Optimizing Spine Surgery Outcomes:
Enhanced Recovery After Surgery (ERAS)
ERAS is a comprehensive approach that involves multiple disciplines to enhance patient care by utilizing a combination of evidence-based techniques. ERAS protocols are founded on the principle that by managing pain, optimizing fluid administration, encouraging early ambulation, and providing adequate nutrition to prevent catabolism and immune dysfunction, patient outcomes can be improved.
In the preoperative phase of ERAS protocols, patients are provided with preventive analgesia, optimization of nutrition and fasting, and education to prepare them for the surgery.
ERAS protocols’ intraoperative phase emphasizes the selection of appropriate anesthetic agents for induction and maintenance, and determining the use of total intravenous anesthesia (TIVA) versus inhaled anesthetics. It also involves the use of non-opioid analgesics.
Postoperative phase of ERAS protocols deals with early mobilization and rehabilitation, early nutritional support, wound management, and pain control. Various ERAS protocols have been reported in the literature.
Certain studies have examined the outcomes of patients who underwent minimally invasive lumbar decompression spine surgery and received either traditional opioid-containing anesthesia or opioid-free anesthesia. Patients who received intraoperative anesthesia containing opioids demonstrated significantly higher perioperative opioid use, without a significant difference in pain levels. The ERAS protocol focused on decreasing the levels of opioids.
Other studies have demonstrated the utilization of ERAS protocols for surgeries such as endoscopic decompression, expandable cage deployment, and percutaneous screw placement, which are performed without general anesthesia. These protocols aim to minimize the use of anesthetics, particularly through the use of short-acting sedatives, and are not exclusively focused on avoiding opioids.
The preoperative care regimen involved administering intravenous acetaminophen, and oral gabapentin or pregabalin, cyclobenzaprine, and oxycodone. The administration of a low dose of oxycodone prior to surgery reduces the need for opioids during the postoperative period.
Other protocols suggest using oral acetaminophen, and anti-nausea medication previous to surgery. Enhancing nutritional intake while restricting solid food intake to 12 hours and liquid intake to 8 hours prior to the surgical procedure is recommended.
Additional aspects to consider include educating the patient, optimizing nutrition, providing counseling to quit smoking, pre-habilitation involving walking and exercise, intervening in cases of drug and alcohol abuse, offering sleep medicine for patients with sleep apnea, and developing plans for discharge.
Literature typically favors the utilization of standard propofol for both induction and maintenance of anesthesia along with an inhaled anesthetic. Ketamine is often considered as an adjuvant during induction, as it has demonstrated the ability to decrease postoperative opioid consumption when given during the surgical procedure.
Administering dexamethasone intravenously during the surgery is effective in reducing postoperative pain scores and opioid consumption. Intraoperative administration of methadone, acetaminophen, fentanyl and lidocaine has demonstrated favorable postoperative outcomes and thus, they have been used during surgeries.
Diazepam, cyclobenzaprine, and ketorolac are used if necessary. To reduce complications and facilitate patient movement, it is advisable to refrain from using Foley catheters during surgeries that last less than 2 hours.
As part of the ERAS protocol in the postoperative period, NSAIDs and/or acetaminophen, gabapentin and pregabalin, and possibly tramadol are administered, along with the use of ice packs.
Furthermore, patients are encouraged to consume food orally and commence mobilization with the aid of early physical therapy within 2 hours of being admitted to the post-anesthesia care unit during the recovery period. Acetaminophen and nonsteroidal anti-inflammatory drugs are the first line of treatment for postoperative pain management.
In cases where patients experience significant pain levels, tramadol or oxycodone may be prescribed. Patients who experience nausea or vomiting are treated with metoclopramide and ondansetron. Hospital-based physiotherapy, wound management, and gum chewing to prevent disruptions of the intestine are included in the postoperative period of the ERAS protocol.
Minimally Invasive Spine Surgery (MISS) Technique
Several advantages are associated with utilizing a Minimally Invasive Spine Surgery (MISS):
- Reduced blood loss
- Reducing damage to the muscles (lower levels of creatine kinase in the bloodstream)
- Quicker ability to walk and move around after surgery
- Reduced incidence of infections after surgery
- Decreased utilization of opioids in the postoperative period
- Reduced duration of hospital stay
Blood Loss and Pain Management
Tramadol has been demonstrated to decrease pain levels. Also, administering methadone at the beginning of surgery has shown to have more favorable effects.
Patients who received methadone at the beginning of surgery also exhibited reduced intravenous and oral opioid consumption in the postoperative period, and it can lower the reuptake of serotonin and norepinephrine, which could also contribute to its positive impact on pain levels. One observed effect is that epidural anesthesia has been demonstrated to reduce postoperative pain levels.
To minimize blood loss and avoid thromboembolic events, antifibrinolytic medications are often given intravenously, with the additional option of oral and topical TXA administration. While TXA has proven effective, there is a risk of postoperative seizures associated with dose-related effects.
Additionally, EACA should be administered slowly and with caution as rapid administration may cause hypotension, bradycardia, or other arrhythmias. Patients who are at risk, such as those undergoing vascular anastomosis or free fibula grafting, or those with a hypercoagulable state, should not be administered antifibrinolytic medications.
Early mobilization in the perioperative period has shown to have positive effects on patient coexisting medical conditions (hypertension, diabetes, obesity/high BMI, hypothyroidism, osteoporosis, COPD, and CAD) and length of stay.
Patients who underwent a strict pre-operative physical activity program, received pain management medications and protein drinks the day before surgery, and started early mobilization, have improved outcomes, with patients experiencing shorter hospitalization and having higher satisfaction after the surgery.
Reduced abdominal pressure positioning has been associated with decreased blood loss in patients. Inadequate patient positioning during surgery can result in elevated abdominal pressures, leading to increased pressure in the vena cava and epidural venous system. This can result in more bleeding during the procedure.
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I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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