Pathway for Enhanced Recovery After Spinal Surgery

A Systematic Review of Evidence for Use of Individual Components

Ana Licina; Andrew Silvers; Harry Laughlin; Jeremy Russell; Crispin Wan


BMC Anesthesiol. 2021;21(74) 

In This Article


This systematic review has been performed according the methodological standards for complex reviews.[22–29] Our findings have been reported according to the standards for the Preferred Reporting Items for Systematic Reviews and Meta-Analysis[30] (supplementary file 1). Protocol for this review was prospectively registered with the International Register of Systematic Reviews identification number CRD42019135289.[31] The authors identified the essential components of enhanced recovery within the area of spinal surgery. The authors performed this process by reviewing the current enhanced recovery protocols as recommended by the ERAS Society. We identified and applied the relevant components to the field of spinal surgery.[1,10,12–15,32] We have published this work through a peer reviewed protocol dissemination.[11]

Eligibility Criteria

Our patient population included adult and paediatric patients undergoing spinal surgical procedure on any spinal anatomical site. These anatomical sites cervical (anterior or posterior cervical decompression and fusion), thoracic (e.g., thoracic decompression and fusion), lumbar (e.g., lumbar decompression and fusion, lumbar laminectomy, sacral or any one combination of these). The interventions of interest have been classified in 5 perioperative pillars: preadmission period, preoperative period, intraoperative period, postoperative period, and audit and compliance processes (Table 1). These interventions (22 individual pathway components) have been defined through previous published work.[11] We reviewed the evidence with regards to each component studied independently or in any one combination.[33] Comparator interventions consisted of standard of care, no treatment or placebo.

In line with other ERAS reviews, we defined our primary outcomes in the following groups:[12,34]

  • Morbidity, including pulmonary, cardiac, and renal complication rates; surgical complication rates; and

  • readmission rates.

  • Mortality from all causes.

  • Patient-reported experiences and outcomes (PREMs/PROMs), including pain-related outcomes.

  • (pain score rating and/or opioid consumption, pain management satisfaction), readiness for surgery, quality of care patient scores, and quality of recovery outcomes.

  • Health service-related outcomes, including length of stay and reported economic/financial outcomes (e.g., costs of the length of stay).

We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies (e.g., cohort studies, case-control studies, cross-sectional studies, and case series). We included human data studies published in the English language after 1990. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Complex Interventions series lays out PICOTS framework for systematic reviews of complex interventions.[35]

Our full review eligibility criteria are listed in Table 2.

Information Sources and Literature Searches

The following electronic databases (from 1990 onwards) were searched: MEDLINE via Ovid SP; EMBASE via.

Ovid SP; and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). We searched the grey literature through the available search engines: Google Scholar, OpenGrey and GreyNet.[36–38] We initiated the original search for studies in January 2020 and updated it in May 2020. For the search strategy, we combined keyword(s) and subject headings for all literature types in the pre-determined databases.[29] Keywords were related to spine surgery, enhanced recovery, pre-operative care, intra-operative care, post-operative care, analgesia, mobilization, fluids. The specific details are contained within the supplementary files (supplementary file 2). We handled study overlap by tracking the index primary studies. For some selected pre-defined pathway components, there was a paucity of identified studies as pertaining to spinal surgery. Under those circumstances, we sought to identify large studies, meta-analysis or societal recommendations of best practice.

Data Extraction, Management, Analysis and Presentation

Standardized data parameters were extracted from each study. These parameters included: publication details, study characteristics, participant characteristics, type of spinal surgery, intervention and comparator characteristics, and outcomes. The results of the data search were presented in a PRISMA flow diagram indicating the number of studies retrieved, screened and excluded as per exclusion criteria (see Figure 1). We have presented our findings according to each individual predetermined element of the multimodal enhanced recovery pathway (Table 1). One author extracted appropriate information from randomized controlled trials on the methodological quality of studies. This information included random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective outcome reporting, and other bias.[39,40] For non- randomized studies data extraction on random sequence generation and allocation concealment was not applicable. Figure 1

Figure 1.

PRISMA diagram

Risk of Bias and Thematic Synthesis

Risk of bias in randomized controlled studies was assessed using the Cochrane Risk of Bias tool.[40] ROBINS-I (Risk of Bias in Non-randomized Studies of Interventions) tool was used to evaluate the risk of bias in non-randomized studies.[41] We used the revised AMSTAR-2 tool to assess the risk of bias in systematic reviews.[42] We used the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) system to classify the evidence into one of four categories: high, moderate, low, and very low.[43,44] Evidence based on randomized controlled trials was considered as high quality unless confidence in the evidence was decreased due to study limitations, inconsistency of results, indirectness of evidence, imprecision, and reporting biases. Observational studies were considered low quality; however, they were graded higher if the treatment effect observed is very large or if there is evidence of a dose-response relationship.[33,44,45]

Endpoint of the GRADE evidence summary consists of Evidence Profile (EP) tables across individual pathway components.[43] Risk of bias across outcomes for individual pathway components was presented in Evidence Profile Tables (supplementary file 3). We performed a thematic synthesis and narrative analysis for each proposed component.[27] Forest plots were generated for the following components: anaesthetic protocol, use of multimodal analgesia and intravenous lignocaine infusion (supplementary file 5). In line with our planned protocol, quantitative data synthesis was not attempted due to the inherent heterogeneity of the studies. This method of evidence synthesis is in line with other published enhanced recovery reviews.[1,13,15,17,18,46,47] We did not make recommendations on the utility of pathway components, in line with recommended practice for systematic reviews.[48]