Enhanced Recovery After Surgery Protocol for Lumbar Spinal Surgery With Regional Anesthesia: A Retrospective Review

Background In the USA, spinal fusion surgery incurs the highest hospital cost. Despite the recent advances in the application of enhanced recovery after surgery (ERAS) protocols in these surgeries, the efficacy of these protocols in improving the perioperative outcomes remains unclear. We conducted a retrospective review as a quality improvement (QI) project to analyze the efficacy of the ERAS protocol with intraoperative modified thoracolumbar interfascial plane (mTLIP) block to determine whether these interventions reduce the length of stay (LOS) and opioid requirements during the postoperative period. Methods Retrospective reviews of adult patients (>18 yrs) who underwent elective lumbar spinal fusion or laminectomy at our institute were reviewed. Patients were administered oral gabapentin and acetaminophen preoperatively. Prior to incision, an mTLIP block was performed using liposomal bupivacaine. Intraoperatively, ketamine, ketorolac, and tranexamic acid were administered. Postoperative, pain control was treated with scheduled acetaminophen, ketorolac, and low-dose ketamine infusion. Hydromorphone and oxycodone were administered for breakthrough pain. Patients who underwent a similar procedure without ERAS protocol were chosen as controls to assess the efficacy of ERAS protocol. Data pertaining to patient demographics, operative and perioperative use of analgesics, LOS, 90-day readmissions, and morbidity were collected. Patients who underwent laminectomy and spinal fusion surgery were analyzed separately Results A total of 65 patients were identified; laminectomy (n- 24), spinal fusion surgery (n-41). In the laminectomy patients, treatment group (n-12) and the control group (n-12). Treatment group receiving the ERAS protocol with the regional anesthesia via the mTLIP (n= 12) opioid requirement was reduced by 51.42% [P = 0.03], and LOS was reduced by 2.04 days [P = 0.01] [0.75 days vs. 2.79 days]). In the spinal fusion patients, treatment group (n-15) and control group (n-26). Treatment group receiving the ERAS protocol with the use of regional anesthesia via the mTLIP group (n= 15), opioid requirement was reduced by 38.33% [P = 0.04]. No difference in LOS was observed at 5.4 days vs. 4.88 days (P = 0.28). Conclusion ERAS protocol in patients undergoing lumbar spinal surgery incorporated the use of regional anesthesia via the mTLIP block, we observed there is a statistically significant reduction in the LOS for lumbar laminectomy and a significant reduction in opioid administration for lumbar laminectomies and spinal fusion surgery.