An enhanced recovery after surgery pathway: association with rapid discharge and minimal complications after anterior cervical spine surgery

• Published in: Neurosurgical focus Vol. 46; no. 4; p. E9
• Main Authors: Soffin, Ellen M, Wetmore, Douglas S, Barber, Lauren A, Vaishnav, Avani S, Beckman, James D, Albert, Todd J, Gang, Catherine H, Qureshi, Sheeraz A
• Format: Journal Article
• Language: English
• Published: United States 01.04.2019
• Subjects: Adult; Aged; Analgesics, Opioid - therapeutic use; Arthroplasty; Cervical Vertebrae - surgery; Cohort Studies; Diskectomy - methods; Enhanced Recovery After Surgery; Female; Humans; Intervertebral Disc Degeneration - surgery; Male; Middle Aged; Pain, Postoperative - etiology; Patient Discharge - statistics & numerical data; Postoperative Complications - epidemiology; Retrospective Studies; Spinal Fusion; Spine - surgery; IQR = interquartile range; cervical disc replacement; CDA = cervical disc arthroplasty; LOS = length of hospital stay; ERAS = enhanced recovery after surgery; PONV = postoperative nausea and vomiting; anterior cervical discectomy and fusion; perioperative factors; MIS = minimally invasive surgery; NRS = numeric rating scale; enhanced recovery after surgery; PACU = postanesthesia care unit; MMA = multimodal analgesia (defined as use of > 1 nonopioid analgesic agent); ACDF = anterior cervical discectomy and fusion; ERAS
• ISSN: 1092-0684; 1092-0684
• DOI: 10.3171/2019.1.FOCUS18643

OBJECTIVEEnhanced recovery after surgery (ERAS) pathways are associated with improved outcomes, lower morbidity and complications, and higher patient satisfaction in multiple surgical subspecialties. Despite these gains, there are few data to guide the application of ERAS concepts to spine surgery. The authors report the development and implementation of the first ERAS pathway for patients undergoing anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA).METHODSThis was a retrospective cohort study of prospectively collected data. The authors created a multidisciplinary pathway based on best available evidence for interventions that positively influence outcomes after anterior cervical spine surgery. Patients were followed prospectively up to postoperative day 90. Patient data were collected via electronic medical record review and included demographics, comorbidities, baseline and perioperative opioid use, postoperative complications, and length of hospital stay (LOS). ERAS process measures and compliance with pathway elements were also tracked.RESULTSThirty-three patients were cared for under the pathway (n = 25 ACDF; n = 8 CDA). The median LOS was 416 minutes (interquartile range [IQR] 210-1643 minutes). Eight patients required an extended stay-longer than 23 hours. Reasons for extended admission included pain (n = 4), dyspnea (n = 1), hypoxia (n = 1), hypertension (n = 1), and dysphagia (n = 1). The median LOS for the 8 patients who required extended monitoring prior to discharge was 1585 minutes (IQR 1423-1713 minutes). Overall pathway compliance with included process measures was 85.6%. The median number of ERAS process elements delivered to each patient was 18. There was no strong association between LOS and number of ERAS process elements provided (Pearson's r = -0.20). Twelve percent of the cohort was opioid tolerant on the day of surgery. There were no significant differences between total intraoperatively or postanesthesia care unit-administered opioid, or LOS, between opioid-tolerant and opioid-naïve patients. There were no complications requiring readmission.CONCLUSIONSAn ERAS pathway for anterior cervical spine surgery facilitates safe, prompt discharge. The ERAS pathway was associated with minimal complications, and no readmissions within 90 days of surgery. Pain and respiratory compromise were both linked with extended LOS in this cohort. Further prospective studies are needed to confirm the potential benefits of ERAS for anterior cervical spine surgery, including longer-term complications, cost, and functional outcomes.