −0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use.CONCLUSIONSPresent data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.

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Current Prehabilitation Programs Do Not Improve the Postoperative Outcomes of Patients Scheduled for Lumbar Spine Surgery: A Systematic Review With Meta-analysis

Journal of Orthopaedic and Sports Physical Therapy ◽

10.2519/jospt.2021.9748 ◽

2020 ◽

pp. 1-47

Author(s):

Esther R.C. Janssen ◽

Ilona M. Punt ◽

Michel J. Clemens ◽

Bart J. Staal ◽

Thomas J. Hoogeboom ◽

...

Keyword(s):

Systematic Review ◽

Lumbar Spine ◽

Spine Surgery ◽

Meta Analysis ◽

Postoperative Outcomes ◽

Lumbar Spine Surgery

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The Impact of an Enhanced Recovery after Surgery (ERAS) Protocol Implementation in a Community-Based Hospital.

Journal of Minimally Invasive Gynecology ◽

10.1016/j.jmig.2020.08.172 ◽

2020 ◽

Vol 27 (7) ◽

pp. S111

Author(s):

D.A. Escobar Jimenez ◽

D. Encalada ◽

M. Teitz ◽

E. Hemmings ◽

C. Salafia ◽

...

Keyword(s):

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Community Based ◽

Protocol Implementation ◽

Eras Protocol ◽

The Impact

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Enhanced recovery after surgery (ERAS) protocol reduces LOS without additional adverse events in spine surgery

Orthopaedics & Traumatology Surgery & Research ◽

10.1016/j.otsr.2020.01.017 ◽

2020 ◽

Vol 106 (6) ◽

pp. 1167-1173

Author(s):

Henri d’Astorg ◽

Vincent Fière ◽

Maud Dupasquier ◽

Thais Dutra Vieira ◽

Marc Szadkowski

Keyword(s):

Adverse Events ◽

Spine Surgery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Eras Protocol

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Design and Implementation of an Enhanced Recovery After Surgery (ERAS) Protocol in Elective Lumbar Spine Fusion by Posterior Approach

Spine ◽

10.1097/brs.0000000000003869 ◽

2020 ◽

Vol Publish Ahead of Print ◽

Author(s):

Bhavuk Garg ◽

Nishank Mehta ◽

Tungish Bansal ◽

Shubhankar Shekhar ◽

Puneet Khanna ◽

...

Keyword(s):

Lumbar Spine ◽

Posterior Approach ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Spine Fusion ◽

Design And Implementation ◽

Lumbar Spine Fusion ◽

Eras Protocol

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Anterior lumbar spine surgery: a systematic review and meta-analysis of associated complications

The Spine Journal ◽

10.1016/j.spinee.2015.02.040 ◽

2015 ◽

Vol 15 (5) ◽

pp. 1118-1132 ◽

Cited By ~ 32

Author(s):

Dexter K. Bateman ◽

Paul W. Millhouse ◽

Niti Shahi ◽

Abhijeet B. Kadam ◽

Mitchell G. Maltenfort ◽

...

Keyword(s):

Systematic Review ◽

Lumbar Spine ◽

Spine Surgery ◽

Meta Analysis ◽

Lumbar Spine Surgery

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Enhanced Recovery After Surgery for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Systematic Review and Meta-Analysis

Frontiers in Surgery ◽

10.3389/fsurg.2021.713171 ◽

2021 ◽

Vol 8 ◽

Author(s):

Feng Mao ◽

Zhenmin Huang

Keyword(s):

Peritoneal Carcinomatosis ◽

Intraperitoneal Chemotherapy ◽

Cytoreductive Surgery ◽

Hyperthermic Intraperitoneal Chemotherapy ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Meta Analysis ◽

Current Evidence ◽

Eras Protocol ◽

The Impact

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising approach for the management of peritoneal carcinomatosis, but is associated with significant morbidity and prolonged hospital stay. Herein, we review the impact of Enhanced recovery after surgery (ERAS) protocol on length of stay (LOS) and early complications in patients undergoing CRS and HIPEC for peritoneal carcinomatosis.Methods: PubMed and Embase were searched for studies comparing ERAS protocol with control for CRS + HIPEC. Mean difference (MD) and risk ratios (RR) were calculated for LOS and complications respectively.Results: Six retrospective studies were included. Meta-analysis indicated statistically significant reduction in LOS with ERAS (MD: −2.82 95% CI: −3.79, −1.85 I2 = 29% p < 0.00001). Our results demonstrated significantly reduced risk of Calvien Dindo grade III/IV complications with the use of ERAS protocol as compared to the control group (RR: 0.60 95% CI: 0.41, 0.87 I2 = 0% p = 0.007). Pooled analysis of limited studies demonstrated no statistically significant difference in the risk of reoperation (RR: 1.04 95% CI: 0.54, 2.03 I2 = 50% p = 0.90) readmission (RR: 0.55 95% CI: 0.21, 1.49 I2 = 0% p = 0.24), acute kidney injury (RR: 0.55 95% CI: 0.28, 1.10 I2 = 0% p = 0.09) or mortality (RR: 0.62 95% CI: 0.17, 2.26 I2 = 0% p = 0.46) between the study groups.Conclusion: For CRS + HIPEC, ERAS is associated with significantly reduced LOS along with lower incidence of complications. Limited data suggest that use of ERAS protocol is not associated with increased readmission, reoperation, and mortality rates in these patients. There is a need for randomized controlled trials to corroborate the current evidence.

