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

Disclosures

BMC Anesthesiol. 2021;21(74) 

In This Article

Discussion

Preadmission Period

The preadmission period is an opportunity for patient education, assessment of comorbidities, risk stratification and optimization of modifiable patient-related factors.

1. Preadmission Information, Education and Counseling. Patient information provision has long been considered a key element of enhanced recovery pathways.[50,51] Patient perioperative experience and the psychological aspect may be improved with pre-admission counselling.[52–55] Psychopathology and patient expectations have been linked to poor results in spinal surgery with increased pain and decreased function. This has led to an increased reliance on pre-surgical psychological screening (PPS) as part of the surgical diagnostic process in spinal surgery.[55–58]

Studies do not show any evidence of harm from preoperative information provision or psychological intervention. There may be utility from information provision, balanced against no known harmful effects. There is limited evidence available pertaining to the intervention specifically in patients undergoing surgery of the spine.

2. Risk Assessment, Preoperative Assessment, Optimization and Lifestyle Factor Modification. 2.1. Pre-operative Risk Stratification: Perioperative period offers an opportunity for risk stratification.[59] Nearly 80 % of patient deaths come from the high-risk patient group.[60] In a major retrospective study in the USA, it was found occurrence of a major complication within 30 days of surgery was associated with reduced median survival by 69% at 8 years.[61] Multiple diverse risk scoring systems are currently in use for major surgery, including spinal surgery. Assessing cardiovascular risk can be undertaken whilst utilizing ACC/AHA guidelines on perioperative cardiovascular evaluation and care for non-cardiac surgery.[62] Lee's cardiac risk index, Revised Cardiac Risk Index (RCRI), POSSUM (Physiological and Operative Severity Scoring for the enumeration of Mortality and morbidity), the Portsmouth POSSUM (P-POSSUM) and Duke Activity Status Index (DASI) scores have been validated for patients undergoing major non-cardiac surgery.[63–66]

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) has been deemed to have high internal validity although external validation has been inconsistent.[67,68] A retrospective cohort study of the NSQIP database consisting of patients who had undergone elective posterior lumbar fusion was undertaken. The variables associated with greater risk and extended length of stay included increasing age, morbid obesity, operative time, multilevel procedure and intraoperative transfusion.[69] In a retrospective review of NSQIP database, patients undergoing elective spinal surgery had the expected risk factors for cardiovascular complications consistent with those demonstrated by the Revised Cardiac Risk Index.[70] Individual preoperative risk assessment tools tests can be used to identify patients at risk of complications and perform a risk-based stratification. There is moderate quality evidence in support individualized risk stratification utilizing the most suitable risk-stratification assessment tool.

2.2 Preoperative Assessment and Optimization: Patient preoperative assessment allows for an opportunity for examination of comorbidities with subsequent identification of fixed and optimization of modifiable conditions.[15–75] Obese patients having spinal surgery were found to have increased blood loss, prolonged hospital stay and were more likely to develop infection.[76,77] Patients with diabetes were found to have greater disability and more likely to have failed spinal fusion as compared to patients without diabetes.[78–80] Frailty is an emerging risk assessment tool, requiring further studies.[81] The degree to which preoperative optimization and modification of multimorbidity, affects healthcare outcomes is unclear.[59,81] Modifiable co-morbidities should be optimized using the preoperative process. Evidence base is of low quality due to a limited number of heterogenous studies.

2.3. Alcohol use: Postoperative morbidity is increased by two- to threefold in alcohol abusers.[82] Preoperative alcohol consumption is associated with an increased risk of postoperative morbidity, general infections, wound complications, pulmonary complications, prolonged stay at the hospital, and admission to intensive care unit.[83] In a subset of patients without clinical or historical evidence of alcohol-related illness, 1 month of preoperative abstinence has been shown to significantly improve outcome.[83–85]

Significant alcohol consumption has been shown to be associated with increased perioperative morbidity. For alcohol abusers, 1 month of abstinence before surgery is beneficial. Evidence is considered to be of moderate quality due to heterogenous endpoints in available studies.

