18. Enhanced Recovery After Endoscopic Spine Surgery (ERAS)
@ProfFishchenkoERAS protocols in spine surgery aim to accelerate recovery and reduce pain and hospital stay. We adapt the program to the type of procedure and the patient's condition.
Preoperative phase
- Patient education: Patients are prepared for surgery by explaining that early movement and pain control are key to recovery. This reduces stress and improves cooperation.
- Optimization of the patient's condition: Correction of anemia, blood glucose control in patients with diabetes, and smoking cessation before surgery improve outcomes.
- Preoperative fasting: healthy adults without an increased aspiration risk undergoing an elective procedure may consume clear fluids, including clear carbohydrate drinks, up to 2 hours before anesthesia or sedation. Separate intervals apply to solid food. When aspiration risk factors are present, the anesthesiologist individualizes the plan. A short operation or sedation does not remove these requirements.
Intraoperative phase
- Anesthesia: general or spinal anesthesia is possible for selected BESS/UBE procedures. The responsible anesthesiologist determines the plan. Multimodal analgesia helps limit opioid use; we use NSAIDs and/or paracetamol with contraindications taken into account.
- Blood loss control: we consider tranexamic acid and other adjuncts after assessing indications, contraindications, and the current local protocol.
Postoperative phase
- Early mobilization: after uncomplicated surgery, standing and walking are possible approximately 2–3 hours later if the patient has recovered sufficiently from anesthesia and can move safely. In our practice, after secure suturing of a dural defect, mobilization is possible before 24 hours according to the patient's condition; after closure with TachoSil without suturing, no earlier than 24 hours. In both cases, we use additional antibiotic therapy and monitor the wound for cerebrospinal fluid leakage during the first week.
- Pain control: multimodal analgesia reduces the need for opioids. We use NSAIDs, paracetamol, and local anesthetics as indicated; we add gabapentinoids selectively rather than routinely for every patient.
- Nutrition: we resume drinking and eating early after sufficient recovery from anesthesia and when swallowing is safe. Tolerance determines the volume and pace, with nausea and vomiting taken into account. We discontinue intravenous fluids when needs can be met orally and no other indications remain.
Evidence and outcomes
- Reduced hospital stay: Studies show that ERAS protocols reduce the average length of hospital stay.
- Complications: in spine surgery studies, ERAS programs are associated with a reduction in the overall incidence of perioperative complications. Early mobilization is part of comprehensive venous thromboembolism prevention but does not replace individual risk assessment.
- Pain control: nonopioid components of analgesia help reduce discomfort and opioid requirements.
References
1. Debono B, Wainwright TW, Wang MY, et al. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Spine J. 2021;21(5):729–752.
DOI: 10.1016/j.spinee.2021.01.001
2. Magableh HM, Ibrahim S, Pennington Z, et al. Transforming outcomes of spine surgery-exploring the power of Enhanced Recovery After Surgery protocol: a systematic review and meta-analyses of 15 198 patients. Neurosurgery. 2024;95(1):3–25.
DOI: 10.1227/neu.0000000000002865
3. Heo DH, Park CK. Clinical results of percutaneous biportal endoscopic lumbar interbody fusion with application of enhanced recovery after surgery. Neurosurg Focus. 2019;46(4):E18.
DOI: 10.3171/2019.1.FOCUS18695
4. Gomes FC, Larcipretti ALL, Elvir FAR, et al. Early ambulation versus prolonged bed rest for incidental durotomies in spine procedures: a systematic review and meta-analysis. Neurosurg Rev. 2023;46(1):310.
DOI: 10.1007/s10143-023-02201-2
5. Joshi GP, Abdelmalak BB, Weigel WA, et al. 2023 American Society of Anesthesiologists practice guidelines for preoperative fasting: carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration—a modular update of the 2017 guidelines. Anesthesiology. 2023;138(2):132–151.
DOI: 10.1097/ALN.0000000000004381