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The Impact of Corticosteroid Injection Timing on Infection Rates Following Spine Surgery: A Systematic Review and Meta-Analysis

Global Spine Journal ◽

10.1177/21925682211026630 ◽

2021 ◽

pp. 219256822110266

Author(s):

Gregory S. Kazarian ◽

Michael E. Steinhaus ◽

Han Jo Kim

Keyword(s):

Systematic Review ◽

Lumbar Spine ◽

Spine Surgery ◽

Postoperative Infection ◽

Corticosteroid Injection ◽

Meta Analysis ◽

Significant Risk ◽

Lumbar Spine Surgery ◽

Injection Timing ◽

The Impact

Study Design/Setting: Systematic review/meta-analysis. Objectives: The objective of this review was to assess how the risk of infection following lumbar spine surgery varies as a function of the timing of preoperative corticosteroid spinal injections (CSIs). Methods: A systematic review and meta-analysis was performed in accordance with the PRISMA guidelines. PubMed and EMBASE databases were searched and data was pooled for meta-analysis. Results: Six studies were identified for inclusion. Two (33.3%) demonstrated a significant relationship between the timing of preoperative CSIs and the risk of postoperative infection, while 4 (66.7%) demonstrated no impact. A total of 2.5% (110/4,448) of patients who underwent CSI <1 month before surgery experienced a postoperative infection, as compared to 1.2% (1,466/120, 943) of controls, which was statistically significant (RR = 1.986 95% CI 1.202-3.282 P = 0.007). A total of 1.6% (25/1,600) of patients who underwent CSI 0-3 months before surgery experienced a postoperative infection, as compared to 1.6% (201/12, 845) of controls (RR = 0.887 95% CI 0.586-1.341, P = 0.569). A total of 1.1% (199/17 870) of patients who underwent CSI 3-6 months before surgery experienced a postoperative infection, as compared to 1.3% (1,382/102, 572) of controls (RR = 1.053 95% CI 0.704-1.575, P = 0.802). Differences in infection risk for 0-3 months and 3-6 months were not statistically significant. Conclusions: CSIs <1 month prior to lumbar spine surgery are a significant risk factor for infection, while CSIs beyond that point showed no such association. Surgeons should consider avoiding CSIs <1 month of the use of CSIs of the spine.

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Safety and efficacy of a novel neurosurgical enhanced recovery after surgery protocol for elective craniotomy: a prospective randomized controlled trial

Journal of Neurosurgery ◽

10.3171/2018.1.jns171552 ◽

2019 ◽

Vol 130 (5) ◽

pp. 1680-1691 ◽

Cited By ~ 10

Author(s):

Yuan Wang ◽

Bolin Liu ◽

Tianzhi Zhao ◽

Binfang Zhao ◽

Daihua Yu ◽

...

Keyword(s):

Clinical Trial ◽

Perioperative Management ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Tertiary Care ◽

Hospital Length Of Stay ◽

Control Group ◽

Complication Rates ◽

Safety And Efficacy ◽

Eras Protocol

OBJECTIVEAlthough enhanced recovery after surgery (ERAS) programs have gained acceptance in various surgical specialties, no established neurosurgical ERAS protocol for patients undergoing elective craniotomy has been reported in the literature. Here, the authors describe the design, implementation, safety, and efficacy of a novel neurosurgical ERAS protocol for elective craniotomy in a tertiary care medical center located in China.METHODSA multidisciplinary neurosurgical ERAS protocol for elective craniotomy was developed based on the best available evidence. A total of 140 patients undergoing elective craniotomy between October 2016 and May 2017 were enrolled in a randomized clinical trial comparing this novel protocol to conventional neurosurgical perioperative management. The primary endpoint of this study was the postoperative hospital length of stay (LOS). Postoperative morbidity, perioperative complications, postoperative pain scores, postoperative nausea and vomiting, duration of urinary catheterization, time to first solid meal, and patient satisfaction were secondary endpoints.RESULTSThe median postoperative hospital LOS (4 days) was significantly shorter with the incorporation of the ERAS protocol than that with conventional perioperative management (7 days, p < 0.0001). No 30-day readmission or reoperation occurred in either group. More patients in the ERAS group reported mild pain (visual analog scale score 1–3) on postoperative day 1 than those in the control group (79% vs. 33%, OR 7.49, 95% CI 3.51–15.99, p < 0.0001). Similarly, more patients in the ERAS group had a shortened duration of pain (1–2 days; 53% vs. 17%, OR 0.64, 95% CI 0.29–1.37, p = 0.0001). The urinary catheter was removed within 6 hours after surgery in 74% patients in the ERAS group (OR 400.1, 95% CI 23.56–6796, p < 0.0001). The time to first oral liquid intake was a median of 8 hours in the ERAS group compared to 11 hours in the control group (p < 0.0001), and solid food intake occurred at a median of 24 hours in the ERAS group compared to 72 hours in the control group (p < 0.0001).CONCLUSIONSThis multidisciplinary, evidence-based, neurosurgical ERAS protocol for elective craniotomy appears to have significant benefits over conventional perioperative management. Implementation of ERAS is associated with a significant reduction in the postoperative hospital stay and an acceleration in recovery, without increasing complication rates related to elective craniotomy. Further evaluation of this protocol in large multicenter studies is warranted.Clinical trial registration no.: ChiCTR-INR-16009662 (chictr.org.cn)

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