2.4. Tobacco use: Smoking is an independent risk factor for non-union in spinal fusion procedures.[86–89] Post-operative infection and wound complications are significantly increased by tobacco consumption.[88] Decreased risk of infection, perioperative respiratory problems, and wound complications have been demonstrated 1 month after cessation of smoking.[90] Longer periods of cessation of smoking appear to be more effective in reducing the incidence/risk of postoperative complications.[91,92] There is translational high quality evidence for cessation of smoking at least 4 weeks pre-operatively.

3. Prehabilitation. Prehabilitation can be defined as "the process of enhancing the functional capability of an individual in preparation for the surgical intervention". This process consists of: functional preoperative prehabilitation, nutritional and psychological intervention.[93] Pre-operative functional capacity is closely related to post-operative morbidity.[66] Whether improving the post-operative outcomes through prehabilitation has beneficial effects on mortality is not yet clear.[94] Multimodal prehabilitation in spinal surgery has been associated with improved recovery milestones, earlier discharge and appreciable improvement in patient satisfaction scores in the study group.[95,96] Health-economic benefits have been greater in patients having prehabilitation.[96,97] Patient reported outcomes such as readiness for surgery and perceived quality of life, were found to be improved by pre-operative neuroscience education and physiotherapy.[98–100] Overall evidence quality for prehabilitation is moderate.

4. Preoperative Nutritional Care. 4.1 Nutritional Assessment and Screening: Preoperative malnutrition as defined by hypoalbuminaemia, has been shown to be an independent risk factor for increased postoperative complication rates, including cardiorespiratory problems, and unplanned readmission within 30 days post discharge after elective spinal surgery.[101–104] Well-known risk factors for nutritional depletion in spinal surgery include: diagnosis of cerebral palsy, circumferential spinal surgery, fusion levels greater than or equal to 10, and age over 50.[88–105]

There is moderate quality evidence available for performance of risk assessment and screening of nutritional status in patients undergoing spinal surgery.

4.2 Perioperative Immuno-nutrition: Overall systematic evidence on immuno-nutrition (IN) in surgery has been contradictory.[106,107] Clinical studies demonstrating benefit of IN are heterogenous with non-standardized primary solutions, controls or timing of administration of supplements.[108] There is no evidence for use of IN in patients undergoing surgery of the spine.

5. Management of Anaemia. Preoperative anemia is an independent risk factor for increased 30-day mortality and morbidity in surgical patients.[109–112] In patients undergoing surgery of the spine, preoperative anaemia was associated with increased length of stay.[113,114] Intraoperative blood transfusion in spinal surgery has been associated with increased postoperative complications, length of hospital stay and 30-day re-admission rates.[115] It is however unclear whether correcting iron deficiency anaemia improves reported outcomes, other than decreasing the risks associated with perioperative blood transfusion.[116,117] It is unknown whether correcting non-anaemic iron deficiency (NAID) decreases the risk of perioperative complications.[118] The association of iron replacement therapy, in particular intravenous format, with infection, is currently contentious.[119,120]

Clinically guided appropriate pre-operative use of intravenous or oral iron, vitamin B12, folic acid or erythropoietin for patients suffering from anaemia and/or low iron stores should be implemented in patients undergoing moderate and major spinal surgery. There is moderate quality translational evidence for correcting the iron deficiency anaemia, in order to decrease the perioperative risk of complications secondary to blood transfusion.

