Development of an Enhanced Recovery After Surgery (ERAS) approach for lumbar spinal fusion

Abstract

OBJECTIVE: Over the past decade, Enhancing Recovery After Surgery (ERAS) programs have been implemented throughout the world across multiple surgical disciplines. However, to date no spinal surgery equivalent has been described. In this report the authors review the development and implementation of a "fast track" surgical approach for lumbar fusion. METHODS: The first 42 consecutive cases in which patients were treated with the new surgical procedure were reviewed. A combination of endoscopic decompression, expandable cage deployment, and percutaneous screw placement were performed with liposomal bupivacaine anesthesia to allow the surgery to be performed without general endotracheal anesthesia. RESULTS: In all cases the surgical procedure was performed successfully without conversion to an open operation. The patients' mean age (± SD) was 66.1 ± 11.7 years, the male/female ratio was 20:22, and a total of 47 levels were treated. The mean operative time was 94.6 ± 22.4 minutes, the mean intraoperative blood loss was 66 ± 30 ml, and the mean hospital length of stay was 1.29 ± 0.9 nights. Early follow-up showed a significant improvement in the mean Oswestry Disability Index score (from 40 ± 13 to 17 ± 11, p = 0.0001). Return to the operating room was required in 2 cases due to infection and in 1 case due to cage displacement. An iterative quality improvement program demonstrated areas of improvement, including steps to minimize infection, improve postoperative analgesia, and reduce cage osteolysis. CONCLUSIONS: ERAS programs for improving spinal fusion surgery are possible and necessary. This report demonstrates a first foray to apply these principles through 1) a patient-focused approach, 2) reducing the stress of the operation, and 3) an iterative improvement process.