Abstract
As the population ages and the incidence of spine surgeries increases, better solutions are needed for the challenges of adequate pain control and lengthy hospital stays, which often result from difficulty with controlling pain, managing complications, or coordinating post-hospitalization care services. Thus, there is an inherent need for ways to improve pain and time to discharge. Minimally invasive techniques aim to minimize tissue disruption and can decrease pain and accelerate recovery. However, these techniques are not indicated for all spine patients, and not all spine surgeons are adequately trained in such techniques, thus limiting generalizability. In contrast, Enhanced Recovery After Surgery (ERAS) has recently been adopted within spine surgery as an alternative management strategy to optimize patient outcomes. Enhanced recovery principles mitigate the surgical stress response through a series of evidence-based, perioperative interventions that have demonstrated success with reducing postoperative pain and complications, increasing ambulation, and shortening length of stay. While still in its infancy within spine surgery, there is ample evidence for the successful implementation of ERAS programs for numerous spine procedures. However, further randomized trials will likely be needed to support the continued application of ERAS within spine surgery.
- enhanced recovery after surgery (ERAS)
- pain management
- postoperative pain
- patient outcomes
- spine surgery
Introduction
With an increasing number of spine procedures performed over the past several decades, there has been a consequent focus on reducing health care-associated costs. As a result, spine surgeons face growing pressure to reduce costs, either through more judicious use of spinal implants or earlier discharges. The latter can be especially challenging for surgeons to manage as lengthy hospital stays are often due to difficulty with controlling pain, managing complications, or coordinating posthospitalization care services. Thus, there is an inherent need for improvements in managing postoperative pain and time to discharge.
Minimally invasive (MIS) techniques have been developed over the past 2 decades to minimize tissue disruption with the goal of decreasing pain and accelerating recovery. More recently, the rise of outpatient spinal endoscopy has offered an even less invasive option for select patients. However, these techniques are not applicable to all spine patients, and not all spine surgeons are adequately trained in such techniques, thus limiting generalizability.
With the success of Enhanced Recovery After Surgery (ERAS) programs in other surgical subspecialties, ERAS has more recently been adopted within spine surgery as an alternative management strategy to optimize patient outcomes. Enhanced recovery principles influence the surgical stress response through a series of evidence-based, perioperative interventions that aim to reduce pain, shorten hospital stays, and reduce costs.
The present article briefly discusses the MIS techniques commonly employed and how they can be incorporated into ERAS pathways. The key principles and applications of enhanced recovery to spine surgery will be reviewed, with special attention to multimodal analgesia and the use of adjuncts, such as liposomal bupivacaine for postoperative pain control, as a means of facilitating earlier discharge and improved patient outcomes.
Literature Review
One of the most important contributing factors to increased length of stay (LOS) for patients undergoing spine surgery, especially fusion procedures, is postoperative pain. Spine surgery also has a public perception as being one of the most painful surgical procedures. However, there are a multitude of factors that can help decrease postoperative pain, facilitate early discharge, and enhance postoperative outcomes for patients undergoing spine surgery.
Emergence of MIS Techniques
New technologies and techniques have enabled surgeons to improve outcomes through various MIS approaches. There is ample evidence that demonstrates MIS techniques are associated with reduced LOS, complications, costs, and narcotics use as well as faster return to work, indicating significant improvements in overall outcomes.1–4 Furthermore, ultra-MIS approaches such as spinal endoscopy have become increasingly employed to even further decrease tissue disruption. Often, endoscopic surgeries can be performed on an outpatient basis, greatly reducing LOS and acute care costs.5,6
However, the steep learning curve associated with MIS techniques, especially endoscopy, may limit its generalizability to all patients, many of whom may not be candidates for a less invasive approach. Thus, the combination of MIS surgery, when appropriately indicated, with a comprehensive perioperative pathway such as an ERAS program, can maximize postoperative outcomes and facilitate earlier discharge.
