Enhanced recovery after surgery is a multimodal, evidence-based perioperative care pathway designed to improve recovery for patients undergoing major surgery. ERAS elements address key factors that have historically extended a patient's hospital stay, such as the need for parenteral analgesia and intravenous fluids, lack of mobility and postoperative complications.
Implementing ERAS protocols can lead to superior outcomes, shorter hospital stays, fewer complications and improved teamwork.
Ibrahim Hussain, MD, neurosurgeon and member of The ERAS Society USA Chapter, spoke with Chicago-based Rush University Medical Center's John O'Toole, MD, about implementing ERAS protocols, the effect they have had on his practice and their future of ERAS in spine care.
Editor's Note: Responses are lightly edited for style and clarity.
Dr. Ibrahim Hussain: How did you get interested in ERAS?
Dr. John O'Toole: Recovery from spine surgery in general has always been pretty tough for patients compared to other potentially equivalent surgeries, such as orthopedic joint replacement, thoracic or abdominal surgery. They seem to have longer or prolonged hospital stays, pain courses and other complications, such as postoperative urinary retention and delirium. It made it difficult to watch these patients struggle in the postoperative period and became clear that this was a problem we needed to fix.
Minimally invasive spine surgery started to take over and my practice, and since the beginning with regards to degenerative spine pathology, has been largely MIS in nature. The promise of MIS has always been improved perioperative outcomes, namely, less blood loss, lower infection rates, shorter length of stay and faster recovery. But I was finding that it wasn't quite fast enough, and length of stay was longer than I thought it should be for some of these patients. ERAS seemed like an opportunity for us to do better and really fulfill the full promise of MIS by working collaboratively with other services in the hospital to improve patient's postoperative experience.
In talking with our anesthesia and pain medicine colleagues here, it became clear that we needed to institute a more programmatic ERAS protocol, and we used MIS as the poster child for this program. As we got into it, we started to realize this really made a huge difference, from preop to the intraop to the post-op setting, and we've continued to modify it along the way. We keep adding new pieces to the puzzle and it continues to evolve to a point now where the hospital is implementing hospitalwide ERAS protocols for every patient undergoing any kind of spine surgery because this has been such a game changer.
IH: You work with a large group of neurosurgeons, orthopedic surgeons, anesthesiologists. What challenges did you face in getting this large group on board with ERAS-related changes?
JOT: It's definitely been an effort. As you know, surgeon preference is often based on little other than anecdotal opinion and bias, so it's taken a long time to get the evidence in front of people to get them to come around. One of the biggest hurdles has been the pharmacologic side of things. Obviously we're trying to reduce opioids as much as possible, but it's also exactly which and what dose of opioids used, whether or not to use intraoperative Decadron, when to use NSAIDs in cases fusion or not fusion. This has generated a lot of vigorous discussion and strong opinions, so we've had to compromise along the way and arrive at something that seemed to work for everybody. Oftentimes, we leave it up to surgeon discretion.
Some of the pushback also initially came from anesthesia — some anesthesiologists didn't want to be told what to do with their intraoperative anesthetic regimen. This is perhaps the cornerstone of a real spinal ERAS program, other than preoperative education for the patients. The "wide open fentanyl drip" in the OR was sort of the historical standard, so it was important to get our anesthesia colleagues on board with a different approach. Part of that may be a generational stance and the anesthesia teams we work with now are fully committed to ERAS protocols. But interdepartmental education, not just in anesthesia, but within neurosurgery and orthopedic surgery has been key.
In the end, this is the ultimate example of collaborative work in a clinical setting. We now have orthopedics, anesthesia, pain medicine, physical therapy, occupational therapy, nursing, radiology and nursing from preop, PACU, floor, outpatient etc. — we have all these stakeholders involved because we know that every step requires buy-in from these services, otherwise the chain falls apart and patients get stuck. We have "champions" in each arena, which if you don't, you're going to be quixotic in your attempts at getting ERAS done efficiently. Patients are excited to hear that they are part of this kind of program to make their postoperative experience better.
IH: What specific changes within your outpatient practice or department have been made to implement ERAS protocols? Do you have dedicated staff focusing on this?
JOT: Unfortunately, we don't have the luxury of being able to hire additional staff specifically for ERAS, so we've used the personnel we have to focus on a few key elements. We asked what are the elements that have been clearly associated with affecting outcomes in spine surgery? Smoking, obesity, nutritional status, bone density and preoperative opioid intake were the ones that emerged as high-yield targets. So we [got] to go for the low hanging fruit in a way. All our patients are screened for smoking status, BMI, opioid intake, DXA and prealbumin lab studies.
Our surgeons and nurses know we have to counsel patients even in the first consultation: We'll say these are the things you need to do or we need to do with you if we're going to have optimal outcomes from surgery. This means sending them to smoking cessation clinics, bariatric surgery clinics, getting them in with nutrition services and referral to our pain service who works closely with us to work on opioid reduction prior to surgery.
The patient education piece is the most important and the hardest to do, particularly in a big urban center like Chicago. You're talking about trying to educate a wide array of people from different backgrounds, education and social situations about what they should do before and after surgery. We're still working on ways to navigate this educational piece, since it's vital for success.