6. Perioperative Blood Conservation Strategies. Patients undergoing moderate and major spinal surgery are at risk of significant blood loss necessitating fluid and blood product replacement.[121,122] Recent systematic analysis of tranexamic acid use in spinal surgery patients concluded that the use of tranexamic acid (TXA) was effective in reducing intra-operative blood loss and decreased the volume of blood transfusion.[123] It is likely that the higher bolus doses employed (greater or equal to 15 mg/kg followed by intraoperative infusion) were more effective in attenuating blood loss and transfusion requirements.[124,125] Lower perioperative blood loss has consistently been demonstrated with the use of -amin-caproic acid (EACA) in spinal surgery.[124] Point of care testing devices allow for standardization of transfusion practices and early identification and treatment of hypofibrinogenemia.[122] In a study of patients undergoing major spinal surgery ROTEM (ROtational ThromboElastoMetry) device used with TXA was found to lead to a significantly lower blood loss and lower transfusion of packed red blood cells as compared to the TXA alone.[126] Studies have demonstrated the utility of ROTEM in decreasing the rate of blood product transfusion.[127,128]

Blood conservation options include preoperative autologous blood donation and intraoperative cell saver use.

Preoperative autologous blood donation in elective major spine surgery has been effective in reducing allogenic transfusion, however inclusion in the program resulted in increased risk of transfusion.[129–131] A Cochrane meta-analysis assessing the use of cell saver in major surgery demonstrated significantly decreased rate of allogenic blood transfusion.[132] The use of the cell saver in posterior spinal instrumentation and fusion surgery in school-aged children and adolescents was able to decrease the amount of intraoperative allogeneic RBC transfusion but failed to decrease total perioperative allogeneic RBC transfusion.[133,134] In contrast, use of cell-saver was found to be associated with increased risk of bleeding in patients having spinal fusion surgery.[135] There is no evidence supporting the use of controlled hypotension to minimize the risk of bleeding, particularly in prone patients.[136] Perioperative blood conservation is aided through simple clinical measures such as temperature regulation, optimal patient positioning and meticulous surgical techniques.

There is high quality evidence for antifibrinolytic use in surgery of the spine when significant blood loss is anticipated. There is moderate quality evidence for cell saver use when significant blood loss is anticipated. There is low quality evidence for use of point of care testing to decrease the number of red blood cell units transfused.

Pre-operative Period

7. Preoperative Fasting and Carbohydrate Loading. In a randomized controlled trial examining patient population having co spinal surgery, preoperative carbohydrate loading did not attenuate postoperative insulin sensitivity.[137] This is contradictory to other general surgical trials which demonstrate improved insulin postoperative sensitivity with CHO loading.[138–141] The clinical relevance of administering preoperative CHO loading in patients with diabetes remains to be established.[47] Permitting patients to drink water or clear fluid preoperatively results in significantly lower gastric volumes.[139] International guidelines allow for unrestricted intake of clear fluids up to 2 h before elective surgery in patients not considered to have impaired gastric emptying.[140,142]

In spinal surgical patients without delayed gastric emptying standard societal fasting implementations can be made. Patients should be allowed to eat up until 6 h and take clear fluids including CHO drinks, up until 2 h before initiation of anaesthesia. Preoperative treatment with oral CHOs may not be suitable in patients with documented delayed gastric emptying, gastrointestinal motility disorders and in patients undergoing emergency surgery.

8. Pre-emptive Analgesia. A number of studies found that pre-emptive administration of gabapentin reduced the opioid consumption and pain scores in the postoperative period in spinal patients.[143–146] The most effective dose in lowering the post-operative pain scores was found to be 600 mg.[144] Impact of multimodal anti-inflammatory regimes combined with gabapentinoids, is significant in lowering the postoperative pain scores.[147,148] Parecoxib and ketorolac were found to be equally effective in improving postoperative pain measures. Both were superior to placebo in patients undergoing posterior lumbar fusion.[149] Pre-emptive epidural analgesia for thoracolumbar spine surgery has not been deemed effective.[150]

Multimodal pre-emptive analgesia utilizing individual gabapentinoids and/or non-steroidal anti-inflammatory agents improves pain scores and functional measures in the immediate post-operative period. There is high quality evidence for preemptive administration of gabapentinoids in patients undergoing surgery of the spine.

