Enhanced Recovery After Surgery (ERAS)

Enhanced Recovery After Surgery is a multi-faceted, multidisciplinary approach that aims to put the patient in charge of their recovery after spine surgery, reduce the need for opioids and improve overall outcomes.

Far too often, the key to recovering from spine surgery in the United States can be summed up in one word: opioids.

However, a new spinal surgery recovery technique known as Enhanced Recovery After Surgery (ERAS) is turning this into a thing of the past. This philosophy is providing a dramatic, groundbreaking shift in care that is resulting in better clinical outcomes, shorter recovery periods and reduced costs with very few, if any, opioids.

But first, it’s worth discussing the problem.

The State of Prescription Opioids

Opioids, a form of prescription pain relievers, are used to fight pain after elective spine surgery (and many other procedures). Over 289 million prescriptions are written for them each year.

Unfortunately, such liberal prescribing of the highly addictive drugs has taken its toll. Opioid overdoses claim the lives of over 72,000 people on a yearly basis and approximately 2 million people will transition to persistent opioid use after their surgery in 2019.

The numbers are staggering and they stem back to the culture of over-prescribing and a cookie-cutter approach to surgical recovery.

Over 85% of patients receive a prescription for pain medication after their spine surgery. It’s become the standard practice, which has led to widespread abuse throughout the nation.

The problem is that much of the time, these prescriptions are given unnecessarily or excessively and patients aren’t properly instructed on how they should take the drugs and what they should do with them after they have made their recovery. According to one study, 67% of the opioids prescribed after surgery weren’t taken by patients and 80% simply left their unused pills somewhere in the house. The blame often stems back to healthcare providers who are prescribing an inconsistent number of pills; a study at one hospital found that they could range anywhere from 0 to 120.

Painkillers can certainly have their place in the recovery process, but when they are given out without any thought or consideration of the patient, it’s an easy gateway to abuse.

Unused medication opens wide the door to abuse for the patient or family members who know where the drugs are stored. As a matter of fact, 75% of heroin users report that they initially started with opioids, typically left over from another patient’s prescription.

ERAS is attempting to solve this epidemic by getting the patient actively involved in their recovery. This philosophy utilizes intimate patient communication, preoperative preparation and intraoperative, minimally invasive, opioid-sparing techniques that help patients achieve their recovery goals with less, if any, need for prescription pain medication.

Summary

The liberal and often unnecessary prescribing of opioids has led to an epidemic of abuse and harm caused by the drugs. Enhanced Recovery After Surgery is attempting to solve this national dilemma.

WHAT IS ENHANCED RECOVERY AFTER SURGERY?

Enhanced Recovery After Surgery is a multi-faceted, multidisciplinary approach that aims to put the patient in charge of their recovery after spine surgery, reduce the need for opioids and improve overall outcomes.1

Too often in healthcare, as a result of understaffing, overworking and limited training, patients are ushered through a cookie-cutter system that is designed to get them in and out of the operating room and hospital as quickly as possible. While surgeons from every facet of care can still deliver incredible results in this type of environment, often it comes at the expense of the patient.

The typical recovery/pain management regimen in today’s healthcare environment looks something like this:

  1. A patient is assessed before surgery to make sure that they’re a good fit for the operation and that it has a good chance of having a favorable outcome.

  2. Surgery is performed.

  3. The patient is once again assessed after the operation, prescribed opioid/non-opioid medication for pain management and discharged.

  4. There may or may not be a follow up appointment based on office and patient availability

As you can see, this model is efficient, but impersonal. It places the emphasis on time as opposed to patients’ overall wellbeing.

This is where ERAS truly changes the game.

At its heart, ERAS is intimately patient-centered and puts their needs at the center of every step of the operation. From taking the time to prepare them properly for surgery to developing a personalized postoperative plan, this recovery model is vastly different than what is currently considered “standard” in the industry.

