ERAS following spine surgery in the elderly: a systematic review and meta-analysis

As the global population ages, Enhanced Recovery After Surgery (ERAS) protocols have gained increasing importance for improving recovery, pain control, and reducing surgical morbidity. However, their impact on spinal surgery in the frail and elderly population remains limited.

To compare clinical outcomes of ERAS versus conventional care in elderly patients undergoing spinal instrumentation, with included studies defining elderly as aged ≥ 60 or ≥ 65 years.

PubMed, Embase, Scopus, and Cochrane were systematically searched for studies comparing ERAS protocol with conventional care in elderly spinal surgery before June 2025. For dichotomous outcomes, pooled relative risks (RR) with 95% confidence intervals (CI) were reported; mean differences (MD) and 95%CIs for continuous outcomes. A random-effects meta-analysis model was used.

Twelve observational studies involving 3184 patients were included. No significant difference in operative time [MD - 7.98 min (95%CI - 18.62, 2.66)] but estimated blood loss was significantly lowered with ERAS [MD - 22.79mL (95%CI - 34.10, - 11.48)]. ERAS was associated with shorter hospital stay [10.47 vs. 12.14 days; MD - 1.67 days (95%CI - 2.51, - 0.82)], earlier ambulation [1.73 vs. 2.50 days; MD - 0.77 days (95%CI - 1.20, - 0.33)], days to first void [1.61 vs. 2.28 days; MD - 0.67 days (95%CI - 1.34, - 0.00)] and first bowel movement [3.41 vs. 3.96 days; MD - 0.55 days (95%CI - 0.96, - 0.14)]. Overall complication rates were reduced [RR 0.67 (95%CI 0.54, 0.83)], particularly for surgical wound-related, gastrointestinal, urological and thromboembolic events. Pain outcomes were largely similar, but more ERAS patients achieved 90-day Minimum Clinically Important Difference (MCID) threshold for leg pain (VAS) and Disability (ODI) scores.

ERAS in elderly spinal surgery appears safe and effective, but findings are limited by retrospective study design and risk of bias. Observed benefits included shorter hospital stays, faster functional recovery, fewer postoperative complications and readmissions. Potential improvements in patient-reported lower limb pain outcomes were also noted.