There is moderate quality evidence for pre-emptive administration of multimodal anti-inflammatory regimes combined with gabapentinoids. Evidence quality is low for sole administration of individual anti-inflammatory agents.

Intraoperative Period

9. Prevention of Nausea and Vomiting (PONV). Postoperative nausea and vomiting (PONV) are amongst the most frequent postoperative complications, impacting the quality of recovery and causing patient dissatisfaction.[151] Patients should be risk-stratified according to the baseline risk of PONV. In patients undergoing spinal surgery a particular risk factor for increased PONV is the need for significant intraoperative and postoperative opioid administration. Standard societal guidelines for PONV prophylaxis and management apply to patients undergoing spinal surgery.[151] With non-pharmacological measures, avoidance of fasting and dehydration has been recommended. Multi-modal analgesia with opioid sparing effect has a beneficial influence on the risk of PONV.[152,153]

Risk assessment of patients according to the anaesthetic and procedural factors is recommended. Step- wise non-pharmacological and pharmacological PONV prophylaxis according to the guidelines is recommended. Use of anaesthetic techniques which minimize risk of PONV in high-risk patients should be considered.

There is high quality evidence for risk stratification of patients and appropriate anti-emetic prophylaxis.

There is moderate quality evidence for opioid sparing techniques as well as avoidance of nitrous oxide and volatile anaesthesia;

10. Surgical Site Preparation and Antimicrobial Prophylaxis. 10.1. Surgical Site Preparation: Reported post-operative infection rates in spinal surgery range from two to 13 %.[154]

Large prospective cohort studies have demonstrated that the surgical site infection rate is equivalent with both topical chlorhexidine gluconate and povidone in spinal surgical patients.[155,156] Topical chlorhexidine with alcohol compared to povidone alone, decreased the bacterial load significantly in spinal surgery.[157,158] A review evaluating randomized controlled trials in all types of surgeries concluded that alcohol-based agents are superior to aqueous solutions.[159]

There is high quality evidence for using alcohol-based preparations. There is moderate quality evidence for decreasing the viable bacterial load utilizing CHG with alcohol solution.

10.2. Antimicrobial Prophylaxis. Risk factors for surgical site infections after spinal surgery include extended duration of procedure (longer than 2 h), excessive blood loss (greater than one liter), staged procedure, multilevel fusion, foreign body placement, combined, anterior and posterior fusion, and poor peri-operative glycemic control.[160] Surgical site infection is less likely in procedures at the cervical spine level or with an anterior surgical approach.[161] Current guidelines recommend intravenous cephazolin as the first choice agent for antimicrobial prophylaxis for most surgical procedures.[162] In patients with MRSA, intravenous vancomycin is recommended 1 h prior to skin incision. Clindamycin is an acceptable alternative in patients with a cephalosporin or vancomycin allergy. In the setting of risk for SSI due to gram-negative pathogens, an additional agent may be warranted (such as an aminoglycoside, aztreonam, or a fluoroquinolone). In order to ensure adequate antimicrobial serum and tissue concentrations, repeat intraoperative dosing is warranted for procedures that exceed two half-lives of the drug and for procedures in which there is excessive blood loss.[162] In a meta-analysis incorporating 6 prospective randomized-controlled trials, antibiotic prophylaxis was found to decrease the rate of infection.[163] Whether postoperative infections are reduced by continuing use of prophylactic antibiotics remains controversial.[164] In a meta-analysis consisting of 14 mostly class 3 evidence studies, vancomycin powder was found to decrease the likelihood of surgical site infection.[165] Vancomycin powder was found to decrease the rate of deep space infections requiring re-operation.[166] Vancomycin powder should be restricted to procedures and patients most at risk of MRSA-related surgical site infection.[167–169]

Routine prophylaxis with cefazolin within 1 h prior to skin incision is recommended. Patients with MRSA should be treated prophylactically with vancomycin initiated 1 h prior to skin incision.

