How Much Benefit Can Patients Acquire from Enhanced Recovery After Surgery Protocols with Percutaneous Endoscopic Lumbar Interbody Fusion?

Abstract

Purpose We aimed to explore the role of enhanced recovery after surgery (ERAS) in patients who underwent percutaneous endoscopic lumbar interbody fusion (PELIF). Patients and Methods We performed a retrospective, observational, cohort study on 91 patients who underwent PELIF for degenerative disc disease. The primary outcomes were postoperative opioid consumption, hospital length of stay (LOS), and hospital cost. Results Forty-six patients comprised the ERAS group, and 45 patients comprised the pre-ERAS group (control group). The groups had comparable demographic characteristics. Good compliance with the ERAS pathway was observed in the ERAS group. Patients in the ERAS group used significantly fewer morphine equivalents compared with the pre-ERAS group (25.0 vs 33.3, respectively; p = 0.017). Hospital LOS did not decrease significantly in the ERAS group compared with the pre-ERAS group (3.1days vs 3.4 days, respectively; p = 0.096). Likewise, there was no significant difference in hospital cost between the pre-ERAS group and the ERAS group ($10,598.60 vs $10,384.50, respectively; p = 0.468). Conclusion In the present study, the benefit of ERAS in the context of PELIF was limited. Although a multidisciplinary ERAS protocol can improve analgesia and decrease opioid consumption, no significant reduction in hospital LOS and cost was observed.

Fast-track protocols for patients undergoing spine surgery: a systematic review

“…Most studies evaluated a fast-track protocol (81%) versus a conventional (non-fast track) protocol (19%), reporting a significantly reduced LOS (in 81% of studies), without increasing complication or readmissions rate in patients treated with fast-track, regardless of follow-up (from 1 month to 2 years), pathology and surgical approach used. Four studies instead reported no significant differences in LOS between the fast-track and non-fast-track groups [ 16 , 33 , 51 , 53 ]. Complication rates with fast-track protocols ranged from 1.5 to 26%.…”

“…Subsequently, for maintenance of anesthesia, inhalational agents such as sevoflurane, isoflurane and desflurane, or intravenous opioid agents such as sufentanil or remifentanil infusions were used. In 21% of studies, a local anesthesia with anesthetic agents as bupivacaine, lidocaine or ropivacaine was employed [ 18 , 27 , 28 , 33 , 35 , 45 , 48 , 63 , 65 , 66 , 70 , 71 ]. Regarding analgesia management, pain scores were tracked in 30 studies.…”

“…=readmission, EBL, transfusion, complications, time ICU, required ICU Fletcher et al 2021 [ 31 ] Prospective 276 patients: -Fast-track group ( n = 203, mean age 14.3 ± 2.1, 78.8% females); −Non-fast-track group ( n = 73, mean age 16.09 ± 2.1, 80.2% females) Yes PSF for AIS NR NR NR 2.2 days 2 wound dehiscence, 1 constipation Readmission, revision surgery 3–4 weeks ↓Major curve (54.0° vs. 62.0°), major curve correction (39.0° vs. 45.5°), LOS (2.2 vs. 4.8 days), operative time (2.8 vs. 4.8 h), EBL (240.0 vs. 500.0 ml), EBL/level (24.0 vs. 47.2 ml), EBL (6.4 vs. 13.3%EBV), levels fused (10.1 ± 2.6 vs. 11.4 ± 1.6), implant density (16.0 vs. 23.0), VAS at discharge (2.0 vs. 4.0), osteotomies (46% vs. 94%) in fast-track group vs. non-fast-track group Garg et al 2021 [ 32 ] Retrospective 812 patients: -Fast-track group ( n = 316, mean age 49.1 ± 11.7, 45% females); −Non-fast-track group ( n = 496, mean age 50.3 ± 12.4, 46,8% females) Yes Elective lumbar spinal fusion at 1, 2, or 3 levels with posterior approach (TLIF with open or MIS techniques) for various adult lumbar spinal disorders (lumbar disc herniation, low-grade spondylolisthesis, lumbar canal stenosis, degenerative disc disease, facet joint cyst) 1–3 Secondary osteoporosis, diabetes NR 2.94 days Complications Clavien-Dindo grade (6.6% grade I, 3.2% grade II, 1.9% grade III) 2.2% 60 days readmission, 1.3% 60 days reoperation 4 weeks, 6 and 12 months ↓LOS (2.94 vs. 3.68 days), VAS score at 1 month (44 ± 10.8 vs. 49.8 ± 12.0), ODI score at 1 month (28 ± 12.8 vs. 31.6 ± 14.2) in fast-track group vs. non-fast-track group. =levels fused, EBL, operative time, complications, 60-day readmission, 60-day reoperation Gong et al 2021 [ 33 ] Retrospective 91 patients: -Fast-track group ( n = 46, mean age 55.2 ± 10.8, 30 females); −Non-fast-track group ( n = 45, mean age 56.8 ± 8.9, 26 females) Yes PELIF for adult degenerative disc disease (degenerative spondylolisthesis, lumbar spinal canal stenosis, segmental instability, recurrent lumbar disc herniation, lumbar discogenic pain, isthmic spondylolisthesis) 1 or 2 Hypertension, diabetes mellitus, coronary artery disease, chronic obstructive pulmonary disease, asthma, liver disease NR 3.1 ± 0.7 days 2 0 readmission 30 days ↓Opioid consumption (25.0 vs. 33.3), VAS score at day 1 (2.0 ± 0.6 vs. 2.6 ± 0.7) in fast-track group vs....…”

