Could a Danish Professor of Surgery Transform U.S. Spine?

From home to hospital and home again, every patient hopes for a smooth journey. Even if all goes well clinically, however, in a traditional recovery scenario, healing may be delayed or impeded for a number of reasons.

Thanks to a perceptive colorectal surgeon from Denmark, however, a new system may be able to help orthopedic surgeons refine their clinical signposts and deliver faster, better, indeed, enhanced recovery after surgery.

In fact, the system is called Enhanced Recovery After Surgery…ERAS.

Ellen M. Soffin, M.D., Ph.D., assistant attending anesthesiologist at Hospital for Special Surgery (HSS) in New York and the lead anesthesiologist on a multidisciplinary team applying ERAS principles to spine surgery, received a $25,000 grant from the HSS Spine Service Research Fund to bring the ERAS approach to spine surgery.

Dr. Soffin told OTW, “In the mid-1990s Professor Henrik Kehlet, Ph.D., M.D., from the University of Copenhagen and winner of the 2014 Excellence in Research award from the American Society of Anesthesiologists, began asking, ‘Why is it that with all of the knowledge we have about interventions that positively affect outcomes, that patients receive different care and have different complications after getting the same procedures in different facilities?’”

“One part of Professor Kehlet’s solution was to take the best available evidence for all interventions that contribute to a good outcome, bundle them into a standardized package of care, and deliver that package to the patient, thus ensuring the delivery of top-of-the-line care. You’re basically bundling the benefits of a systems approach so that you can track what you’ve done and examine the outcomes.”

Todd Albert, M.D., surgeon-in-chief, chief medical officer and Korein-Wilson Professor of Orthopedic Surgery at HSS, said, “ERAS has proven itself to be beneficial in a number of surgical subspecialties, resulting in improved outcomes and patient satisfaction, as well as reduced length of stay (LOS) and complications.”

“The ERAS principles have yet to be applied to spine surgery. HSS’s Sheeraz Qureshi, M.D., M.B.A. and I are co-authors of two studies on ERAS, one involving minimally invasive surgery (MIS) lumbar decompression and another on anterior cervical surgery.”

“Our team developed a 15-item ERAS protocol for lumbar decompression that includes a range of pre-, intra- and postoperative components, including pre-emptive analgesia, standardized intraoperative anesthesia, minimally invasive surgical techniques, and postoperative physical therapy and opioid-sparing analgesia.”

Cutting Average Length of Stay to 4 Hours

“In the lumbar decompression study we found the median length of stay was just over 4 hours. There were no admissions to the hospital, although 4 patients required extended stay—3 of them for pain control. Importantly, we did not observe any complications or readmissions within 30 days of surgery.

And what happened when HSS used its ERAS in anterior cervical surgery?

Dr. Albert told OTW, “We had 34 patients cared for under the pathway, 26 of whom were discharged on the day of surgery. The median length of stay was 16 hours/38 minutes. Extended observation was required in 8 patients due to pain or for respiratory monitoring. We were very pleased that the overall pathway compliance was 82.2%.”

Eliminate the Need for Opioids in Spine Surgery

And, says Dr. Albert, the opioid issue is paramount when it comes to planning and implementing an ERAS protocol. In fact, he envisions spine patients leaving the hospital having never seen an opioid.

“Interestingly, over 37% of the lumbar decompression cohort was identified as opioid tolerant on the day of surgery. Although opioid tolerance is typically associated with prolonged length of stay and more overall complications, we did not find any effect of opioid use on time-to-discharge or other complications.”

“We believe an ERAS strategy that includes multimodal analgesia, postoperative nausea and vomiting (PONV) prophylaxis, short surgical duration and minimally invasive techniques can mitigate or eliminate the need for opioids.”

“Based on our findings, we are creating protocols and pathways that will allow patients to recover faster after surgery and with less pain, nausea, etc. We have already found that patients are ambulatory faster and more alert when they receive less total perioperative opioid. This is especially important for the opiate naive patient.”

