OBJECTIVEEnhanced Recovery After Surgery (ERAS) programs follow a multimodal, multidisciplinary perioperative care approach that combines evidence-based perioperative strategies to accelerate the functional recovery process and improve surgical outcomes. Despite increasing evidence that supports the use of ERAS programs in gastrointestinal and pelvic surgery, data regarding the development of ERAS programs in spine surgery are scarce. To evaluate the impact of an Enhanced Recovery After Spine Surgery (ERSS) program in a US academic cancer center, the authors introduced such a program and hypothesized that ERSS would have a significant influence on meaningful clinical measures of postoperative recovery, such as pain management, postoperative length of stay (LOS), and complications.METHODSA multimodal, multidisciplinary, continuously evolving team approach was used to develop an ERAS program for all patients undergoing spine surgery for metastatic tumors at The University of Texas MD Anderson Cancer Center from April 2015 through September 2016. This study describes the introduction of that ERSS program and compares 41 patients who participated in ERSS with a retrospective cohort of 56 patients who underwent surgery before implementation of the program. The primary objectives were to assess the effect of an ERSS program on immediate postoperative pain scores and in-hospital opioid consumption. The secondary objectives included assessing the effect of ERSS on postoperative in-hospital LOS, 30-day readmission rates, and 30-day postoperative complications.RESULTSThe ERSS group showed a trend toward better pain scores and decreased opioid consumption compared with the pre-ERSS group. There were no significant differences in LOS, 30-day readmission rate, or 30-day complication rate observed between the two groups.RESULTSAn ERSS program is feasible and potentially effective on perioperative pain control and opioid consumption, and can expedite recovery in oncological spine surgery patients. Larger-scale research on well-defined postoperative recovery outcomes is needed.

Therapeutic study, level II.

SUMMARY Background Traditionally, the use of ketamine for patients with traumatic brain injuries is contraindicated due to the concern of increasing intracranial pressure (ICP). These concerns, however, originated from early studies and case reports that were inadequately controlled and designed. Recently, the concern of using ketamine in these patients has been challenged by a number of published studies demonstrating that the use of ketamine was safe in these patients. Aims The purpose of this article was to review the current literature in regards to using ketamine in patients with traumatic brain injuries in different clinical settings associated with anesthesia, as well as review the potential mechanisms underlying the neuroprotective effects of ketamine. Results Studies examining the use of ketamine for induction, maintenance, and sedation in patients with TBI have had promising results. The use of ketamine in a controlled ventilation setting and in combination with other sedative agents has demonstrated no increase in ICP. Conclusions The role of ketamine as a neuroprotective agent in humans remains inconclusive and adequately powered; randomized controlled trials performed in patients undergoing surgery for traumatic brain injury are necessary.