Reduction of Postoperative Opioid Use After Elective Spine and Peripheral Nerve Surgery Using an Enhanced Recovery After Surgery Program

Abstract

Objective Enhanced recovery after surgery (ERAS) pathways have previously been shown to be feasible and safe in elective spinal procedures. As publications on ERAS pathways have recently emerged in elective neurosurgery, long-term outcomes are limited. We report on our 18-month experience with an ERAS pathway in elective spinal surgery. Methods A historical cohort of 149 consecutive patients was identified as the control group, and 1,141 patients were prospectively enrolled in an ERAS protocol. The primary outcome was the need for opioid use one month postoperation. Secondary outcomes were opioid and nonopioid consumption on postoperative day (POD) 1, opioid use at three and six months postoperation, inpatient pain scores, patient satisfaction scores, postoperative Foley catheter use, mobilization/ambulation on POD0–1, length of stay, complications, and intensive care unit admissions. Results There was significant reduction in use of opioids at one, three, and six months postoperation (38.6% vs 70.5%, P < 0.001, 36.5% vs 70.9%, P < 0.001, and 23.6% vs 51.9%, P = 0.008) respectively. Both groups had similar surgical procedures and demographics. PCA use was nearly eliminated in the ERAS group (1.4% vs 61.6%, P < 0.001). ERAS patients mobilized faster on POD0 compared with control (63.5% vs 20.7%, P < 0.001). Fewer patients in the ERAS group required postoperative catheterization (40.7% vs 32.7%, P < 0.001). The ERAS group also had decreased length of stay (3.4 vs 3.9 days, P = 0.020). Conclusions ERAS protocols for all elective spine and peripheral nerve procedures are both possible and effective. This standardized approach to patient care decreases opioid usage, eliminates the use of PCAs, mobilizes patients faster, and reduces length of stay.

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

“…These data are consistent with previous studies, indicating that implementation of ERAS could successfully reduce opioid use in the postoperative period without negatively increasing pain scores. 12 , 34 , 35 Our results also suggest that ERAS protocols in spinal surgery are safe. A non-significant decrease in complications was observed in the ERAS group compared with the pre-ERAS group (2 vs 3, respectively; p = 0.627).…”

“…Postoperative opioid consumption was significantly reduced in the ERAS group, as was hospital LOS. 12 In 2020, Yang et al studied the clinical outcomes of ERAS protocols for minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). The results suggest that ERAS protocols decrease hospital LOS and provide relief from back pain.…”

Enhanced Recovery After Surgery Protocol in Minimally Invasive Lumbar Fusion Surgery Reduces Length of Hospital Stay and Inpatient Narcotic Use

“…For one, ERAS has been shown to be more cost effective than traditional care approaches. 3 , 13 , 19 , 20 It has also been found to significantly reduce LOS 3 , 8 , 9 , 10 , 13 , 14 , 19 , 21 , 22 , 23 , 24 , 25 , 26 length of intensive care unit stay, 3 , 19 postoperative pain scores, 9 , 20 , 21 amount of opioids used postoperatively in the hospital, 9 , 12 , 21 , 22 , 23 , 27 , 28 and postoperative catheterization. 22 , 26 , 27 Evidence also suggests that ERAS in spine surgery may reduce the amount of rescue antiemetic medications used, 29 readmission rate, 25 , 30 and reoperation rate.…”

Postoperative Pain Management in Enhanced Recovery Pathways

“… 32 Accordingly, several studies suggest opioid-sparing strategies may be associated with lower rates of opioid-related adverse effects, including nausea, vomiting, sedation, urinary retention, and constipation. 24 , 30–36 Reduced consumption of opioids does not appear to negatively impact patient-reported pain or satisfaction levels and, in some studies, is associated with improved patient-reported pain scores. 25–31 , 34–38 The effect of opioid-sparing strategies during the acute postoperative period on chronic opioid use remains unclear, with some studies demonstrating a reduction of longer term opioid use while others showing no difference.…”

“… 25–31 , 34–38 The effect of opioid-sparing strategies during the acute postoperative period on chronic opioid use remains unclear, with some studies demonstrating a reduction of longer term opioid use while others showing no difference. 30 , 38–43 Although opioid-sparing postoperative analgesic interventions have clear advantages with respect to reduced adverse effects and some studies even suggest that opioid medications may provide superior analgesia for acute pain compared to non-opioid therapies, the feasibility of opioid-free postoperative analgesia remains controversial and additional research in this area is needed. 44–46 …”