There is high quality evidence for intra-operative antibiotic prophylaxis. There is low quality evidence for use of intravenous vancomycin in patients at risk of MRSA.

11. Local Anaesthetic Infiltration. The benefits of intra-operative wound infiltration for postoperative analgesia in spinal surgery are controversial. A number of studies have demonstrated conflicting results in this area.[170–173] A meta-analysis of nine trials exploring the effect of wound infiltration in spinal surgery concluded that only a few trials observed a mild to modest pain score reduction. Of the trials which did show pain reduction, the analgesic benefit was noted in the immediate post-operative period.[174]

Local anaesthetic wound infiltration in major spinal surgery has some immediate benefit on postoperative pain scores. There is moderate quality evidence for intra-operative administration of long-acting local anaesthetic administration.

12. Standard Anaesthetic Protocol. Prior systematic reviews and meta-analysis have concluded that recovery parameters are improved with the use of total intravenous anaesthesia (TIVA).[175,176] There is some evidence that patients receiving TIVA had improved cognitive outcomes in post-anaesthesia recovery unit in all types of surgical patients.[177] Patients anesthetized with propofol-based TIVA reported less pain during coughing and consumed less daily and total PCA fentanyl after lumbar spine surgery.[178] This finding was not consistent across all studies.[179] Remifentanil, ultra-short acting phenyl-piperidine derivative is used in spinal surgery as part of total intravenous anaesthesia or inhalational anaesthesia protocols. Indications for use in spinal surgery include: improved endotracheal tube tolerance, improved surgical conditions and facilitations of peripheral neuromuscular monitoring. Severe postoperative pain after the intraoperative use of remifentanil has repeatedly been linked to the development of acute tolerance and/or opioid induced hyperalgesia.[180] In patients undergoing spinal fusion remifentanil dosage up to 0.16 mg/kg/min did not cause an increased post-operative opioid consumption.[181] In contrast, in patients having correction of scoliosis where higher doses of remifentanil of 0.28 mcg/kg/min were used for longer duration, the requirements for post-operative analgesia were 30 % higher in the remifentanil group.[182] Neurologic monitoring in spinal surgery is performed using the intraoperative somatosensory potentials (SSEP's) and/or the Motor Evoked Potentials (MEP's). During the SSEP monitoring anaesthetic drugs produce a dose dependent increase in latency and a decrease in amplitude. The overall quality of SSEP is superior when propofol total intravenous anaesthesia is used. International Society of Intraoperative Neurophysiology recommends use of propofol and opioid.[183] MEP's display extreme sensitivity to the inhibitory effects of volatile agents even at concentrations as low as 0.25 MAC. Due to a lower level of interference with monitoring MEP's, propofol total intravenous anaesthesia is recommended for patients requiring spinal cord neurophysiological monitoring during surgery.

There is moderate quality evidence for use of total intravenous anaesthesia in patients undergoing surgery of the spine. There is low quality evidence for continuous intra-operative remifentanil infusion use in spine surgery.

13. Surgical Access (Open and Minimally Invasive Spinal Surgery, Including Robotic Surgery). Minimally Invasive Spinal Surgical (MISS) techniques can be viewed as a critical component of enhanced recovery in spinal surgery protocols (ERSS).[184] Reduced length of stay together with significant cost saving has been identified in studies utilizing MISS techniques.[32] MISS techniques have been efficacious in decreasing postoperative pain in observational studies.[185] With a focus on minimally invasive transcutaneous lumbar inter-body fusion, Wang et al. demonstrated that ERAS in this group of patients was feasible and afforded improved early functional outcomes.[186] MISS approach studied within the enhanced recovery protocol was found to be effective in oncological spinal patients, where it was found to decrease the pain scores and lower the opioid consumption.[187] Significantly faster mobilization was demonstrated in patients undergoing minimally invasive thoracic inter-lumbar body fusion compared to open procedure.[188] In contrast to single studies and qualitative reviews, a quantitative meta-analysis found there was equipoise in patients undergoing lumbar minimally invasive procedures.[189] A multicenter study found equivalent outcomes for obese patients having spinal MISS or open techniques.[190] Conversely, Senkar et al. found minimally invasive surgical techniques had the highest utility in patients with multiple comorbidities.[191]