“…Nutritional consultation (BMI < 18.5 or > 25 kg/m2 or with serum albumin < 3.5 g/dL), pain management (> 30 morphine equivalents of opioids for > 4 weeks), sleep medicine (scoring > 2 on the STOP-BANG questionnaire), endocrinology for clearance (serum glucose > 200 g/dL or HbA1c > 8%) NR Carbohydrate load (Gatorade, day before surgery and 2 h before arriving at hospital) NR NR Multimodal analgesia (gabapentin with opioid and nonopioid analgesics) NR NR Fletcher et al 2020 [ 30 ] Pulmonology, gastroenterology, neurology and other specialists’ consultation NR NR NR NR NR NR NR Fletcher et al 2021 [ 31 ] NR NR NR NR NR NR NR NR Garg et al 2021 [ 32 ] General informations, no smoking and alcohol. Preanesthetic (HbA1c < 7 for diabetic patients) and nutritional (if BMI < 18.5 or > 30, hematinics for anaemia, protein supplementation for poorly nourished patients) consultation; bone mineral density evaluation (calcium and vitamin D supplementation, teriparatide injection, for osteoporotic patients) Rehabilitation Fasting (6 h before for solid food, 2 h before for clear liquids, IV 5% dextrose solution 500-1000 ml, overnight before surgery) NR Preemptive analgesia (75 mg oral pregabalin, 1000 mg acetaminophen, 2 h before surgery), chlorhexidine (4% the night before and morning of surgery), nasal swab (5 days before to detect Staphylococcus aureus , 2% nasal mupirocin, vancomycin) Multimodal total IV anesthesia with < 0.5% MAC, avoidance of IV long-acting opioids, infiltration of subfascial local anesthetic drugs (0.25% bupivacaine before wound closure), antibiotic prophylaxis (cefuroxime injection), 2 to 3 of 3.5% povidone-iodine infused pulsatile lavage for wound TXA bolus (20 mg/kg) and infusion (2 mg/kg/h), warmed IV fluids, invasive blood pressure monitoring, normothermia maintenance (> 36°, convection warmers) 8 mg dexamethasone, 4 mg ondansetron (30 to 45 min before emergence from anesthesia) Gong et al 2021 [ 33 ] General informations. Nutritional (protein, glucose, omega-3 fatty acids, and specific amino acids, glutamine, arginine) consultation NR Fasting (4 h for liquids, 6 h for solid), carbohydrate loading (clear carbohydrate-rich drink 4 h before surgery) Pre-emptive oral analgesics (celecoxib, eperisone, extended-release tramadol, pregabalin, on day of admission) Antimicrobial prophylaxi...…”

Endoscopic Techniques for Lumbar Interbody Fusion: Principles and Context

“…Moreover, endoscopic techniques further reduce the length of stay associated with MIS surgeries [ 7 , 39 , 40 ]. Though a recent retrospective study failed to corroborate this finding, it did suggest that percutaneous endoscopic LIF was associated with improvements in analgesia and decreased opioid usage, another potential benefit [ 41 ]. In a recent review, Wang et al found that endoscopic TLIF saved the healthcare system an average of $3444 when compared to standard MIS TLIF [ 40 ].…”