Enhanced Recovery After Surgery (ERAS) for Spine Surgery

Educational Objectives

The goal of this program is to improve patient outcomes through understanding of enhanced recovery after surgery (ERAS) protocols in spine surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Compare outcomes in patients undergoing spine surgery with and without use of ERAS protocols.

Summary

Extensive spine surgery: is performed frequently in the United States, with postoperative pain presenting substantial challenges because of chronic neuropathic pain and dependence on opioid medication; appropriate pain control is essential for enhanced recovery, and several risk factors contribute to severe postoperative pain, including significant surgical trauma, preexisting neuropathic pain, preoperative opioid use, and preoperative anxiety or mood disorders; inadequate postoperative analgesia has been associated with adverse cardiac and pulmonary events, chronic postsurgical pain, reduced satisfaction, and increased morbidity and mortality; multimodal pain management utilizing acetaminophen, nonsteroidal anti-inflammatory drugs, steroids, lidocaine, N-methyl-d-aspartate antagonists (NMDA), and regional techniques has shown effectiveness in reducing postoperative pain and related complications

Enhanced recovery after surgery (ERAS): represents a multidisciplinary and multimodal strategy that applies procedure-specific evidence-based protocols to improve outcomes; a central feature is the attenuation of the surgical stress response; protocols in spine surgery have demonstrated shorter hospital stays and accelerated functional recovery without increased complications or readmissions; common elements include minimally invasive techniques when feasible, multimodal analgesia, early rehabilitation, and early nutrition

A study from the Hospital for Special Surgery: examined minimally invasive lumbar microdiscectomy or decompression using a protocol with 15 ERAS elements spanning preoperative, intraoperative, and postoperative phases; patients were allowed solid food until 6 hr before surgery and clear fluids until 4 hr prior; a carbohydrate-rich drink was provided 4 hr before surgery; preoperative medications included acetaminophen 1000 mg, gabapentin 300 mg, and scopolamine for high-risk patients; intraoperative management employed total intravenous anesthesia with propofol and ketamine, discretionary opioid use, up to half a MAC of inhaled agent, intravenous ketorolac, lidocaine infusions, and dual antiemetic prophylaxis with ondansetron and dexamethasone

A randomized controlled trial: evaluated whether an ERAS pathway improved recovery after 1- to 2-level lumbar fusion and used a similar protocol to that above with the addition of postoperative hydromorphone patient-controlled analgesia (PCA); the primary endpoint, the QoR-40 score on postoperative day 3, demonstrated higher scores in the ERAS group along with earlier oral intake, reduced PCA duration, lower opioid use, decreased pain scores, and reduced therapy needs, without significant differences in length of stay

Gabapentinoids: are approved for postherpetic neuralgia and seizure adjunct therapy but are used widely for off-label indications (eg, acute and chronic pain, anxiety, sleep disorders, migraine, drug and alcohol withdrawal); a retrospective analysis comparing opioid-treated patients receiving naloxone with or without gabapentinoids identified similar frequencies of respiratory depression, though higher doses in other studies have been associated with greater risk; concerns about non-steroidal anti-inflammatory drugs relate to potential effects on bone healing, with meta-analysis indicating increased delayed union and nonunion but minimal effect at low doses and short durations

Intravenous lidocaine: demonstrated improved pain scores and reduced opioid requirements by ≈25% in a Cleveland Clinic study; ketamine, an NMDA antagonist, has shown benefit in opioid-dependent patients undergoing spine surgery, with meta-analysis confirming reduced postoperative opioid consumption within the first 24 hr; consensus guidelines support its perioperative use in moderate to severe pain and in opioid-tolerant patients, with specified dosing and relative contraindications

Readings

Bansal T, Sharan AD, Garg B. Enhanced recovery after surgery (ERAS) protocol in spine surgery. J Clin Orthop Trauma. 2022;31:101944. Published 2022 Jul 9. doi:10.1016/j.jcot.2022.101944; Debono B, Wainwright TW, Wang MY, et al. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Spine J. 2021;21(5):729-752. doi:10.1016/j.spinee.2021.01.001; Naftalovich R, Singal A, Iskander AJ. Enhanced Recovery After Surgery (ERAS) protocols for spine surgery - review of literature. Anaesthesiol Intensive Ther. 2022;54(1):71-79. doi:10.5114/ait.2022.113961; Pahwa A, Gong H, Li Y. Enhanced recovery after elective spinal surgery: an Australian pilot study. J Spine Surg. 2024;10(1):30-39. doi:10.21037/jss-23-115; Savelloni J, Gunter H, Lee KC, et al. Risk of respiratory depression with opioids and concomitant gabapentinoids. J Pain Res. 2017;10:2635-2641. Published 2017 Nov 10. doi:10.2147/JPR.S144963; Sescu D, Dahiya D, Scaramuzzo L, et al. Optimising postoperative spine outcomes: an umbrella review of enhanced recovery after spinal surgery (ERASS) protocols. Br J Anaesth. 2025;135(6):1663-1683. doi:10.1016/j.bja.2025.08.037.

Disclosures

For this program, members of the faculty and the planning committee reported nothing relevant to disclose. Dr. Harshavardhana’s lecture includes off-label or investigational use of gabapentinoids in acute and chronic pain, anxiety, sleep disorders, migraine, and drug and alcohol withdrawal.

Acknowledgements

Dr. Harshavardhana was recorded at the 2025 Annual Convention and Conclave of the American Osteopathic College of Anesthesiologists, held September 6-9, 2025, in Savannah, GA, and presented by American Osteopathic College of Anesthesiologists. For information about upcoming CME activities from this presenter, please visit https://www.aocaonline.org/. AudioDigest thanks the speakers and American Osteopathic College of Anesthesiologists for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

AN680403

Qualifies for:

ABA MOCA

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.