Enhanced recovery after surgery (ERAS) for open transforaminal lumbar interbody fusion: a retrospective propensity-matched cohort study

Abstract

Background: The enhanced recovery after surgery (ERAS) protocol is a multidisciplinary, multimodal approach which has been shown to facilitate recovery of physiological function, and reduce postoperative pain, complication rates, and length of stay without adversely affecting readmission rates. Design and implementation of ERAS protocols in the recent spine surgery literature has primarily focused on patients undergoing minimally invasive lumbar surgery. However, conventional open transforaminal lumbar interbody fusion (TLIF) remains a common procedure and to date there are no studies assessing an ERAS protocol in this patient population.

Purpose: This study presents a single surgeon experience implementing an ERAS protocol in patients undergoing 1- or 2-level open TLIF.

Study design/setting: Retrospective consecutive patient cohort with controls propensity-matched for age, body mass index, sex, and smoking status.

Patient sample: Consecutive patients that underwent 1- or 2-level open TLIF for degenerative disease from 12/2018 - 02/2021 and controls from 12/2011-12/2017 by a single surgeon. ERAS was implemented in December 2018.

Outcome measures: Primary: length of stay; Secondary: first day to ambulate, first day to bowel movement, first day to void, daily average and maximum pain scores, opioid use, discharge disposition, 30-day readmission rate, and re-operations.

Methods: Demographic, perioperative, clinical, radiographic data were collected. Multivariate mixed-linear regression models were developed for length of stay, physiological function, pain scales, and opiate use.

Results: There were 114 patients included with 57 in each cohort. After propensity matching, patient characteristics were similar between groups. Operative time decreased significantly after institution of ERAS (170±44 vs. 141±37 minutes, p <.0001) as did length of stay (4.6±1.7 vs. 3.6±1.6 days, p<.0001). First day of ambulation, bowel movement, and bladder voiding improved by 0.8 (p<.0001), 0.7 (p=.008), and 0.8 (p<.0001) days, respectively, in the ERAS cohort. Total daily intravenous morphine milligram equivalent (MME) (8±9 vs. 36±38, p<0.0001) and total 72-hour MME consumption (53±33 vs. 68±48, p<.0001) was significantly lower in the ERAS cohort; however, 72-hour MME consumption was not found to be significantly different in a sensitivity analysis controlling for preoperative MME. Average daily pain scores were similar between groups.

Conclusions: Consistent with other studies demonstrating benefit of an ERAS protocol for minimally invasive spine procedures, ERAS was associated with decreased operative time, reduced length of stay, decrease in IV opioid consumption, and improved physiological outcomes for open 1- and 2-level TLIF. ERAS can be a potentially effective strategy for improving patient outcome and efficiency of healthcare resources for common conventional spinal surgeries such as open TLIF.

Keywords: Ambulation; Enhanced recovery; Fast track; Length of stay; Morphine milligram equivalent; Opioid intake; Pain; Transforaminal lumbar interbody fusion (TLIF).

Conflict of interest statement

Declarations of competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Published by Elsevier Inc.

Figures

Fig. 1.

(A) Average daily Defense and Veterans Pain Rating Scale (DVPRS) scores over post-operative day (POD) 0–3. (B) Average daily maximum DVPRS scores over POD 0–3. POD 0 showed significant reduction with ERAS. Solid line=ERAS cohort; dashed line=Pre-ERAS cohort. *=p<.05>

Fig. 2.

(A) Total daily average morphine milligram equivalents (MME) over post-operative day (POD) 0–3. POD 2–3 showed significant reduction with ERAS. (B) Total daily orally-consumed MME over POD 0–3. POD 0–1 showed significant reduction pre-ERAS while POD 3 showed significant reduction with ERAS. (C) Total daily intravenous MME over POD 0–3. All days showed significant reduction with ERAS. All values have been logarithmically transformed to approximate a normal distribution (left axis). Equivalent non-transformed MME scale is shown on the right axis. Solid line=ERAS cohort; dashed line=Pre-ERAS cohort. *= p<.05>