IH: Many ERAS protocols have "hard stops," which limit certain populations eligible for surgery. This, among other aspects of ERAS, clearly has an economic impact on the greater hospital organization. Have you run into issues in this regard?
JOT: That's a real-world issue and you can talk about optimal selection criteria, but at the end of the day, you have to treat the patients that you see. But I would say that in general, certainly for deformity and multilevel fusion cases, the vast majority of us would put a hard stop on nicotine use and a few of us will test cotinine levels a week or so before surgery. We'll inform the patient that continuing nicotine up through surgery is a setup for failure, and we don't want poor outcomes. Fortunately, most of us have seen reasonably good compliance rates, probably because the people that aren't willing to take these additional steps usually won't sign up for surgery. They likely seek care somewhere elsewhere and frankly we are most interested not in the quantity of cases, but the quality of our outcomes, and it bears out in the kind of results we’ve had.
Another example is obesity — most of us have a BMI of 40 cutoff for elective cases with some exceptions such as severe cervical myelopathy or acute foot drop, but otherwise these patients are referred to the bariatric clinic. We emphasize the need for weight management preop because the data is fairly compelling on lower quality long-term and short-term outcomes with obesity.
To some extent there are hard stops, and it is surgeon dependent, but you have to design these protocols and procedures in the context of your environment — nobody is operating in a vacuum. If the local environment is that 60 percent of the population are smokers, the economic analysis isn't about outcomes in spine surgery with smokers, but more of the institution stepping in and implementing smoking cessation clinics. But if only 5 percent of the population are smokers, you know where the value is, so I think understanding your patient population and getting your administration to understand that is important. Institutions aren't just looking at your total [relative value units] for the year alone anymore. They are also looking at quality, reoperations and readmissions. These have become some of the most important metrics for hospital administrators, which ERAS works to address.
IH: A significant portion of your practice is dedicated to spine oncology. Have you had success applying ERAS protocols to this oftentimes difficult to manage population?
JOT: You're right that this is a tough population and it's not straightforward. If you think about the surgeries that ERAS started with, it was elective colorectal surgery, then moved into hips and knees, and spinal oncology is, in some respects, as far afield as you can get from these. These cases are semi-elective at best, so we've used it in select cases and mainly cases where we're doing MIS surgery for spinal tumors, like primary intradural cases. These basically proceed like an MIS [transforaminal lumbar interbody fusion] or laminectomy. For the metastatic disease population, it's limited to cases where we're performing percutaneous screw stabilization, or MIS separation surgery, or even MIS lateral corpectomies. The biggest problem with so many of these oncology patients is that they're coming in on significant doses of preoperative opioids, and even though we try to select patients with good [eastern cooperative oncology group] and [Karnofsky performance scale] scores, they still might have challenges post-op. I think the people who can help us figure that out are at major cancer centers because it's going to take a large volume of patients to start to stratify them. What does keep with the spirit of ERAS with these patients, however, is doing surgery with the right multidisciplinary team to reduce the incidence of complications.
IH: What's the feedback you've gotten from your patients?
JOT: I think the only way a patient can really give you some information on what we're doing right with ERAS is if they've had prior surgery elsewhere. Most patients forget their postoperative experience if their surgery was more than a year or two ago and if they do remember, it's usually due to a subjectively negative experience. Patient satisfaction frequently has little to do with typical validated outcome measures, and that is where managing expectations helps. With ERAS, you deliberately educate patients about what they might or should feel at the various phases of their care. What we don't want is the patient telling you, "I had no idea it was going to feel like this" or "if I had known how this was going to go, I would never have done the surgery."
The part we've added in the last year or two where we've seen patients have a different subjective experience is the addition of regional anesthesia. We perform erector spinae plane blocks for all minimally invasive surgeries and patients clearly note the difference, particularly in the first 24 to 48 hours. They are shocked because they very often are pain free for the first day or so, which if they've had prior surgery, was usually not the case.
IH: What do you see as the future of ERAS in spine surgery?
JOT: I think regional anesthesia as I mentioned is a big component, and we're working on a number of studies to confirm that right now. The other key element is doing a better job at patient selection. We talk all the time about patient selection based on clinical symptoms and radiology — that's what our training is all about and what we discuss at conferences. But patient selection with regard to health optimization is something that's hard and we're not necessarily good at all the time. For instance, setting criteria for properly selecting patients for outpatient surgery that's more than single-level decompression or discectomy type cases, such as fusions, is currently being refined. And mitigating the effects of frailty remains a conundrum that is also requiring a multidisciplinary approach with our colleagues in geriatrics for example.
I also think a lot of the advancements in ERAS are going to have to come from pharma. We're going to need better drug options, longer acting regional anesthetics and medications that treat pain that aren't opioid based. The pharmaceutical industry is a big part of this; the advent of gabapentinoids changed so much of what we do, so we need to find the next class of drugs that will come along to help us more optimally manage patients' postoperative pain. Our surgeries can keep getting smaller, like endoscopic TLIF for example, that's a procedural change that can really help influence the patient's experience. But at some point we're going to reach a limit in being able to do effective fusions and instrumentation through smaller approaches, and then we'll have to rely on these other modalities to help us get there.
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