The Impact of Peri-operative Enhanced Recovery After Surgery Protocols on Outcomes Following Adult Cervical Deformity Surgery

Abstract

Study DesignRetrospective cohort study.ObjectivesTo assess the impact of Enhanced recovery after surgery (ERAS) protocols on peri-operative course in adult cervical deformity (ACD) corrective surgery.MethodsPatients ≥18 yrs with complete pre-(BL) and up to 2-year (2Y) radiographic and clinical outcome data were stratified by enrollment in an ERAS protocol that commenced in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, peri-operative factors and complication rates were assessed via means comparison analysis. Logistic regression analysed differences while controlling for baseline disability and deformity.ResultsWe included 220 patients (average age 58.1 ± 11.9 years, 48% female). 20% were treated using the ERAS protocol (ERAS+). Disability was similar between both groups at baseline. When controlling for baseline disability and myelopathy, ERAS- patients were more likely to utilize opioids than ERAS+ (OR 1.79, 95% CI: 1.45-2.50, P = .016). Peri-operatively, ERAS+ had significantly lower operative time (P < .021), lower EBL (583.48 vs 246.51, P < .001), and required significantly lower doses of propofol intra-operatively than ERAS- patients (P = .020). ERAS+ patients also reported lower mean LOS overall (4.33 vs 5.84, P = .393), and were more likely to be discharged directly to home (χ2(1) = 4.974, P = .028). ERAS+ patients were less likely to require steroids after surgery (P = .045), were less likely to develop neuromuscular complications overall (P = .025), and less likely experience venous complications or be diagnosed with venous disease post-operatively (P = .025).ConclusionsEnhanced recovery after surgery programs in ACD surgery demonstrate significant benefit in terms of peri-operative outcomes for patients.

Keywords: adult cervical deformity; cervical spine; enhanced recovery after surgery; spine surgery.

Figure 1.

63 year old man. History of right-sided neck pain and spasms after sustaining work-related injury 6 years prior. Symptoms were unresolved with conservative measures and progressively worsened with time, leading to spondylolisthesis and C7-T1 herniation. The patient was unable to undergo ERAS protocols due to severity of symptoms and moderate-to-severe frailty. Underwent C3-C7 ACDF, C3 and C6-T1 partial corpectomy, C4 & C5 corpectomy, and C3-T1 posterior cervical fusion, and was discharged 8 days post-op. He continued to use opioids intermittently. At 2 years post-op he was displaying signs of distal junctional kyphosis and had redeveloped pain symptoms.

Figure 2.

74 year old female progressive, atraumatic severe neck pain with radiation into right upper extremity and right upper limb weakness. Patient undertook full ERAS protocols, and underwent C3-C7 ACDF, partial corpectomy C3-C7 and C2-T2 posterior cervical fusion, and was discharged 3 days post-op. Also underwent interval L5-S1 ALIF with L2-Pelvis posterior fusion. Patient reported discontinuing opioids 3 days after discharge. At 2 years post-op, radiographic alignment was still maintained without evidence of DJK.