ERAS Principles
In the 1990s, a “fast track” surgery program was developed by Henrik Kehlet, a Danish general surgeon. His novel protocol sought to mitigate the surgical stress response and thus improve patient outcomes.7 Common physiological stressors, including pain, general anesthesia, and immobility, propagated an inflammatory cascade leading to metabolic and homeostatic imbalance. Therefore, through a perioperative series of targeted, evidence-based interventions aimed at mitigating this adverse inflammatory response, he reported significant reductions in postoperative complications, improvements in early ambulation, and ultimately shorter length of stay.7 An initial series of patients within this enhanced recovery pathway demonstrated an LOS of just 2 days compared with the average of 5 days for open sigmoidectomy.8 Given the early successes, ERAS protocols were further refined, and subsequent iterations led to expansion across surgical subspecialties, including spine surgery most recently.
The past decade has seen the rapid application of enhanced recovery principles to spine surgery. Given the significant pain and often negative public perception associated with spine surgery, a pathway to minimize pain and facilitate earlier discharge garnered significant interest among surgeons. While multimodal analgesia remains a cornerstone of enhanced recovery, there are several additional perioperative interventions that are critical to successfully optimizing patient outcomes, as outlined in the consensus guidelines for lumbar fusion.9
Preoperative patient education and expectation management are the first steps toward a successful outcome. Outlining the patient’s perioperative journey helps alleviate the psychosocial factors that are often a barrier to recovery for spine patients. Preoperative counseling can optimize common comorbid conditions such as anxiety and depression.10 Educational materials regarding the goals of ERAS and the recovery process are also useful adjuncts to outline patient expectations following surgery. Not only is preoperative psychological optimization important, but prehabilitation programs to physically prepare patients to undergo spine surgery and the subsequent recovery have also demonstrated improved outcomes for patients. Muscle strengthening and mobility exercise regimens often aid in early ambulation postoperatively, which in turn leads to shorter LOS and faster recovery.11
Furthermore, in combination with the use of MIS surgical techniques when appropriately indicated, there are several targeted intraoperative interventions that support early discharge within spine ERAS programs. Goal-directed fluid therapy, antiemetics, and bleeding prophylaxis strategies require careful collaboration with the anesthesia team to limit unwanted complications such as postoperative fluid overload, severe nausea or emesis, and anemia requiring blood transfusion, which limit early mobilization.12,13
Perhaps most importantly, however, is the use of multimodal analgesia techniques both intraoperatively and postoperatively. High-dose intraoperative opioids result in acute tolerance and propagate an increased need for opioids postoperatively.14 Therefore, a multimodal approach to anesthesia and postoperative pain control has demonstrated significant reductions in narcotic requirements during and after surgery, leading to decreased incidence of opioid-induced complications, including urinary retention, constipation, and immobility.15,16 Although there are a variety of well-studied medication regimens in the literature, many programs incorporate preoperative gabapentinoids, NSAIDs, or acetaminophen as part of the premedication regimen.17,18 Immediate postoperative infusion of IV acetaminophen has also demonstrated efficacy within ERAS pathways.19
Additionally, long-acting local anesthetic agents have demonstrated significant benefit as adjuncts in a multimodal analgesia regimen. Liposomal bupivacaine, or Exparel (Pacira Biosciences, Brisbane, CA), is a long-acting injectable solution of bupivacaine hydrochloride that is formulated to remain locally in the tissues.20,21 The liposomal formulation allows for prolonged local release of bupivacaine, extending the analgesic effect up to 72 hours.22 Therefore, injection of liposomal bupivacaine provides long-lasting local analgesia when injected along percutaneous pedicle screw tracts or circumferentially around the incision.19,20 Given the extended duration of effect for liposomal bupivacaine, it is particularly beneficial for outpatient spine procedures where patients can be discharged home safely and with adequate acute pain relief. Compared to the injection of non-liposomal bupivacaine, patients who received liposomal bupivacaine required less opioids during hospitalization and up to 180 days postoperatively.23 Furthermore, patients who received liposomal bupivacaine experienced fewer visits to the emergency room, demonstrating a potential benefit for reducing health care costs.23
