Newly Published
Perioperative Medicine  |   May 2020
Enhanced Recovery after Lumbar Spine Fusion: A Randomized Controlled Trial to Assess the Quality of Patient Recovery
Author Notes
  • From the Departments of Anesthesiology, Critical Care and Pain Management, (E.M.S., J.D.B., A.T., M.U., C.R.G., J.A.N., I.F.A., S.G.M.), Orthopedic Surgery (R.C.H., H.-J.K., F.P.C., F.J.S.), and the Biostatistics Core (H.Z.), Hospital for Special Surgery, New York, New York; and Weill Cornell Medical College, New York, New York.
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication December 23, 2019. Accepted for publication April 10, 2020.
    Submitted for publication December 23, 2019. Accepted for publication April 10, 2020.×
  • Correspondence: Address correspondence to Dr. Soffin: Critical Care and Pain Management Hospital for Special Surgery, 535 East 70th Street, New York, New York 10021. soffine@hss.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Gastrointestinal and Hepatic Systems / Neurosurgical Anesthesia / Pain Medicine / Pharmacology / Quality Improvement / Opioid
Perioperative Medicine   |   May 2020
Enhanced Recovery after Lumbar Spine Fusion: A Randomized Controlled Trial to Assess the Quality of Patient Recovery
Anesthesiology Newly Published on May 18, 2020. doi:https://doi.org/10.1097/ALN.0000000000003346
Anesthesiology Newly Published on May 18, 2020. doi:https://doi.org/10.1097/ALN.0000000000003346
Abstract

Background: Prospective trials of enhanced recovery after spine surgery are lacking. We tested the hypothesis that an enhanced recovery pathway improves quality of recovery after one- to two-level lumbar fusion.

Methods: A patient- and assessor-blinded trial of 56 patients randomized to enhanced recovery (17 evidence-based pre-, intra-, and postoperative care elements) or usual care was performed. The primary outcome was Quality of Recovery-40 score (40 to 200 points) at postoperative day 3. Twelve points defined the clinically important difference. Secondary outcomes included Quality of Recovery-40 at days 0 to 2, 14, and 56; time to oral intake and discharge from physical therapy; length of stay; numeric pain scores (0 to 10); opioid consumption (morphine equivalents); duration of intravenous patient-controlled analgesia use; complications; and markers of surgical stress (interleukin 6, cortisol, and C-reactive protein).

Results: The analysis included 25 enhanced recovery patients and 26 usual care patients. Significantly higher Quality of Recovery-40 scores were found in the enhanced recovery group at postoperative day 3 (179 ± 14 vs. 170 ± 16; P = 0.041) without reaching the clinically important difference. There were no significant differences in recovery scores at days 0 (175 ± 16 vs. 162 ± 22; P = 0.059), 1 (174 ± 18 vs. 164 ± 15; P = 0.050), 2 (174 ± 18 vs. 167 ± 17; P = 0.289), 14 (184 ± 13 vs. 180 ± 12; P = 0.500), and 56 (187 ± 14 vs. 190 ± 8; P = 0.801). In the enhanced recovery group, subscores on the Quality of Recovery-40 comfort dimension were higher (longitudinal mean score difference, 4; 95% CI, 1, 7; P = 0.008); time to oral intake (−3 h; 95% CI, −6, −0.5; P = 0.010); and duration of intravenous patient-controlled analgesia (−11 h; 95% CI, −19, −6; P < 0.001) were shorter; opioid consumption was lower at day 1 (−57 mg; 95% CI, −130, −5; P = 0.030) without adversely affecting pain scores (−2; 95% CI, −3, 0; P = 0.005); and C-reactive protein was lower at day 3 (6.1; 95% CI, 3.8, 15.7 vs. 15.9; 95% CI, 6.6, 19.7; P = 0.037).

Conclusions: Statistically significant gains in early recovery were achieved by an enhanced recovery pathway. However, significant clinical impact was not demonstrated.

Editor’s Perspective:

What We Already Know about This Topic:

  • Recovery from surgery may be improved by optimizing pre-, intra-, and postoperative management.

  • Enhanced recovery pathways involving spine surgery have scarcely been evaluated.

What This Article Tells Us That Is New:

  • Use of an enhanced recovery pathway for patients undergoing one- or two-level lumbar spinal fusion was associated with higher (better) Quality of Recovery-40 scores 3 days after surgery. This difference was not deemed clinically significant, however.

  • Several secondary endpoints including time to oral intake, duration of patient-controlled analgesia use, and day 1 opioid consumption were improved by use of the enhanced recovery pathway.

  • Further refinement of enhanced recovery strategies for spinal surgery is required.