Efficacy of an Enhanced Recovery After Surgery (ERAS) Pathway in Elderly Patients Undergoing Spine and Peripheral Nerve Surgery

Joseph Ifrach; Rohan Basu; Disha S Joshi; Tracy M Flanders; Ali K Ozturk; Neil R Malhotra; Rachel Pessoa; Michael J Kallan; Eileen Maloney; William C Welch; Zarina S Ali

doi:10.1016/j.clineuro.2020.106115

Efficacy of an Enhanced Recovery After Surgery (ERAS) Pathway in Elderly Patients Undergoing Spine and Peripheral Nerve Surgery

Clin Neurol Neurosurg. 2020 Oct:197:106115. doi: 10.1016/j.clineuro.2020.106115. Epub 2020 Jul 31.

Authors

Affiliations

¹ Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
² Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
³ Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
⁴ Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States. Electronic address: zarina.ali@uphs.upenn.edu.

PMID: 32841823
DOI: 10.1016/j.clineuro.2020.106115

Abstract

Objective: Elderly patients are a vulnerable patient population in elective spinal surgery. Older patients have more medical comorbidities and are also more sensitive to opiate medications. Despite this, spine and peripheral nerve surgery is still feasible in these patients, and an Enhanced Recovery After Surgery (ERAS) regimen can further enhance the safety profile.

Methods: This is a before and after cohort study at a single institution on elderly patients who underwent elective spine and peripheral nerve surgery. Patients were prospectively enrolled in a novel ERAS protocol from April 2017 to December 2018. The control group was a historical cohort of patients who underwent surgery from September 2016 to December 2016. The primary outcome was self-reported opioid use at 1- and 3-months postoperatively. The secondary outcome was compliance with the ERAS protocol across several measures including patient-controlled (PCA) use, patient-reported pain scores, mobilization and ambulation status, and Foley catheter use.

Results: Among 504 patients aged 65 and older compared to historic controls there was a significant reduction in the use of post-operative opioids at one month (36.2% vs. 71.7%, p < 0.001) and 3 months after surgery (33.0% vs. 80.0%, p < 0.001). 504 consecutive elderly patients were included in the ERAS protocol compared to a control group of 60. The two groups had similar surgical procedures and baseline demographics, with similar mean ages (ERAS 73.2 years vs. control 73.5 years, p = 0.67). The ERAS group showed improved mobilization and ambulation on POD 0 in compliance with our protocol compared to the control group (mobilization: 60.0% vs. 10.0%, p < 0.001; ambulation: 36.1% vs. 10.0%, p < 0.001), with no inpatient falls reported for either group.

Conclusions: ERAS facilitates reduction in opiate use at 1- and 3-month intervals postoperatively in patients greater than 65 years old undergoing elective spine and peripheral nerve surgery. Early mobilization and ambulation are safe and feasible in this population.

Keywords: elderly; enhanced recovery after surgery (ERAS); opioid; spine surgery.

MeSH terms

Aged
Aged, 80 and over
Analgesics, Opioid / therapeutic use
Elective Surgical Procedures / rehabilitation*
Enhanced Recovery After Surgery*
Female
Humans
Length of Stay
Male
Neurosurgical Procedures / rehabilitation*
Pain, Postoperative / drug therapy
Peripheral Nerves / surgery*
Retrospective Studies
Spine / surgery*

Substances

Analgesics, Opioid