THE ENHANCED RECOVERY AFTER SURGERY RECOVERY MODEL

The ERAS model can be broken down into five different stages: Preadmission, Preoperative, Intraoperative, Postoperative and Post-discharge/Active Recovery. Each stage of this pathway is carefully designed to be tailored to the needs of each patient and ensure that they not only receive a positive surgical outcome but that they’re able to return to a normal, pain-free life as quickly as possible.

We’ll break down each of these stages below:

1. PREADMISSION

The Preadmission stage of ERAS is all about education and planning to make sure that the patient is fully aware of what to expect from their surgery, informed about the possible outcomes and has a practical plan set in place to ensure the quickest and best possible recovery.

Education is one of the most important, though perhaps the most overlooked, aspects of surgery. Many surgeons and nurses do not adequately prepare their patients for spine surgery. This can cause unnecessary anxiety, which studies are finding might actually have an impact on their surgical outcome as a whole.

On the other hand, by learning exactly what is happening in their spine and walking through the specifics of their surgery, patients are able to regain some control over their situation and feel more at ease with the procedure as a whole. As a matter of fact, studies are beginning to find that patients who are better-educated about their surgery typically have better outcomes.

Consultation

The preadmission stage starts with a face-to-face consultation with your neurosurgeon. They will examine any previous scans taken of your spine, ask you questions about your current levels of pain, medical history, lifestyle and other topics to get a comprehensive understanding of where you are physically in order to plot a proper direction for surgery. Additionally, they will try to get a grasp on your expectations from surgery.

At this point, your spine surgeon will recommend a surgical procedure or another conservative treatment option tailored to your specific condition. If you opt for surgery, you will enter what is known as the education phase of preadmission.

Education/Intervention

During this time, you will receive dedicated preoperative counseling from your neurosurgeon and an ERAS-certified nurse practitioner. At this point, they will explain exactly what’s going to happen in your specific surgery, the reasoning behind why they’re taking that approach and be available to address any questions or concerns that you may have about the operation. They will also walk you through the active role that you need to be playing in preparation for the operation, specifically in terms of your personal health.

This is what is known as a preadmission intervention. During this time, expect your nurse practitioner or neurosurgeon to be very honest about where you are in terms of your health and how that might play a role in the operation. They will also help you lay out a preoperative plan to optimize your health before the surgery ever takes place.

This typically includes an exercise routine to help strengthen the areas around the operating site in the spine, recommendations for alcohol and tobacco cessation in the weeks leading up to your surgery and, if applicable, the identification and correction of anemia, or deficiency of iron in the blood.

There will also likely be a discussion of how long you should expect to be in the hospital, a transparent discussion of the risks that come along with the surgery and what you expect to feel during the recovery phase.

Your nurse practitioner will help you create a customized plan management plan that will fit your specific needs and is ready to go the moment that you wake up from surgery.

Each of these pieces are included to help manage your expectations as a patient and keep you fully informed throughout the process.

​Summary

The preadmission stage is designed to help educate you and your family on what to expect from your surgery, get you involved in optimizing your health in the weeks leading up to the procedure and help develop a treatment plan tailored to your specific needs.

2. PREOPERATIVE

The preoperative phase of ERAS begins in the weeks leading up to your spine surgery and includes committed, patient-driven health optimization and fasting guidelines to prepare you for the procedure.

As we mentioned previously, during the preadmission stage, your neurosurgeon and ERAS-certified nurse practitioner will help lay out a health plan to help strengthen your body before surgery. This can include cessation of smoking and alcohol consumption, a better diet or simply an exercise regimen dedicated to help promote positive outcomes during surgery.

ERAS guidelines can help relieve some of the discomforts leading up to the procedure by reducing the amount of time fasting and the anxiety that can naturally come as a result of the operation. Additionally, steps are taken in to prepare the bodies of patients for intraoperative and postoperative recovery and pain management.

Fasting

In the hours leading up to your surgery, you will be given some fasting guidelines to help keep you safe while you’re under general anesthesia.

For decades, patients have been told that they are required to refrain from eating or drinking anything 6-12 hours before their operation which gives food and liquid enough time to move through the stomach and digestive system.

