Enhanced recovery after surgery (ERAS) improves return of physiological function in frail patients undergoing one- to two-level TLIFs: an observational retrospective cohort study

Abstract

Background context: The enhanced recovery after surgery (ERAS) protocol is a multimodal approach which has been shown to facilitate recovery of physiological function, and reduce early post-operative pain, complications, and length of stay (LOS) in open one- to two-level TLIF. The benefit of ERAS in specifically frail patients undergoing TLIF has not been demonstrated. Frailty is clinically defined as a syndrome of physiological decline that can predispose patients undergoing surgery to poor outcomes.

Purpose: This study primarily evaluated the benefit of an ERAS protocol in frail patients undergoing one- or two-level open TLIF compared to frail patients without ERAS. Secondarily, we assessed whether outcomes in frail patients with ERAS approximated those seen in nonfrail patients with ERAS.

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

Patient sample: Consecutive patients that underwent one- or two-level open TLIF for degenerative disease from August, 2015 to July, 2021 by a single surgeon. ERAS was implemented in December 2018.

Outcome measures: Primary outcome measure was return of postoperative physiological function defined as the summation of first day to ambulate, first day to bowel movement, and first day to void. Additional outcome measures included LOS, daily average pain scores, opioid use, discharge disposition, 30-day readmission rate, and reoperation.

Methods: A retrospective analysis of frail patients > 65 years of age undergoing one- to two-level open TLIF post-ERAS were compared to propensity matched frail pre-ERAS patients. Frailty was assessed using the Fried phenotype classification (score >1). Patient demographics, LOS, first-day-to-ambulate (A1), first-day-to-bowel movement (B1), first-day-to-void (V1) were collected. Return of physiological function was defined as A1+B1+V1. Primary analysis was a comparison of frail patients pre-ERAS versus post-ERAS to determine effect of ERAS on return of physiologic function with frailty. Secondary analysis was a comparison of post-ERAS frail versus post-ERAS nonfrail patients to determine if return of physiologic function in frail patients with ERAS approximates that of nonfrail patients.

Results: In the primary analysis, 32 frail patients were included with mean age ± standard deviation of 72.8±4.4 years, mean BMI 28.8±5.5, 65.6% were male, 15 pre-ERAS and 17 post-ERAS. Patient characteristics were similar between groups. After ERAS implementation, return of physiological function improved by a mean 3.2 days overall (post-ERAS 3.4 vs. pre-ERAS 6.7 days) (p<.0001), indicating a positive effect of ERAS in frail patients. Additionally, length of stay improved by 1 day (4.8±1.6 vs. 3.8±1.9 days, p<.0001). Total daily intravenous morphine milligram equivalent (MME) as well as average daily pain scores were similar between groups. Secondarily, 26 nonfrail patients post ERAS were used as a comparison group with the 17 post-ERAS frail cohort. Mean age of this cohort was 73.4±4.6 years, mean BMI 27.4±4.9, and 61.9% were male. Return of physiologic function was similar between cohorts (post-ERAS nonfrail 3.5 vs. post-ERAS frail 3.4 days) (p=.938), indicating the benefit with ERAS in frail patients approximates that of nonfrail patients.

Conclusions: ERAS significantly improves return of physiologic function and length of stay in patients with frailty after one- to two-level TLIF, and approximates improved outcomes seen in non-frail patients.

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

Fig. 1.. Physiologic function.

Stacked bar graph showing physiologic function in days for pre-ERAS frail, post-ERAS frail, and post-ERAS nonfrail cohorts.

Fig. 2.. Pain Scores and Opioid Use.

(A) Average daily Defense and Veterans Pain Rating Scale (DVPRS) scores over post-operative day (POD) 0-3. (B) Total daily average morphine milligram equivalents (MME) over postoperative day (POD) 0-3. There was no significant change with ERAS. Dashed line=pre-ERAS frail cohort; solid line = post-ERAS frail cohort; gray line = post-ERAS non-frail cohort. * = p<0.05