ERAS for Spine Surgery: A New Frontier By Ellen M. Soffin, MD, PhD; Alana E. Sigmund, MD, FHM & Chad M. Craig, MD, FACP I t is evident that Enhanced Recovery After Surgery (ERAS) has become an established and effective mechanism for perioperative care across surgical subspecialties. In our companion piece in the Newsletter, we propose total joint arthroplasty (TJA) as the quintessential orthopedic procedure to benefit from ERAS principles: There is already convincing evidence that clinical pathways effect cost savings and clinical benefits for TJA patients, including decreased length of stay and complications. In contrast, there is a paucity of data in the published literature and reports at the institutional level for the role of ERAS pathways in spine surgery. There is much in common between the spine surgery and colorectal surgery patient (where most ERAS evidence exists to date), including predicted systemic inflammatory response (SIR), length of stay, requirement for parenteral analgesics and complications (particularly ileus). Given the evidence and enthusiasm for ERAS, it is unexpected that spine surgery should remain so understudied with respect to ERAS protocols. This inattention occurs despite compelling biochemical, clinical and economic arguments to support ERAS for spine surgery. First, major spine surgery is associated with predicable increases in stress hormones and inflammatory cytokines1 which may be associated with a host of postoperative complications, including thromboembolism, atrial fibrillation and delirium.2,3 Preoperative steroids Specific interventions have been demonstrated to reduce biomarkers of surgical stress and improve outcomes after spine surgery. For example, intraoperative administration of the alpha-2 adrenergic agonist, dexmedetomidine, lowers interleukin-10 and cortisol and improves quality of recovery after multilevel lumbar fusion.4 lower interlukin-6 and C-reactive protein after cervical laminoplasty without increasing the risk of wound infection or compromised healing.5 Minimally invasive surgical techniques are associated with lower levels of cytokines compared to conventional techniques up to 8 days post lumbar fusion.6 The overall safety and efficacy benefits of minimally invasive approaches have yet to be fully established in lumbar spine surgery,7 but represent an intriguing possibility for future research as a component of ERAS for spine pathways. The minimally invasive approach may indeed be the ERAS-for-spine analogy to the laparoscopic approach in ERAS-for-colorectal surgery, in terms of benefits on outcomes and biomolecular markers of surgical stress.8 The second argument in favor of ERAS for spine surgery is an economic one. The demand for spine surgery and the cost of surgery are both increasing exponentially in the United States and abroad.9 Indeed, a recent economic report estimated the total annual cost for back pain in the United States (including diagnosis, treatment and rehabilitation) at over $50 billion US dollars annually, and costs are projected to increase 4.8% annually in the near term.10 According to the report, the demand for spine surgery is being driven by an aging population, an increase in the number of fusions being performed, and technical ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org advances making complex surgery more commonplace. Given these pressures, any reduction in length of stay, no matter how modest, is likely to produce significant economic gains, as has been demonstrated repeatedly for ERAS in other surgical disciplines. As an illustrative example of potential economic gains, we can consider lumbar fusion: The hospital costs associated with lumbar fusion without instrumentation was recently reported in a cohort study to be approximately $14,700.00 US dollars.11 The average length of stay was 3.5 days in a sample of 77 patients. A reduction in length of stay of just 0.5 days per patient would 13
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