There is evidence that minimally invasive surgical approaches improve pain scores, decrease opioid consumption and decrease length of stay, when used within the appropriate clinical context. There is moderate quality evidence for the intervention in appropriate clinical context.

14. Maintenance of Normothermia. Maintenance of normothermia has been shown to decrease the frequency of morbid cardiac events and the rate of blood product transfusion in major surgery.[192,193] In spinal procedures with potential neurological cord compromise, maintenance of normothermia and avoidance of hyperthermia is recommended.[194] There is little scientific literature supporting the neuroprotective effects of hypothermia on the spinal cord in elective or emergency spinal surgery.[195] In pediatric spinal surgery maintenance of normothermia was found to be associated with a lower allogenic red blood cell transfusion rate.[196] In contrast hypothermia may be associated with a lower rate of acute kidney injury in spinal surgery under general anaesthesia.[197]

Measures to maintain normothermia should be implemented in spinal surgical patients. There is moderate quality evidence for maintenance of intraoperative normothermia.

15. Intraoperative Fluid and Electrolyte Therapy. For the minor range of spinal surgeries intraoperative fluid management goals are achievable with routine monitoring. In major surgery, goal-directed therapy has been recommended.[198] Advanced haemodynamic monitoring equipment chosen should be based on a clinical risk-management strategy and patient, anaesthetic, surgical and institutional factors. Prior meta-analysis have demonstrated that pre-emptive hemodynamic monitoring and proactive therapy reduces mortality and morbidity in major surgical procedures.[199,200] In a retrospective observational trial in patients undergoing prone spinal surgery, goal directed fluid management was found to decrease blood loss and transfusion, improve postoperative respiratory performance and allow for faster return of bowel function.[201] In contrast, liberal fluid strategy was associated with an increased rate of pulmonary complications.[202]

Goal-directed fluid management may decrease the rate of complications and duration of stay when implemented in the appropriate clinical context. There is low quality evidence for goal-directed intraoperative fluid management using contextually appropriate indicators and measurements of cardiac output in patients undergoing major surgery of the spine.

16. Peri-operative Analgesia. Poorly controlled pain in the post-operative period can influence mobility and result in increased rate of complications of deep venous thrombosis, pulmonary embolism and pneumonia.[203]

NSAIDS and Acetaminophen: A recent meta-analysis of eight trials identified that NSAIDs are effective in postoperative analgesia after lumbar spine surgery. The study found that NSAID dose, different surgery types, and analgesic type might influence the efficacy of NSAIDs.[204] A meta-analysis of 17 studies demonstrated that addition of NSAIDs to opioid analgesics alone resulted in lower pain scores and less morphine equivalents consumed.[205] In a meta-analysis of seven spine fusion studies, no statistically significant association between NSAID exposure and nonunion was identified (odds ratio = 2.2, 95% confidence interval 0.8–6.3).[206] It is likely that adverse effects of NSAID's on bone healing/fusion in adult spine surgery are dose-dependent.[207] While there is limited evidence for the use of acetaminophen specifically in spinal surgery, it is a well-established analgesic agent for a wide range of related surgeries.[203]

N-methyl D-aspartate Antagonists: Randomized controlled trials demonstrating decreased opioid consumption and lower pain scores following intraoperative and post-operative ketamine.[208–210] These findings are in line with a meta-analysis of eight trials.[211] A single study showed no benefit of low dose ketamine in major lumbar surgery.[212] Methadone and magnesium through their NMDA antagonism may also be of benefit; however, data are limited and further studies are indicated.[213–215]

