Does an enhanced recovery after surgery protocol change costs and outcomes of single-level lumbar microdiscectomy?

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Enhanced recovery after surgery (ERAS) is a multimodal approach that aims to improve perioperative surgical outcomes. The aim of this study was to evaluate the benefits of ERAS in terms of cost-effectiveness and postoperative outcomes in single-level lumbar microdiscectomy.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>This study was a single-center retrospective comparing costs and outcomes before and after implementation of the ERAS pathway. Data were collected from the electronic medical records of patients who had undergone single-level lumbar microdiscectomy during 2 time periods—during the 2 years preceding implementation of the ERAS pathway (pre-ERAS group) and after implementation of the ERAS pathway (ERAS group). Each group consisted of 60 patients with an American Society of Anesthesiologists (ASA) Physical Status Classification of class 1. Patients were excluded if their physical status was classified as ASA class II–V or if they were younger than 18 years or older than 65.</jats:p><jats:p>Groups were compared in terms of age, sex, body mass index (BMI), perioperative hemodynamics, operation time, intraoperative blood loss, intraoperative fluid administration, intraoperative opioid administration, time to first oral intake, time to first mobilization, postoperative nausea and vomiting (PONV), difference between preoperative and postoperative visual analog scale (VAS) scores, postoperative analgesic requirements, length of hospital stay, and cost of anesthesia.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The ERAS and pre-ERAS groups were comparable with respect to age, sex, and BMI. Operation time, intraoperative blood loss, intraoperative opioid administration, and intraoperative fluid administration were all less in the ERAS group. First oral intake and first mobilization were earlier in the ERAS group. The incidence of PONV was less in the ERAS group. Postoperative analgesic requirements and postoperative VAS scores were significantly less in the ERAS group. The length of hospital stay was found to be shorter in the ERAS group. The ERAS approach was found to be cost-effective.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>ERAS had clinical and economic benefits and is associated with improved outcomes in lumbar microdiscectomy.</jats:p></jats:sec>

What Is the Evidence for Early Mobilisation in Elective Spine Surgery? A Narrative Review

“…A further 63 articles were removed (abstracts (2); no control group or comparison data (8); not available in the English language (4); early mobilisation protocol not described or initiated later than postoperative day one (20); excluded study design (15); ambulatory surgery (4); excluded patient group (9); or neural mobilisation intervention (1). Four studies (five articles) that compared the effects of early mobilisation to no mobilisation [28,38,39,40,41] (Table 2), and nine studies that compared the implementation of a multimodal intervention that was inclusive of an early mobilisation protocol [21,24,42,43,44,45,46,47,48] (Table 3) were included in the results synthesis. The flowchart of the study selection process is presented in Figure 1.…”

“…Nine studies that were retrospective analyses of pre/post intervention data following implementation of a multimodal spinal surgery pathway (named either: Enhanced Recovery after Surgery, enhanced recovery after spine surgery, evidence based clinical care pathway, multidisciplinary committee meeting or perioperative protocol) were also included in a separate analysis and are summarised in Table 3 Procedures included in these studies were: discectomy, decompression, fusion and realignment operations to the cervical, thoracic and lumbar spine [21], tubular microdiscectomy and mini-open decompression as well as minimally invasive anterior or posterior fusion [46], laminoplasty [47], spine surgery for metastatic tumours [43], single-level microdiscectomy [44], lumbar spine fusion [42,45], lumbar and cervical surgery (less than or equal to four levels) [48] and multilevel lumbar or thoracolumbar spinal fusion [24].…”

“…These studies report outcomes as a total, and do not segregate out any effects related to each specific component of the intervention. It is important to note, however, that a multimodal, multidisciplinary approach to the care of a patient, inclusive of a specific early mobilisation initiated no later than day one post-surgery, is reported to improve length of hospital stay [21,42,44,45,46,47,48], healthcare costs [21,44,45], complication rate [24,44,48], pain or pain control [43,44,47] and patient satisfaction [21]. Compliance to early mobility protocol was recorded as 91.22% in one study [47], with those with severe weakness of the lower limbs unable to walk on postoperative day one.…”

“…The intervention delivered by Shields et al [45] required patients to sit on the edge of the bed on the night of surgery, have two sessions of physiotherapy on postoperative day one, and walk in the hall and climb stairs on postoperative day two. Both Staarjtes et al [46] and Tarikci Kilic et al [44] encouraged patients to sit out of the bed for mobilisation within two hours after surgery. Early mobilisation in the study by Li et al [47] involved on-bed movement on the day of surgery as well as sitting and assisted walking on postoperative day one.…”

“…Recovery following spinal surgery continues to be refined through improved multidisciplinary care. The evidence for early mobilisation included within enhanced recovery or multimodal interventions is encouraging; however, it is not possible to segregate the effects on outcomes from these studies [21,24,42,43,44,45,46,47,48]. Consistent with other surgical specialties, the implementation of enhanced recovery protocols in spine surgery are associated with a shorter length of stay and accelerated return to function without an increase to complications.…”