However, despite this being the common practice in healthcare, these recommendations are not based on any meaningful science and continue to persist despite the fact that more and more studies are beginning to find that prolonged fasting can actually delay patient recovery and cause poorer outcomes.

Additionally, it has very little, if any, impact during the operation itself. Physicians recommend that you fast leading up to your surgery because general anesthesia can cause vomiting, which could result in aspiration (vomit going down into your lungs) or other complications.

However, studies have found that there really is no difference in the amount of gastric content or gastric pH in patients who drank clear liquids 12 hours before surgery and patients who drank clear liquids 2 hours before surgery.

This being the case, ERAS preoperative guidelines follow the updated recommendations from the American Society of Anaesthesiology and other international organizations which recommend that patients actually drink clear liquids up to 2 hours before surgery and ingest a light meal 6 hours before their procedure.

Below is a summary of the guidelines from the American Society of Anaesthesiology:


Carbohydrate Drink

In addition to fasting, your ERAS-certified nurse practitioner will also give you a commercially available carbohydrate-rich drink, like Gatorade, to consume 2-3 hours before your operation.

Surgery naturally induces what is known as a catabolic state in the body. This response causes the body to break down fats and proteins while protecting fluids and electrolytes, all of which are essential components of the recovery process.

However, studies have found that drinking a carbohydrate-rich drink before a surgical operation puts the patient’s body in a metabolically fed state which reduces the loss of critical fats, proteins and nitrogen. It also helps maintain muscle strength and lean body mass which give the body strength after the surgery is completed.

On a very practical level, being able to eat and drink also reduces preoperative thirst, hunger and anxiety which helps the patient feel more at ease before going under anesthesia.

Premedication

Finally, the ERAS model requires physicians to properly prepare the patient’s body for pain management and recovery; this often comes through the method of premedication.

Premedication can and does often involve giving the patient light pain-management medicine before their operation. This is used primarily to prevent the use of intraoperative opioids.

However, premedication also typically involves many other non pharmacological preparation methods that keep patients away from addicting opioids and other drugs that can have detrimental side-effects.

Studies have found that approximately 80% of patients show signs of anxiety before their surgery. This isn’t uncommon and doctors will often prescribe forms of medication and sedatives to help calm nerves. However, most medication comes with side-effects and these sedatives are no different. As a matter of fact, they can actually impair the patient’s ability to properly perform all of their preoperative responsibilities like eating, drinking and exercising.

Rather than turn immediately to medication, the ERAS model focuses on helping patients find relief from anxiety naturally. One of the most effective ways of doing this includes a preoperative meeting with their anesthesiologist where they can address questions and concerns as well as pick out calming music that will play as they’re being prepared for the operation.

Summary

The Preoperative stage is dedicated to prepare the patient for surgery and a quick recovery in the days leading up to their procedure.

3. INTRAOPERATIVE

During the intraoperative phase of ERAS, the main focus of the surgeon is to perform the procedure with minimal disruption to the tissue surrounding the spine and reducing the amount of opioids being delivered to the body.

Anesthesia

When the patient is first taken into the operating room, the anaesthesiologists will apply what is known standard anesthesia protocol which, essentially, means that they will use typical anesthesia chemicals to put you asleep for the entire operation.

However, in accordance with ERAS regulations, they will use short-acting agents like sevoflurane or desflurane that allow patients to wake up quickly and are more likely to reduce postoperative nausea and vomiting. This is important because recovering from anesthesia is often one of the first major hurdles that a patient must jump over after the surgery is complete.

Additionally, surgeons will use what is known as regional or local anesthesia to numb a specific area of the body. You’ve likely experienced regional anesthesia if you’ve ever had a tooth drilled at the dentist office or been to the emergency room for stitches.

Essentially, your anesthesiologist will use a needle injection to numb the nerves in the area surrounding the incision site, ensuring that you feel nothing during the procedure while keeping the body calm and stable. This allows them to use less pain killing opioids during the operation which means that the body is less likely to be dependent on them for pain management further down the road.

