Introduction

The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes – it has been widely adopted across various surgical disciplines in the past decade. While there are early, encouraging reports of the success of ERAS in spine surgery from developed countries, the design and implementation of an ERAS protocol for spine surgery has not yet been explored in developing countries. The objectives of our study were: i) To design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine surgery by posterior approach and, ii) To compare the results after ERAS implementation in patients undergoing elective lumbar spine surgery with conventional perioperative care in the setting of a public healthcare facility in a developing country

Methods: Hospital records of adult patients who underwent 1- to 3-level elective lumbar spine surgery (either lumbar decompression or lumbar spine fusion) by posterior approach at a single centre were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented in totality at our institute in December 2016 – dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate and patient reported outcome measures (VAS and ODI score) at stipulated time intervals.

Results: A total of 944 patients were included – 502 in the pre-ERAS group and 442 in the post-ERAS group. The two groups did not differ from each other in baseline demographic, clinical and surgery-related variables, including the type and number of levels operated upon. While there was no significant difference between the two groups in the rate of postoperative complications (13.2% v/s 11.8%), 60-day readmissions (1.6% v/s 2.1%) and 60-day reoperation (1.1% v/s 1.1%), a significantly shorter LOS (2.72 days v/s 3.52 days) was observed in the post-ERAS group. Patient-reported outcome scores (VAS and ODI) were similar between the two groups at baseline – but were found to be significantly lower in the post-ERAS group (VAS: 46.8 ± 10.4 v/s 42.8 ± 10.2, ODI: 32.6 ± 14.2 v/s 28.6 ± 11.8) at 4 weeks after surgery. This difference, however, was not significant at intermediate follow-up (6 months and 12 months).

Discussion: It is imperative to validate fruitful use of ERAS in different healthcare settings for it to gain global sanction as a standard of care practice. Our results demonstrate the feasibility of applying ERAS to elective lumbar spine surgery in a developing country. Implementation of an ERAS in such a setting leads to shorter LOS and improved early pain and functional outcome scores, without an added incidence of complications or reoperations.