OBJECTIVEEnhanced Recovery After Surgery (ERAS) protocols have rapidly gained popularity in multiple surgical specialties and are recognized for their potential to improve patient outcomes and decrease hospitalization costs. However, they have only recently been applied to spinal surgery. The goal in the present work was to describe the development, implementation, and impact of an Enhanced Recovery After Spine Surgery (ERASS) protocol for patients undergoing elective spine procedures at an academic community hospital.METHODSA multidisciplinary team, drawing on prior publications and spine surgery best practices, collaborated to develop an ERASS protocol. Patients undergoing elective cervical or lumbar procedures were prospectively enrolled at a single tertiary care center; interventions were standardized across the cohort for pre-, intra-, and postoperative care using standardized order sets in the electronic medical record. Protocol efficacy was evaluated by comparing enrolled patients to a historic cohort of age- and procedure-matched controls. The primary study outcomes were quantity of opiate use in morphine milligram equivalents (MMEs) on postoperative day (POD) 1 and length of stay. Secondary outcomes included frequency and duration of indwelling urinary catheter use, discharge disposition, 30-day readmission and reoperation rates, and complication rates. Multivariable linear regression was used to determine whether ERASS protocol use was independently predictive of opiate use on POD 1.RESULTSIn total, 97 patients were included in the study cohort and were compared with a historic cohort of 146 patients. The patients in the ERASS group had lower POD 1 opiate use than the control group (26 ± 33 vs 42 ± 40 MMEs, p < 0.001), driven largely by differences in opiate-naive patients (16 ± 21 vs 38 ± 36 MMEs, p < 0.001). Additionally, patients in the ERASS group had shorter hospitalizations than patients in the control group (51 ± 30 vs 62 ± 49 hours, p = 0.047). On multivariable regression, implementation of the ERASS protocol was independently predictive of lower POD 1 opiate consumption (β = −7.32, p < 0.001). There were no significant differences in any of the secondary outcomes.CONCLUSIONSThe authors found that the development and implementation of a comprehensive ERASS protocol led to a modest reduction in postoperative opiate consumption and hospital length of stay in patients undergoing elective cervical or lumbar procedures. As suggested by these results and those of other groups, the implementation of ERASS protocols may reduce care costs and improve patient outcomes after spine surgery.

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We report a patient who underwent a routine dental procedure and developed subcutaneous emphysema (SCE) and pneumomediastinum (PM). Clinical management included oxygen therapy, pain control, rest and supportive therapy as needed. Our patient clinically improved with this treatment, and was discharged home two days later. It is important to be aware that even minimally invasive dental procedures can lead to SCE and PM.

Here we present the case of a 64 year old female with a history of neck radiation and Reinke's edema that experienced unexpected respiratory failure after a sedation anesthetic. After the case terminated, the patient was noted to be hypoventilating and stridorous. Mask ventilation, laryngeal mask airway ventilation, and direct laryngoscopy failed. The patient was intubated with video laryngoscopy. Reinke's edema, a benign lesion characterized by swelling of the vocal folds, was thought to contribute to the difficulty in ventilating and intubating this patient. We present a discussion of Reinke's edema and its potential relevance to the practice of anesthesia.