Impact of Enhanced Recovery After Surgery Protocols on Outcomes Up to Two Years After Adult Structural Spine Disorder Surgery
Authors: Yung Anthony , Onafowokan Oluwatobi O. , Das Ankita , Fisher Max R. , Cottrill Ethan J. , Prado Isabel P. , Ivasyk Iryna , Wu Caroline M. , Tretiakov Peter S. , Lord Elizbeth L. , Jankowski Pawel P. , Orndorff Douglas G. , Schoenfeld Andrew J. , Shaffrey Christopher I. , Passias Peter G. 
Published: November 2024

Study Design.
Retrospective cohort study of prospectively enrolled database.

Objective.
We analyze the recovery pattern of patients with adult structural spine disorder (ASD) who underwent corrective surgery with enhanced recovery after surgery (ERAS+) protocol, including physical and psychological prehabilitation components, compared with a non-ERAS protocol (ERAS-) up to 2 years (2Y) after surgery.

Background.
Spine surgery for ASD is often highly invasive, which can contribute to prolonged recovery. The trajectory of recovery may be accelerated by the application of enhanced recovery principles.

Materials and Methods.
Inclusion criteria were operative patients with ASD older than 18 years with complete baseline, 90 days perioperative, and 2Y postoperative data. We assessed differences in baseline demographics, surgical details, baseline health-related quality of life (HRQL), and surgical outcomes between ERAS+ and ERAS- patients. Outcomes included adverse events, reoperations, and radiographic parameters such as sacral slope, pelvic tilt, pelvic incidence-lumbar lordosis mismatch, sagittal vertical axis, lumbar lordosis, T2 to T12 kyphosis, and maximum Cobb angle. In addition, HRQL measures included the physical component summary, Oswestry Disability Index, Neck Disability Index, EuroQol 5 dimensions, Scoliosis Research Society Questionnaire 22r total and domain scores, Numeric Pain Rating Scale–back, and Numeric Pain Rating Scale–leg. We used multivariable logistic regression and analysis of covariance to adjust for confounding.

Results.
A total of 471 patients with ASD met the inclusion criteria, with 59 designated ERAS+. Those individuals with ERAS+ were older (64.1 ± 13.0 vs. 58.0 ± 16.0; P = 0.005), had a higher Charlson Comorbidity Index, (2.4 ± 1.8 vs. 1.4 ± 1.6; P < 0.001), and exhibited a higher modified ASD frailty index (8.2 ± 5.4 vs. 6.3 ± 4.9; P = 0.019). The adjusted analysis demonstrated the ERAS+ cohort demonstrated a lower likelihood of overall reoperations (Odds ratio (OR): 0.3; 95% CI: 0.13–0.89), and a lower likelihood of overall adverse events (OR: 0.4; 95% CI: 0.19–0.93). ERAS+ was more likely to achieve the minimal clinically important difference in the Scoliosis Research Society Questionnaire 22r total scores at 6 months (6M; OR: 3.1; 95% CI: 1.2–8.4), self-image domain at 6M (OR: 9.0; 95% CI: 1.6–50.0), in the pain domain at 6M (OR: 3.5; 95% CI: 1.01–11.9) and 1 year postoperatively (OR: 2.6; 95% CI: 1.03–6.7), and in the SF-36’s physical component summary (PCS) scores at 1 year (OR: 2.1; 95% CI: 1.05–4.2). No other statistically significant differences in HRQL were observed at the remaining time points (P > 0.05).

Conclusion.
Our work is the first to evaluate HRQL metrics and complications over 2Y following ASD correction with ERAS. Despite presenting with more severe baseline frailty and higher comorbidity profiles, patients with ASD who underwent corrective surgery with an ERAS protocol experienced fewer short-term adverse events and improved HRQL. We believe ERAS following ASD surgery leads to faster functional recovery, reduced postoperative deconditioning, and improved quality of life.