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.

Preoperative Component

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.

Intraoperative Component

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.

Postoperative Component

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 Ambulation

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.

Patient Positioning

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.

If you are interested in knowing more about Optimizing spine surgery outcomes (ERAS) you have come to the right place!

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Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

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.

Please take a look at my profile page and don't hesitate to come in and talk.