“Based on our initial findings, we designed an opioid-free protocol for lumbar microdiscectomy. We are currently analyzing data from 20 patients who have received zero pre- and intraoperative opioids. Not only do these patients have acceptable pain scores in the PACU [post anesthesia care unit], but they are literally setting records for how fast they are ready to leave the recovery room—as little as 3 hours after surgery.”

Albert’s Three Goals

Dr. Albert has three basic goals for the ERAS program.

“We now have a service-specific study underway whose primary goal is to assess the average opioid medication they are being given (how many pills) and how many they take.”

“The second goal is to examine service-specific guidelines, i.e., since instituting guidelines number of pills saved in a year ranged from 2800 (carpal tunnel) to 19,600 (spinal decompression).”

“Our third goal is to use ERAS to create multimodal pain relief (preoperative gabapentin, dual antiemetic therapy, IV Tylenol, etc.).”

Putting ERAS to Work in Spine

As for Dr. Soffin, she always has the fundamental question in mind, “What are the gaps in our knowledge or willingness that are preventing us from providing the highest-level of care on a consistent basis, and how can ERAS help us do better?”

“In spine surgery we have been late to the party with regard to ERAS. I think this is partly because the evidence base is somewhat underdeveloped to guide us in choosing ERAS components that may benefit spine surgery patients.”

But now that ERAS is gaining traction in the orthopedic arena, there is no going back. Patients will begin asking for it.

Dr. Soffin, also a co-investigator on these studies, told OTW, “It’s no accident that the first component of an ERAS pathway is usually patient education, something that starts when the decision is made to proceed with surgery. These protocols may be anesthesia-driven, but surgeons have a huge opportunity to introduce the concept of recovery. Patients are informed early and often how they can take control of their recovery process.”

“In many cases, the physical therapist meets with patients in advance of surgery.”

“We have formal preoperative classes that are mandatory for joint replacement (not for spine at the moment).”

“Nutrition is also part of the protocol. Professor Kehlet hypothesized that if patients fast after midnight before an elective procedure then they are presenting the OR in a catabolic state, which is not optimal for recovery. Healing and tissue repair depend on an anabolic state. We advocate for a safe, shorter fast of approximately four hours depending on the surgery. Our work has shown that early, postoperative oral nutrition is beneficial, thus we allow patients to eat in the recovery room whenever they are ready. Our ongoing research indicates that early oral nutrition is driving patient satisfaction…and indeed the quality of the recovery does appear to be superior when this aspect of the protocol is followed.”

The Key Is Pain Management and the Anesthesiologist

Dr. Soffin notes, “One major complication that impedes recovery is pain. If you are incapacitated by pain then you cannot work with physical therapy. Postoperative immobility is too often followed by respiratory compromise and thromboembolic events. And to treat the pain, opioids have so many side effects (constipation, nausea, vomiting, sedation, respiratory depression, etc.).”

“The reason anesthesiologists are so well poised to advance ERAS is that we have the tools to address pain, namely regional analgesia, peripheral nerve blocks, and multimodal analgesia.”

So where should a hospital start if it wants to embark on an ERAS pathway?

Dr. Soffin says, “The perceived wisdom says that you start locally to show benefits, and then approach the hospital administration. Find the key champions who will propel the effort forward. Show them what our team of committed anesthesiologists and surgeons has done using ERAS for spine at our facility.”

“Go to the literature and uncover evidence for the components of care that work. There are now even major societies such as The ERAS Society and The American Society for Enhanced Recovery that have a wealth of resources on how to construct and implement an ERAS pathway.”

The future looks promising for these evidence-based protocols, says Dr. Soffin. “Virtually every study published to date has obtained results indicating that ERAS definitely improves outcomes, reduces LOS, and enhances patient care. By using the best available medical science to craft a reproducible experience we can offer patients the most up-to-date and high-quality recovery available.”