However, results with liposomal bupivacaine are heterogeneous. A recent systematic review found that while many retrospective series demonstrate the efficacy of liposomal bupivacaine with respect to reducing narcotic use and LOS, there remains a paucity of higher-level evidence and randomized controlled trials supporting its use.21 One prospective randomized trial found no significant benefit in reducing pain, narcotics consumption, or LOS in patients who received intraoperative liposomal bupivacaine compared with saline control.24 There are, however, promising results from randomized controlled trials in a wide range of other surgical procedures that demonstrate modest improvements in pain and immediate postoperative opioid use following liposomal bupivacaine infiltration.25–27 Thus, more randomized and prospective studies will be needed to further elucidate the benefit of liposomal bupivacaine injections for patients undergoing spine surgery. Furthermore, because ERAS pathways integrate multiple perioperative strategies, it is difficult to disentangle the specific impact of liposomal bupivacaine from the cumulative effect of the protocol.
While liposomal bupivacaine is often used intraoperatively, it has also shown benefit in the immediate preoperative setting when used in transverse abdominis plane or thoracolumbar interfascial plane blocks.16,28 A thoracolumbar interfascial plane block can be performed safely and efficiently in the operating room following intubation but prior to skin incision with ultrasound guidance29 ( Figure 1 ). The addition of an erector spinae block with liposomal bupivacaine demonstrates further reductions in postoperative pain, narcotics use, time to ambulation, and LOS, even in patients already receiving traditional local subfascial anesthetic injections.30
Thoracolumbar interfascial plane (TLIP) block in the immediate preoperative period prior to lumbar fusion.
Lastly, early mobilization strategies for patients, even on postoperative day 0, are associated with shorter LOS and reduced complications.31 Collaboration with physical and occupational therapy teams, as well as social workers, is important for identifying barriers to discharge early in the postoperative course. Figure 2 summarizes how these key perioperative ERAS interventions optimize outcomes within spine surgery.
Flow diagram highlighting the key perioperative interventions that aim to enhance patient outcomes in Enhanced Recovery After Surgery pathways.
Discussion
The combination of each of these enhanced recovery interventions, among others as outlined in the ERAS Society consensus guidelines, aims to reduce postoperative pain and narcotics consumption, resulting in shorter LOS and decreased hospitalization costs for patients undergoing spine surgery.9 Thus, even prior to the publication of the guidelines for lumbar fusion, early ERAS protocols were developed, which further supported applications of enhanced recovery within spine surgery.32
Our early series of patients who underwent awake endoscopic TLIF demonstrated significant reductions in LOS and patient-reported outcome measures.33 This initial protocol focused on an ultra-MIS surgical technique, paired with awake anesthesia to obviate the need for general anesthesia and injection of liposomal bupivacaine along the percutaneous pedicle screw tracts. A number of iterative improvements to the protocol, such as injection of liposomal bupivacaine prior to screw placement and preemptive proton pump inhibitors, helped further refine outcomes.
Our lumbar fusion ERAS program was then expanded to include all elective 1 to 3 level lumbar fusions and incorporated preoperative education components, multimodal analgesia with liposomal bupivacaine and IV acetaminophen, and early discharge planning coordinated through the daily rounding of a dedicated ERAS care team.19 Outcomes from the initial ERAS cohort were compared with a similar group of lumbar fusion patients from the preceding 6 months prior to ERAS protocol implementation. The small series of enhanced recovery interventions led to a significant reduction in postoperative narcotic use on each postoperative day as well as overall consumption, which was supported by decreased self-reported daily pain scores during hospitalization. Furthermore, the ERAS cohort ambulated farther and on earlier postoperative days compared with the pre-ERAS group, likely a result of improved pain control and preoperative expectation management. Ultimately, ERAS patients demonstrated a significant reduction in LOS and postoperative complications, highlighting the utility of enhanced recovery programs for facilitating early discharge at our institution.