This is an absolutely essential point to make because approximately 99% of patients who receive surgery in the United States are prescribed opioids at some point during the course of their operation. However, studies are beginning to find that, in many cases, the use of these pain-management drugs, especially during surgery, is unnecessary.

The ERAS method allows surgeons to use less, if any, intraoperative opioids which, apart from reducing the risk of dependence and abuse in the patient, can also help reduce some of the undesirable side-effects that come along with the drugs and actually keep them safer during and immediately after the operation.

Minimally Invasive Spine Surgery

Another key component of ERAS is the methodology of the surgery itself. Minimally invasive spine surgery, often coupled with robotic spine surgery or endoscopic spine surgery, aims to cause as little disruption to the body as possible while achieving the highest levels of accuracy. When a minimally invasive methodology is used, it allows patients to have a safer operation and achieve a much quicker recovery.

Physicians achieve this by working through a small opening in the back, usually two inches or less, and using high-definition visualization and precision robotics to ensure that the surgery is performed safely and accurately.

Intravenous Fluid (IV) Therapy

Intravenous fluid, also commonly known as an IV, is a commonly used asset in the operating room that helps maintain a normal state of blood, salt and other vital fluids in the body.

However, studies have begun to find that even a small miscalculation in the amount of fluid pumped into the body, whether too much or too little, can be very dangerous.

There is no one-size-fits all solutions for patients across the board. Therefore, it’s very important for surgeons and nurse-practitioners to be monitoring a patient’s response to IV fluid very carefully and ensuring that their bodies maintain a level, normal amount of blood. This can be done by monitoring the heart and the pressure inside the veins and arteries.

Based on what they’re seeing, nurses can carefully adjust the amount of fluid being delivered into the body to ensure a safe and healthy operation.

Active Warming

Finally, in order to keep the patient as safe as possible while also maximizing their recovery potential, surgeons following ERAS-guidelines may also use an active warming device and core temperature monitoring to ensure that there is no risk of intraoperative hypothermia.

Summary

The intraoperative stage of ERAS focuses on speeding up your recovery by minimizing the invasiveness of the surgery, using fewer opioids during the procedure and using techniques to help you wake up from anesthesia more quickly.

4. POSTOPERATIVE

The postoperative stage of ERAS is one of the most important because it’s the first time that the patient will actually be in the process of recovering from their surgery and is focused on helping them get back to their normal life as quickly as possible.

Opioids

As we’ve mentioned before, studies have found that the vast majority of patients receive a prescription for opioids after the completion of their surgery. ERAS attempts to put a stop to the liberal and uneducated prescribing of opioids to patients.

The first way it does this is by simply prescribing less, if any opioids at all. All the preoperative steps leading up to this point, whether they be diet, exercise or education, have been designed to prepare the patient’s body for surgery and help it recover more quickly. Additionally, the use of minimally invasive surgery, less intraoperative opioids, less anesthesia and close monitoring of the body all help make the recovery process more speedy and less painful for the patient.

Customized Recovery Plan

When the patient first wakes up from their spine surgery, an ERAS-certified nurse practitioner is responsible for assessing their level of pain. Based on how they are feeling, the NP will make any necessary adjustments to the pain management plan that they set out with the patient in the preoperative phase of ERAS.

This is a really important part of the recovery model. Every patient is different and every patient experiences surgery differently. Their bodies may require more time to recover, they may be more sensitive to pain than they originally imagined, they may feel absolutely fine and able to function normally. It’s difficult to say for sure until the surgery has actually been completed.

At this point, nurse practitioners are able to make educated decisions about the patient’s recovery plan and tailor the regimine to each individual person.

This is vastly different than what is currently practiced in the healthcare industry.

On the contrary, opioids are often viewed as the one-pill-fixes-all solution for patients. Doctors and nurses simply don’t have, or won’t take, the time to customize a treatment plan for every patient they see. Rather, they prescribe pain medication and send them on their way with well-wishes and glad tidings. That’s not enough and it’s leaving uninformed people to fend for themselves in one of the most critical parts of their care.

