Reductions in length of stay, narcotics use, and pain following implementation of an enhanced recovery after surgery program for 1- to 3-level lumbar fusion surgery

Abstract

OBJECTIVELumbar fusion is typically associated with high degrees of pain and immobility. The implementation of an enhanced recovery after surgery (ERAS) approach has been successful in speeding the recovery after other surgical procedures. In this paper, the authors examined the results of early implementation of ERAS for lumbar fusion.METHODSBeginning in March 2018 at the authors’ institution, all patients undergoing posterior, 1- to 3-level lumbar fusion surgery by any of 3 spine surgeons received an intraoperative injection of liposomal bupivacaine, immediate single postoperative infusion of 1-g intravenous acetaminophen, and daily postoperative visits from the authors’ multidisciplinary ERAS care team. Non–English- or non–Spanish-speaking patients and those undergoing nonelective or staged procedures were excluded. Reviews of medical records were conducted for the ERAS cohort of 57 patients and a comparison group of 40 patients who underwent the same procedures during the 6 months before implementation.RESULTSGroups did not differ significantly with regard to sex, age, or BMI (all p > 0.05). Length of stay was significantly shorter in the ERAS cohort than in the control cohort (2.9 days vs 3.8 days; p = 0.01). Patients in the ERAS group consumed significantly less oxycodone-acetaminophen than the controls on postoperative day (POD) 0 (408.0 mg vs 1094.7 mg; p = 0.0004), POD 1 (1320.0 mg vs 1708.4 mg; p = 0.04), and POD 3 (1500.1 mg vs 2105.4 mg; p = 0.03). Postoperative pain scores recorded by the physical therapy and occupational therapy teams and nursing staff each day were lower in the ERAS cohort than in controls, with POD 1 achieving significance (4.2 vs 6.0; p = 0.006). The total amount of meperidine (8.8 mg vs 44.7 mg; p = 0.003) consumed was also significantly decreased in the ERAS group, as was ondansetron (2.8 mg vs 6.0 mg; p = 0.02). Distance ambulated on each POD was farther in the ERAS cohort, with ambulation on POD 1 (109.4 ft vs 41.4 ft; p = 0.002) achieving significance.CONCLUSIONSIn this very initial implementation of the first phase of an ERAS program for short-segment lumbar fusion, the authors were able to demonstrate substantial positive effects on the early recovery process. Importantly, these effects were not surgeon-specific and could be generalized across surgeons with disparate technical predilections. The authors plan additional iterations to their ERAS protocols for continued quality improvements.