Alpha-2 Receptor Agonists: Data supporting the use of alpha-2 receptor agonists in major spine surgery are limited; studies have demonstrated conflicting findings.[216]

Gabapentinoids: In a systematic review and meta-analysis by Yu et al., perioperative administration of gabapentinoids was found to decrease opioid consumption and pain intensity in the immediate post-operative period.[145] Other high quality prospective studies have deemed gabapentinoids effective at reducing the opioid consumption when continued for at least 24 h post-operatively.[146] A prospective, double-blind study, randomized control trial by Khurana et al. showed a stronger benefit for pregabalin over gabapentin versus placebo for pain and functional status in the post-operative period and at 3 months.[217]

Intravenous Lignocaine: In a number of controlled trials in both adult and pediatric major and minor spine surgery, perioperative lignocaine infusion was demonstrated to improve pain scores and decrease opioid consumption.[218–221] Conversely, in a randomized controlled trial of 70 patients undergoing posterior spine surgery, there was no analgesic benefit of a systemic lignocaine infusion as compared to placebo.[222]

Regional Analgesia: Intrathecal morphine administration in a wide dosage range as a single injection has been found to be effective as a postoperative analgesic in spinal surgery, though doses greater than six mcg, kg− 1 are associated with postoperative respiratory depression.[223–230] In a meta-analysis of eight randomized controlled trials, intrathecal morphine was an effective analgesic.[231]

Multimodal Regimens: Prior review articles have highlighted multimodal analgesia as a significant contributor to enhanced recovery in spinal surgery.[10,203,232] Multimodal analgesia bundles have been incorporated into most care pathways of enhanced recovery in spinal surgery.[8,12,233] A numbed of retrospective studies have demonstrated decreased pain measurement outcomes including post-operative opioid consumption.[234–237] In contrast to other studies, a single randomized controlled trial of optimally dosed multimodal regime did not show any benefit over the placebo components when evaluated in terms of quality of recovery scores or analgesic components.[238] Minimally invasive opioid free enhanced recovery protocols in spinal surgery have been shown to have a favorable profile on perioperative opioid consumption.[239]

Simple analgesics such as acetaminophen and NSAIDs are safe and efficacious, particularly in combination. There is high quality evidence for perioperative administration of NSAID's. Ketamine in both intraoperative and post-operative infusions, reduces pain scores, opioid requirements in the immediate and late post-operative phases. There is moderate quality for intraoperative ketamine administration. There is very low quality evidence for administration of other NMDA antagonists and alpha-2-agonists. There is high quality evidence for perioperative gabapentinoid administration. Consideration should be given to perioperative intravenous lignocaine infusion administration. There is moderate quality evidence for perioperative intravenous lignocaine administration. There is moderate quality evidence for use of intrathecal morphine in spinal surgery, although its utility may be limited by logistical factors. Clinically appropriate multimodal opioid-sparing regimens should be considered in all patients undergoing spine surgery. There is moderate quality evidence for instituting peri-operative multimodal analgesia.

Postoperative Period

17. Thromboprophylaxis. Mechanical thromboprophylaxis is a proven measure to decrease the risk of deep venous thrombosis (DVT) in the absence of chemoprophylaxis.[240] A meta-analysis conducted in 2018 found that the incidence of DVT and pulmonary embolism (PE) in spinal surgical population was relatively low regardless of prophylaxis type. The authors commented that there was a higher mean incidence of DVT and PE in the mechanoprophylaxis group (DVT: 1%, PE: 0.81%) compared to the chemoprophylaxis group (DVT: 0.85%, PE: 0.58%).[241] In this study, when PE occurred it was fatal in 6 % of patients. Perception of true incidence of post-operative epidural haematoma in spinal surgical patients is varied.[242]

Patients undergoing spinal surgery should have mechanical thromboprophylaxis by well-fitting compression stockings and/or intermittent pneumatic compression until discharge. There is moderate quality evidence for postoperative mechanical thromboprophylaxis in patients undergoing spinal surgery.