Patients should not be content with a doctor who performs a surgery and considers their job done.

The job is done when you have recovered recovered from your surgery and are satisfied with the results of your procedure.

Think about it this way:

Say you’ve hired a contractor to come into your home and help you get rid of some mold that has started taking over your basement. You are paying them to see the project through to completion, right? You might even lay out a contract with them, spelling out exactly what you expect your money will get you and what completion of the project looks like in your eyes. In this case, it would be removing the mold from the basement and returning the area to a normal, breathable state.

Now, what would you do if that contractor completely gutted your basement, pulled out all the mold and called the job done. Certainly he got out what was causing the problem, but he didn’t finish the job.

The job is done when the contractor has met the expectations that you laid out in the original contract. If he hasn’t done that, the job isn’t done. You might call him back to your house, you might call his boss and demand a refund, you might even take him to court. Not finishing a job you’ve been paid for is a pretty serious offense.

It’s similar in healthcare, the only difference is that since you’re typically not paying the physician directly so there’s a little less skin in the game for them. The healthcare industry knows that they’re going to get paid regardless of your results. You could have a failed back surgery and be in the same amount of pain that you were in before and they would still get paid. This being the case, they’re incentivized to push as many people through the operating room as possible, regardless of their outcomes.

This shouldn’t be the case, and customized recovery plans based on ERAS guidelines are changing the healthcare industry for the better.

Not only will your ERAS-certified nurse practitioner help you customize your recovery plan, but if certain multimodal medications are required for pain management and recovery, they’ll also take the time to walk you through how you should handle the drugs safely and effectively. They also will not prescribe any more than are absolutely necessary, helping avoid the risk of addiction.

Additionally, they will also walk you through how to recover from your anesthesia and prepare you for what you should expect in the following hours and days in terms of pain and post-surgical bodily behavior. Expect to receive practical, understandable instructions on what you should eat, what kind of activities you should do and which ones you should avoid, how to sit, how to sleep, how to stretch and more.

These instructions are designed to put you, not opioids, in the driver’s seat of your recovery and help it go as smoothly and quickly as possible.

Summary

The postoperative stage of ERAS gives you active control of your recovery from the moment you wake up from anesthesia. Your physician and nurse practitioner immediately diagnoses your condition and adjusts your recovery plan to match where you are.

5. POST DISCHARGE & ACTIVE RECOVERY

The final component of the ERAS recovery pathway is known as the post discharge, active recovery stage. This is the period of time that begins the moment you leave the hospital all the way through your recovery.

Many healthcare providers will schedule a follow up appointment with patients after their surgery, just to check in and address any problems or concerns that may have come up during recovery.

However, ERAS takes this a step further. Expect to have at least one follow up appointment with your nurse practitioner where you sit down and analyse how your recovery is going in terms of pain and compliance with the steps laid out for you after your surgery. From there, your NP can tailor your treatment plan and make sure it’s still meeting your goals and right for where you are in the recovery process.

Additionally, your nurse practitioner will be fully available to you by phone, email or in-office consultations whenever you have a question or concern. They will walk alongside you every step of your recovery and make sure that you achieve the best recovery possible.

Summary

In the post discharge / active recovery phase of ERAS, you will work alongside your nurse practitioner to tailor your customized recovery plan to meet your current, post-surgical needs.

WHAT ARE THE BENEFITS OF ENHANCED RECOVERY AFTER SURGERY (ERAS)?

The results of ERAS after surgery are groundbreaking in healthcare. This philosophy allows patients to spend less time in the hospital, enjoy a quicker recovery, save money, need less opioids, and reduce readmission rates.

LESS TIME IN THE HOSPITAL

Spending less time in bed at the hospital is typically a top-priority for most patients and caring physicians. Getting people out of bed rest and back home typically helps promote a faster, safer recovery.

