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


Our search strategy retrieved a total of 5423 studies excluding duplicates using 22 different searches for the each relevant ERSS item as outlined in Table 1. During the review of full text articles, we excluded studies which did not pertain to the topic studied (surgery of the spine), which did not describe the intervention in sufficient detail or published articles which were not methodologically suited (case reports, opinions, comments, narrative reviews). Where studies were not available pertaining to pre-defined pathway component of spinal surgery, databases and grey literature were reviewed as relating to societal recommendations and major pertinent studies for perioperative patient management. This methodology yielded 148 further studies for inclusion. We included 664 studies in the final review. The results of our search have been presented in Figure 1, PRISMA Diagram. We have grouped the evidence base according to the component of the pathway.

Evidence Profile tables were generated when a number of studies were identified investigating an intervention for one of the predetermined outcomes. We have generated Evidence Profile tables for the following pathway components: 2.4 Tobacco use, 3. Prehabilitation, 4.1 Preoperative nutritional screening, 5. Management of anemia, 6. Peri-operative blood conservation strategies, 12. Standard anaesthetic protocol, 16. Perioperative analgesia including use of intravenous lignocaine and 21. Mobilization.

For the following elements we identified published meta-analysis: 6. Peri-operative blood conservation strategies, use of tranexamic acid, 8. Pre-emptive analgesia, 10.2 Antimicrobial prophylaxis, 11. Local anaesthetic infiltration, 13. Surgical access (open and minimally invasive spinal surgery), 16. Perioperative analgesia including use of NSAIDS, ketamine, gabapentinoids and intrathecal morphine and 17. Thromboprophylaxis. We incorporated the relevant meta-analysis findings into each pathway.

We were able to identify heterogenous studies pertaining to surgery of the spine for the following components: 10.1 Surgical site preparation, 14. Maintenance of normothermia, 15. Intra-operative fluid and electrolyte therapy, 18. Urinary drainage, 19. Post-operative nutrition and fluid management and 20. Post-operative glycemic control. For these components, we were unable to construct evidence profile tables. As such, we performed a thematic synthesis of evidence.

Due to the paucity of evidence pertaining to spinal surgery, we identified societal recommendations for the following components: 1. Preadmission information, Risk assessment (2.1 Preoperative risk stratification, 2.2 Preoperative optimization and 2.3 Alcohol use), 4.2 Peri-operative immuno-nutrition, 7. Pre-operative fasting and carbohydrate loading, 9. Prevention of post-operative nausea and vomiting and 22. Audit.


We have presented our findings according to each individual element of the multimodal enhanced recovery pathway in line with other subspecialty ERAS pathways.[13,14,49] Please see Table 3 and supplementary file 4.