Reduction of Postoperative Opioid Use After Elective Spine and Peripheral Nerve Surgery Using an Enhanced Recovery After Surgery Program.

OBJECTIVE: Enhanced recovery after surgery (ERAS) pathways have previously been shown to be feasible and safe in elective spinal procedures. As publications on ERAS pathways have recently emerged in elective neurosurgery, long-term outcomes are limited. We report on our 18-month experience with an ERAS pathway in elective spinal surgery. METHODS: A historical cohort of 149 consecutive patients was identified as the control group, and 1,141 patients were prospectively enrolled in an ERAS protocol. The primary outcome was the need for opioid use one month postoperation. Secondary outcomes were opioid and nonopioid consumption on postoperative day (POD) 1, opioid use at three and six months postoperation, inpatient pain scores, patient satisfaction scores, postoperative Foley catheter use, mobilization/ambulation on POD0-1, length of stay, complications, and intensive care unit admissions. RESULTS: There was significant reduction in use of opioids at one, three, and six months postoperation (38.6% vs 70.5%, P < 0.001, 36.5% vs 70.9%, P < 0.001, and 23.6% vs 51.9%, P = 0.008) respectively. Both groups had similar surgical procedures and demographics. PCA use was nearly eliminated in the ERAS group (1.4% vs 61.6%, P < 0.001). ERAS patients mobilized faster on POD0 compared with control (63.5% vs 20.7%, P < 0.001). Fewer patients in the ERAS group required postoperative catheterization (40.7% vs 32.7%, P < 0.001). The ERAS group also had decreased length of stay (3.4 vs 3.9 days, P = 0.020). CONCLUSIONS: ERAS protocols for all elective spine and peripheral nerve procedures are both possible and effective. This standardized approach to patient care decreases opioid usage, eliminates the use of PCAs, mobilizes patients faster, and reduces length of stay.

Efficacy of an Enhanced Recovery After Surgery (ERAS) Pathway in Elderly Patients Undergoing Spine and Peripheral Nerve Surgery.

OBJECTIVE: Elderly patients are a vulnerable patient population in elective spinal surgery. Older patients have more medical comorbidities and are also more sensitive to opiate medications. Despite this, spine and peripheral nerve surgery is still feasible in these patients, and an Enhanced Recovery After Surgery (ERAS) regimen can further enhance the safety profile. METHODS: This is a before and after cohort study at a single institution on elderly patients who underwent elective spine and peripheral nerve surgery. Patients were prospectively enrolled in a novel ERAS protocol from April 2017 to December 2018. The control group was a historical cohort of patients who underwent surgery from September 2016 to December 2016. The primary outcome was self-reported opioid use at 1- and 3-months postoperatively. The secondary outcome was compliance with the ERAS protocol across several measures including patient-controlled (PCA) use, patient-reported pain scores, mobilization and ambulation status, and Foley catheter use. RESULTS: Among 504 patients aged 65 and older compared to historic controls there was a significant reduction in the use of post-operative opioids at one month (36.2% vs. 71.7%, p < 0.001) and 3 months after surgery (33.0% vs. 80.0%, p < 0.001). 504 consecutive elderly patients were included in the ERAS protocol compared to a control group of 60. The two groups had similar surgical procedures and baseline demographics, with similar mean ages (ERAS 73.2 years vs. control 73.5 years, p = 0.67). The ERAS group showed improved mobilization and ambulation on POD 0 in compliance with our protocol compared to the control group (mobilization: 60.0% vs. 10.0%, p < 0.001; ambulation: 36.1% vs. 10.0%, p < 0.001), with no inpatient falls reported for either group. CONCLUSIONS: ERAS facilitates reduction in opiate use at 1- and 3-month intervals postoperatively in patients greater than 65 years old undergoing elective spine and peripheral nerve surgery. Early mobilization and ambulation are safe and feasible in this population.