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Magableh HM, Ibrahim S, Pennington Z, Nathani KR, Johnson SE, Katsos K, Freedman BA, Bydon M. 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 2024:00006123-990000000-01058. [PMID: 38358272 DOI: 10.1227/neu.0000000000002865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/05/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Enhanced recovery after surgery (ERAS) protocols aim to optimize patient outcomes by reducing the surgical stress response, expediting recovery, and reducing care costs. We aimed to evaluate the impact of implementing ERAS protocols on the perioperative surgical outcomes and financial implications associated with spine surgeries. METHODS A systematic review and meta-analysis of peer-reviewed studies directly comparing outcome differences between spine surgeries performed with and without utilization of ERAS pathways was conducted along Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Of 676 unique articles identified, 59 with 15 198 aggregate patients (7748 ERAS; 7450 non-ERAS) were included. ERAS-treated patients had shorter operative times (mean difference [MD]: 10.2 mins; P < .01), shorter hospitalizations (MD: 1.41 days, P < .01), fewer perioperative complications (relative risk [RR] = 0.64, P < .01), lower postoperative opioid use (MD of morphine equivalent dose: 164.36 mg; P < .01), and more rapid mobilization/time to first out-of-bed ambulation (MD: 0.92 days; P < .01). Spine surgeries employing ERAS were also associated with lower total costs (MD: $1140.26/patient; P < .01), especially in the United States (MD: $2869.11/patient, P < .01) and lower postoperative visual analog pain scores (MD = 0.56, P < .01), without any change in odds of 30-day readmission (RR: 0.80, P = .13) or reoperation (RR: 0.88, P = .60). Subanalyses based on the region of spine showed significantly lower length of stay in both cervical and lumbar surgeries implementing ERAS. Type of procedure showed a significantly lesser time-to-initiate mobilization in fusion surgeries using ERAS protocols compared with decompression. CONCLUSION The present meta-analysis indicates that current literature supports ERAS implementation as a means of reducing care costs and safely accelerating hospital discharge for patients undergoing spine surgery.
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Affiliation(s)
- Hamzah M Magableh
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Sufyan Ibrahim
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachary Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Karim Rizwan Nathani
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah E Johnson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Konstantinos Katsos
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Kazarian GS, Lovecchio F, Merrill R, Clohisy J, Zhang B, Du J, Jordan Y, Pajak A, Knopp R, Kim D, Samuel J, Elysee J, Akosman I, Shahi P, Johnson M, Schwab FJ, Lafage V, Kim HJ. Why Didn't You Walk Yesterday? Factors Associated With Slow Early Recovery After Adult Spinal Deformity Surgery. Global Spine J 2023:21925682231197976. [PMID: 37614144 DOI: 10.1177/21925682231197976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
STUDY DESIGN This is a retrospective case-control study. OBJECTIVES The objectives of this study are to identify (1) risk factors for delayed ambulation following adult spinal deformity (ASD) surgery and (2) complications associated with delayed ambulation. METHODS One-hundred and ninety-one patients with ASD who underwent posterior-only fusion (≥5 levels, LIV pelvis) were reviewed. Patients who ambulated with physical therapy (PT) on POD2 or later (LateAmb, n = 49) were propensity matched 1:1 to patients who ambulated on POD0-1 (NmlAmb, n = 49) based on the extent of fusion and surgical invasiveness score (ASD-S). Risk factors, as well as inpatient medical complications were compared. Logistic regressions were used to identify risk factors for late ambulation. RESULTS Of the patients who did not ambulate on POD0-1, 32% declined participation secondary to pain or dizziness/fatigue, while 68% were restricted from participation by PT/nursing due to fatigue, inability to follow commands, nausea/dizziness, pain, or hypotension. Logistic regression showed that intraoperative estimated blood loss (EBL) >2L (OR = 5.57 [1.51-20.55], P = .010) was independently associated with an increased risk of delayed ambulation, with a 1.25 times higher risk for every 250 mL increase in EBL (P = .014). Modified 5-Item Frailty Index (mFI-5) was also independently associated with delayed ambulation (OR = 2.53 [1.14-5.63], P = .023). LateAmb demonstrated a higher hospital LOS (8.4 ± 4.0 vs 6.2 ± 2.6, P < .001). The LateAmb group trended toward an increase in medical complications on POD3+ (14.3% vs 26.5%, P = .210). CONCLUSIONS EBL demonstrates a dose-response relationship with risk for delayed ambulation. Delayed ambulation increases LOS and may impact medical complications.
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Affiliation(s)
- Gregory S Kazarian
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Francis Lovecchio
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Robert Merrill
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - John Clohisy
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Bo Zhang
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jerry Du
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Yusef Jordan
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Anthony Pajak
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Rachel Knopp
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - David Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Justin Samuel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jonathan Elysee
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Izzet Akosman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Pratyush Shahi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Mitchell Johnson
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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