achieve overall hospital costs savings of approximately $161,700.00 in this cohort alone. The third argument should ideally be made on the basis of evidence to indicate improved outcomes, reduced complications and rising patient satisfaction associated with ERAS for spine. However, this evidence is currently scarce and there are no published accounts of comprehensive ERAS pathways for any spine surgery subtypes at this time. However, there is an extensive literature regarding components of care that classically comprise ERAS pathways, together with encouraging results on a range of clinically important outcomes. A full review is outside the scope of this commentary, but several observations can be highlighted: multimodal analgesic regimens incorporating acetaminophen, non-steroidal antiinflammatories, anti-convulsants, and local anesthetics are opioid sparing, and associated with improved patient satisfaction, reduced length of stay, and better pain control than intravenous opioid-based therapy after spine surgery;12 a blood conservation strategy including the anti-fibrinolytic, tranexamic acid, reduces autologous blood transfusion without increasing the risk of thromboembolic events after major reconstructive spine surgery;13 identifying patients at risk of nutritional deficiency and optimizing nutritional status was associated with a faster return to nutritional baseline (or anabolic state) after major reconstruction surgery (>10 spinal levels);14 and intravenous fluid restriction is associated with less post-operative ileus after lumbar fusion irrespective of surgical approach.15 If follows that these examples could be used as the basis for ERAS for spine pathways. However, a closer examination of the state of the evidence base raises more questions than it answers and exposes significant gaps in research and knowledge: What is the role of pre-operative education and shared-decision making in the spine population? How can we standardize pathways for such heterogeneous patients, indications and surgical interventions? What is the role of epidural analgesia after spine surgery? Is early mobilization appropriate after major reconstructive procedures? These are just a very few of the questions that need to be answered urgently if ERAS for spine is to become relevant and useful. In order to most efficiently provide solutions, we advocate creating an ERAS for spine pathway that can be adopted according to institutional capability. At Hospital for Special Surgery, we have recently implemented an ERAS pathway for lumbar spine fusion. The pathway is based on current best evidence, but where evidence is lacking, we have implemented measures that have demonstrated efficacy in other ERAS protocols. We are currently enrolling patients in a prospective study to investigate the effect(s) of the pathway on patient centered outcomes. Additionally, we call for research and well-designed studies that focus on procedure-specific interventions, improving logistics, and fostering a culture of enhanced recovery across disciplines. n References 1. Watt DG, Horgan PG, McMillan DC: Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review. Surgery 2015; 362-80. 2. Hu YF, Chen YJ, Lin YJ, Chen SA: Inflammation and the pathogenesis of atrial fibrillation. Nature Rev Cardiol 2015; 12(4):230-43. 3. Van Munster BC, Korevaar JC, Zwinderman AH, Levi M, Wiersinga WJ, De Rooij SE: Time-course of cytokines during delirium in elderly patients with hip fractures. J Am Geriatr Soc 2008; 56(9):1704-9. 4. Bekker A, Haile M, Kline R, Didehvar S, Babu R, Martiniuk F, Urban M: The effect of intraoperative infusion of dexmedetomidine on quality of recovery after major spinal surgery. J Neurosurg Anesthesiol 2013; 25(1):16-24. 5. Demura S, Takahashi K, Murakami H, Fujimaki Y, Kato S, Tsuchiya H: The influence of steroid administration on systemic response in laminoplasty for cervical myelopathy. Arch Orthop Trauma Surg 2013; 133(8):1041-5. 6. Kim KT, Lee SH, Suk, SK, Bae SC: The quantitative analysis of tissue injury markers after mini-open lumbar fusion. Spine; 31(6):712-6. 7. Payer M: “Minimally invasive” lumbar spine surgery: a critical review. Acta Neurochir (Wein) 2011; 153(7):1455-9. 8. Zhuang CL, Huang DD, Chen FF, Zhou CL, Zheng BS, Chen BC, Shen X, Yu Z: Laparoscopic versus open colorectal surgery within enhanced recovery after surgery programs: a systematic review and meta-analysis of randomized controlled trials. Surg Endosc 2015; 29(8):2091100. 9. Wainwright TW, Immins T, Middleton RG: Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery. Best Pract Res Clin Anaesthesiol 2016; 30(1):91-102. 10. Ken Research. The US Spinal Surgery Market Outlook to 2017: Ageing population and technological advances to intensify the competition. 2013; Available at www.marketresearch.com/product/ sample-7535890.pdf 11. Molina CA, Zadnik PL, Gokaslan ZL, Witham TF, Bydon A, Wolinsky JP, Sciubba DM: A cohort analysis of lumbar laminectomy—current trends in surgeon and hospital fees distribution. Spine J 2013; 13(11):1434-7. 12. Devin CJ, McGirt MJ: Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes. J Clin Neurosci 2015; 22:930-38. 13. Soroceanu A, Oren JH, Smith JS, Hostin R, Shaffrey CI, Mundis GM, Ames CP, Burton DC, Bess S, Gupta MC, Deviren V, Schwab FJ, Lafage V, Errico TJ: Effect of antifibrinolytic therapy on complications, thromboembolic events, blood product utilization, and fusion in adult spinal deformity surgery. Spine 2016; 41(14):E897-86. 14. Lapp MA, Bridwell KH, Lenke LG, Baldus C, Blanke K, Iffrig TM: Prospective randomization of parenteral hyperalimentation for long fusions with spinal deformity: its effect on complications and recovery from postoperative malnutrition. Spine 2001;26(7):809-17. 15. Fineberg SJ, Nandyala SV, Kurd MF, MarquezLara A, Noureldin M, Sankaranarayanan S, Patel AA, Oglesby M, Singh K: Incidence and risk factors for postoperative ileus following anterior, posterior and circumferential lumbar fusion. Spine J 2014; 1680-5. 14 ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org
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