There is low quality evidence for postoperative chemical thromboprophylaxis in patients undergoing spinal surgery.

18. Urinary Drainage. Urinary catheter use beyond 48 h following surgery has been associated with an increase in hospital-acquired urinary tract infections and 30-day mortality.[243] In a nested cohort study in a neurological intensive care unit, an increased rate of urinary infection was noted in patients, where catheter remained in place for longer than 7 days.[244] Risk factors for postoperative urinary retention in spinal surgery include older age, benign prostatic hypertrophy, chronic constipation, longer duration of surgery and posterior spinal fusion.[245–247]

If urinary drainage is indicated, the duration of catheterization should be individualized based on known risk factors for urinary retention. There is moderate quality evidence for urinary catheter removal within 48 h after surgery.

19. Postoperative Nutrition and Fluid Management. Many of the studies report on early mobilization in conjunction with dietary libertization.[185,248] When performed together, the two can reduce length of stay and costs without increasing early or late complications in adolescents undergoing posterior spinal fusion.[249] Results of the RELIEF trial suggest that we should be more cautious with postoperative restrictive fluid strategies in patients having major abdominal surgery.[250] In patients having major spine surgery, goal orientated post-operative fluid management may be more appropriate than a restrictive approach, although specific evidence is currently lacking. Intraoperative haemodynamic framework may be continued into the post-operative period in the high-risk patient group. In line with other ERAS guidelines patients should be encouraged to transition as early as tolerated to oral intake.

20. Postoperative Glycemic Control. A retrospective cohort study incorporating population undergoing spine surgery found that perioperative hyperglycemia increases the risk of adverse post-operative events in the non-diabetic patient group.[251] Tighter glycemic control may mitigate the risk of surgical site infection in patients with diabetes.[252] There remains insufficient evidence that strict glycemic control is advantageous over conventional management for prevention of surgical site infection.[253] Although it is clear that perioperative hyperglycemia is deleterious, the optimal management paradigm in the postoperative period remains uncertain.[252]

It is prudent to maintain more conventional blood glucose target in the postoperative period in patients undergoing spinal surgery. There is low quality evidence for conventional postoperative blood glucose control.

21. Early Mobilization. Early mobilization is thought to be a key component of ERSS.[12,254] There is no clear definition of mobilizing, which may include simple exercise in bed, walking in the room or walking further distances.[47] The overall outcome of these pathways has been that of significant decreased length of stay; as well as improved patient satisfaction measures in selected studies.[185,233,248,255–257] A study focusing on behavioral outcomes of early mobilization and rehabilitation education, identified decreased postoperative patient anxiety and enhanced self-care ability.[258] Reduced complication rates, improved patient-reported outcomes and decreased length of stay were noted in a narrative review in patients undergoing early mobilization.[259]

Patients should be encouraged to mobilize actively on the day of surgery as guided by clinical condition and surgical concerns. In the absence of a clear definition of early mobilization, institutions should be encouraged to set their own benchmarks. There is moderate quality evidence for the intervention due to the imprecision in defining mobilization as well as retrospective nature of studies.

Quality of care measures

22. Audit. Systematic audit is the preferred practice pattern in order to review compliance rates with the ERAS implemented interventions.[260] There is evidence in retrospective studies that greater compliance with ERAS processes and protocols improves desired perioperative outcomes.[261–264] Full compliance with ERAS protocols has been identified to be an issue in prior studies. Compliance with ERAS pathways has been deemed to be a 5-year survival measure.[265] Overall compliance with ERAS protocols has been shown to be associated with better patient reported outcome measures.[266] There is a paucity of audit data in multimodal ERSS protocols.

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