ERAS pathways, while initially implemented for lumbar fusion, have expanded indications from cervical to lumbar and degenerative to oncologic, and beyond single-center series to multi-institutional trials. While many of these programs incorporate similar interventions such as preoperative education, multimodal analgesia, and early ambulation regimens, some centers have developed novel interventions to improve early discharge outcomes. Scheduling ERAS patients as first or second cases of the day and inclusion of relatives into the discharge planning process for early transport following outpatient lumbar discectomy led to shorter LOS.34,35 One study demonstrated feasibility of an ERAS program for outpatient anterior cervical fusion or arthroplasty, with an average LOS of less than 7 hours.36 Other groups have focused on technology-based interventions as novel additions to ERAS pathways. Mobile applications to guide and monitor patients throughout their perioperative course may allow for preoperative risk stratification, provide patient instructions before and after surgery, and monitor real-time data such as activity levels and pain.37–39 More recent multicenter studies examining global ERAS protocols across various spine procedures also demonstrate a significant benefit for improving patient outcomes.40,41
Several meta-analyses support the implementation of ERAS pathways within spine surgery.42,43 In a large series of nearly 16,000 patients split between ERAS and non-ERAS cohorts, significant reductions in LOS, opioid use, time to first ambulation, and postoperative pain scores were shown.43 Additionally, average costs per patient associated with ERAS spine surgeries were lower compared with non-ERAS procedures. Even in more complex spinal oncology patients, which often require more extensive surgery and multidisciplinary care, significant reductions in LOS and costs were seen, without a subsequent increase in complication or readmission rates.44
Implementation of ERAS within spine surgery remains in its infancy but has already shown great promise with respect to enhancing outcomes and facilitating early discharge. Future randomized clinical trials comparing ERAS protocols to traditional management strategies will likely be needed to support continued expansion. Finally, continued iterations of existing protocols are necessary to further optimize the evidence-based interventions and refine ERAS programs.
Conclusion
In practical terms, pain control is the hinge on which early discharge turns. Discharge readiness is best defined by functional pain milestones—adequate control on oral medication, ability to ambulate, and confidence in self-management at home. Spine surgeons have traditionally sought to reduce postoperative pain through the development of MIS surgical techniques, including the recent growth of spinal endoscopy. However, not all patients may be optimal candidates for such procedures, nor are all surgeons trained in the respective techniques. Additionally, the surgery itself is just 1 component of a patient’s recovery, with myriad other factors influencing their hospital course and overall outcome. Therefore, a more generalizable approach for all patients undergoing spine surgery is likely to offer the greatest potential benefit such as ERAS. An ERAS pain pathway typically includes preoperative education and prehabilitation, intraoperative multimodal analgesia with adjuncts such as regional blocks or long-acting local anesthetics, and postoperative strategies emphasizing scheduled nonopioid medications with early mobilization. ERAS protocols have been implemented for a variety of spine procedures and have demonstrated improved patient outcomes, especially regarding reducing pain and hospital stay. Future randomized trials will likely further support the efficacy of ERAS programs within spine surgery.
Footnotes
Funding This special issue article is sponsored in part by Pacira Biosciences Inc, Brisbane, CA.
Declaration of Conflicting Interests G.D.B. has no conflicts of interest to disclose. M.Y.W. serves as a consultant to Depuy-Synthes Spine, Aesculap Spine, JoiMax, and K2M; receives royalties from Children’s Hospital of Los Angeles, Depuy-Synthes Spine, Springer Publishing, and Quality Medical Publishing; holds stock in Innovative Surgical Devices and Spinicity; and receives grants from the Department of Defense.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2025 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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