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Abstract：
OBJECTIVEEnhanced recovery after surgery (ERAS) has led to a paradigm shift in various surgical specialties. Its application can result in substantial benefits in perioperative healthcare utilization through preoperative physical and mental patient optimization and modulation of the recovery process. Still, ERAS remains relatively new to spine surgery. The authors report their 5-year experience, focusing on ERAS application to a broad population of patients with degenerative spine conditions undergoing elective surgical procedures, including anterior lumbar interbody fusion (ALIF).METHODSA multimodal ERAS protocol was applied between November 2013 and October 2018. The authors analyze hospital stay, perioperative outcomes, readmissions, and adverse events obtained from a prospective institutional registry. Elective tubular microdiscectomy and mini-open decompression as well as minimally invasive (MI) anterior or posterior fusion cases were included. Their institutional ERAS protocol contains 22 pre-, intra-, and postoperative elements, including preoperative patient counseling, MI techniques, early mobilization and oral intake, minimal postoperative restrictions, and regular audits.RESULTSA total of 2592 consecutive patients were included, with 199 (8%) undergoing fusion. The mean hospital stay was 1.1 ± 1.2 days, with 20 (0.8%) 30-day and 36 (1.4%) 60-day readmissions. Ninety-four percent of patients were discharged after a maximum 1-night hospital stay. Over the 5-year period, a clear trend toward a higher proportion of patients discharged home after a 1-night stay was observed (p < 0.001), with a concomitant decrease in adverse events in the overall cohort (p = 0.025) and without increase in readmissions. For fusion procedures, the rate of 1-night hospital stays increased from 26% to 85% (p < 0.001). Similarly, the average length of hospital stay decreased steadily from 2.4 ± 1.2 days to 1.5 ± 0.3 days (p < 0.001), with a notable concomitant decrease in variance, resulting in an estimated reduction in nursing costs of 46.8%.CONCLUSIONSApplication of an ERAS protocol over 5 years to a diverse population of patients undergoing surgical procedures, including ALIF, for treatment of degenerative spine conditions was safe and effective, without increase in readmissions. The data from this large case series stress the importance of the multidisciplinary, iterative improvement process to overcome the learning curve associated with ERAS implementation, and the importance of a dedicated perioperative care team. Prospective trials are needed to evaluate spinal ERAS on a higher level of evidence.
摘要：
目的增强手术后恢复（ERAS）导致了各种外科专业的范式转变。它的应用可以通过术前身体和精神患者的优化以及恢复过程的调整，在围手术期的医疗保健利用中带来实质性的好处。尽管如此，ERAS对于脊柱手术来说仍然相对较新。作者报告了他们5年的经验，专注于ERAS应用于接受选择性外科手术的退行性脊柱疾病患者的广泛人群，包括前路腰椎椎间融合术（ALIF）。METHODSA多模式ERAS协议在2013年11月至2018年10月期间应用。作者分析了住院时间，围手术期结局,再入院,以及从前瞻性机构登记处获得的不良事件。包括选择性管状显微椎间盘切除术和微型开放减压以及微创（MI）前后融合病例。他们的机构ERAS协议包含22个pre，intra-,和术后元素，包括术前病人咨询,MI技术，早期动员和口服摄入，最小的术后限制，和定期审计。结果共纳入2592例连续患者，199（8％）进行融合。平均住院时间为1.1±1.2天,30天再入院20例（0.8%），60天再入院36例（1.4%）。94％的患者在最长1晚住院后出院。在5年期间,观察到一个明显的趋势，即出院后回家的患者比例较高（p<0.001），伴随着整体队列中不良事件的减少(p=0.025),而再入院没有增加.对于融合程序，1晚住院率从26%上升至85%(p<0.001).同样，平均住院时间从2.4±1.2天稳步下降到1.5±0.3天(p<0.001)，随着方差的显著降低，导致护理费用估计减少46.8%。结论ERAS方案在5年内应用于接受外科手术的不同人群，包括ALIF,治疗脊柱退行性疾病是安全有效的，不增加再入院。这个大型病例系列的数据强调了多学科的重要性，迭代改进过程，以克服与ERAS实现相关的学习曲线，以及专门的围手术期护理团队的重要性。需要前瞻性试验以更高水平的证据评估脊柱ERAS。
