The Enhanced Recovery After Surgery pathway for posterior cervical surgery: a retrospective propensity-matched cohort study

Abstract

Objective: The Enhanced Recovery After Surgery (ERAS) protocol is a comprehensive, multifaceted approach aimed at improving postoperative outcomes. It incorporates a range of strategies to promote early and more effective recovery, including reducing pain, complications, and length of stay, without increasing readmission rate. To date, ERAS for spine surgery patients has been primarily limited to lumbar surgery and anterior cervical decompression and fusion (ACDF). ERAS has not been previously studied for posterior cervical surgery, which may present a greater opportunity for improvement in patient outcomes with ERAS than ACDF. This single-institution, multi-surgeon study assessed the impact of an ERAS protocol in patients undergoing posterior cervical decompression surgery.

Methods: This study included a retrospective consecutive patient cohort with controls that were propensity matched for age, body mass index, sex, home opioid use, surgical levels, Nurick grade, and smoking status. In addition, consecutive patients who underwent posterior cervical decompression surgery for degenerative disease from December 2014 to December 2021 were included. ERAS was implemented in December 2018. Demographic, perioperative, clinical, and radiographic information was gathered. Regression models were created to evaluate length of stay, physiological function, pain levels, and opioid use. The primary focus was length of stay, with secondary outcomes including timing of ambulation, bowel movement, and voiding; daily pain scores; opioid consumption; discharge status; 30-day readmission rates; and reoperation rates.

Results: There were 366 patients included in the study, all of whom were included in multivariate models, and 254 (127 in each cohort) were included on the basis of matching. After propensity matching, patient characteristics, operative procedures, and operative duration were similar between groups. The ERAS cohort had a significantly improved length of stay (3.2 vs 4.7 days, p < 0.0001) and home discharge rate (80% vs 50%, p < 0.001) without an increase in readmission rate. The ERAS cohort had an earlier day of the first ambulation (p = 0.003), bowel movement (p = 0.014), and voiding (p = 0.001). ERAS demonstrated a significantly lower composite complication rate (1.1 vs 1.8, p < 0.0001). ERAS resulted in better maximum pain scores (p = 0.043) and trended toward improved mean pain scores (p = 0.072), although total opioid use was similar.

Conclusions: Implementing a novel ERAS protocol significantly improved length of stay, return of physiological function, home discharge, complications, and maximum pain score after posterior cervical surgery.

Keywords: ambulation; cervical laminoplasty; enhanced recovery; fast track; length of stay; morphine milligram equivalent; opioid intake; pain; posterior cervical decompression and fusion.

FIG. 1.

Postoperative radiographic examples of standard laminectomy at C4–T1 (A) and standard laminoplasty at C4–7 (B).

FIG. 2.

Pain scores. A: Average daily DVPRS scores on POD 0–3. Scores on POD 1–2 showed significant reduction with ERAS. B: Percentage of daily maximum DVPRS scores > 8/10 on POD 0–3. Scores on POD 3 showed significant reduction with ERAS. C: Total daily average MME on POD 0–3. Scores on POD 1 showed significant increase with ERAS. The solid line represents the ERAS cohort, and the dashed line represents the pre-ERAS cohort. *p < 0.05. Figure is available in color online only.