Abstract
BackgroundEnhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review.MethodsWe included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway.ResultsWe identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components.ConclusionsWe identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS.Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.
Highlights
Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes
During the review of full text articles, we excluded studies which did not pertain to the topic studied, which did not describe the intervention in sufficient detail or published articles which were not methodologically suited
Where studies were not available pertaining to pre-defined pathway component of spinal surgery, databases and grey literature were reviewed as relating to societal recommendations and major pertinent studies for perioperative patient management
Summary
Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review. Enhanced recovery after surgery (ERAS) programs have demonstrated improvements in outcomes. Improvements have been demonstrated in recovery, functional measures, lower morbidity, decreased length of stay with healthcare cost savings [1, 2]. Limited enhanced recovery pathways have been applied to spinal surgery. A consistent feature is a uniform finding of decreased length of stay [5,6,7,8]. There was a notable decrease in the adverse events during hospital stay [8, 9]
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