From a practical side, people are much more comfortable and relaxed when they’re at home. They’re able to do things on their own schedule, feel safer and typically have the constant support of their family and friends around them.

In terms of personal health, it’s also beneficial to get out of the hospital as soon as you can because staying in a medical facility can actually increase your chances of getting an infection after your surgery.

The truth of the matter is that hospitals are full of sick people and germs. Most do a great job of maintaining sanitary conditions for patients, but it’s impossible to remove all risk from the building. Couple this with the fact that patients who are recovering from spine surgery have a fresh wound that is trying to heal really opens up the risk for a postoperative infection. This is why one of the largest risk-factors for getting an infection while in the hospital is the length of stay.

This being the case, it truly benefits patients to leave the hospital as quickly as they can after their surgery.

ERAS allows patients to do this more effectively than any other recovery methodology in healthcare today.

As a matter of fact, minimally invasive, ERAS-guided surgeries allow patients to recover more quickly after they have completed their operation which studies have found can reduce the amount of time they spend in the hospital by an average of 3-4 days, even after major spinal operations.

Considering that the average hospital stay is around 5 days, and the average cost to spend a day in the hospital is between $1,800-$2,200, that’s a pretty significant change.

SAVE MONEY

According to several studies, the ERAS recovery model can help patients save between $800-$5,560 on their operation.

This is the case because care is standardized across the board for the patient. So, instead of jumping around to specialist after specialist to prepare, complete and recover from surgery, ERAS allows patients to get everything they need from fewer places which helps reduce costs.

Additionally, preparing patients properly for surgery and using minimally invasive methods cuts down on costs because it reduces the potential for intensive care, the amount of surgery that’s required and the length of the recovery.

LESS OPIOIDS

Because ERAS prepares patients better for surgery and minimally invasive methodology causes less trauma to the body, patients are able to recover more quickly from their procedure. Often with less, if any, need for opioids.

One study found that patients who used the ERAS pathway consumed an average of 72% less opioids and 16% were completely off opioids by the time they left the hospital after their surgery. Patients that were prescribed pain medication were fully educated on how to use them and were only given what they needed for recovery, nothing more.

QUICKER RECOVERY

As we’ve mentioned quite extensively above, ERAS-guidelines are focused on helping patients achieve the quickest recovery possible after their spine surgery.

Thanks to better preparation, smarter operations and tailored recovery plans, patients are able to return to their normal activities more quickly than ever before. In the past, after a typical, open spine surgery, patients could expect a recovery period of about 3-4 months.

Today, thanks to advances in technology and the invention of ERAS patients typically see a nearly full recovery in less than six weeks. Many patients are even able to walk from their stretcher to their hospital bed after surgery, something that is absolutely unheard of in typical spine cases.

CONCLUSION

All in all, Enhanced Recovery after Surgery is changing the patient experience around spine surgery.

Its collaborative nature between the patient and the entire hospital care team allows and encourages you to take charge of your health and play an active role in your surgery. By having the opportunity to be educated about the entire operation, voice concerns, work with a nurse practitioner to develop a personalized recovery plan and set realistic goals, you are able to feel confident going into your procedure and reach your recovery goals more effectively without the use of prescription pain medication.

Spine surgery is still a serious procedure and not something that our physicians will push you into lightly. Our philosophy is to explore every possible conservative option for treating your spinal condition before recommending you for surgery.

However, if minimally invasive spine surgery is your best option for relief, ERAS can help make the entire process less-stressful, safer and more effective.

References

1. Enhanced Recovery after Surgery. (n.d.). Retrieved March 7, 2019, from http://www.future-of-anesthesi...

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Atlantic Brain and Spine A graduate of both Yale and Stanford, Dr. Jae Lim is a board-certified spine surgeon who specializes in minimally invasive spine surgery and robotic spine surgery, significantly reducing surgical impact and recovery times. (703) 876-4270
8501 Arlington Blvd. Suite 330
Fairfax
Virgina
22031
United States
Jae Y. Lim Ben L. Nguyen