ERAS Protocol Elements and Neurosurgery-Specific Considerations: A Narrative Review

Enhanced recovery after surgery (ERAS) is a structured, evidence-based, multimodal perioperative framework designed to reduce surgical stress and accelerate recovery. Although these pathways are widely established across surgical specialties, their implementation in neurosurgery presents unique challenges because recovery-enhancing interventions must be balanced against neurological protection, haemodynamic stability, intracranial physiology, and procedure-specific safety considerations. This narrative review synthesises current evidence regarding ERAS implementation across cranial and spinal neurosurgical procedures, including elective craniotomy, spine surgery, pituitary surgery, vascular neurosurgery, and selected paediatric and geriatric populations. While available studies consistently demonstrate reductions in hospital length of stay, opioid consumption, and resource utilisation without increasing perioperative complications, interpretation of these findings is limited by substantial heterogeneity in protocol design, outcome definitions, and adherence reporting, and by the scarcity of long-term neurological and patient-reported outcomes. Beyond summarising existing evidence, this review proposes a conceptual framework distinguishing two fundamentally different ERAS paradigms within neurosurgery: a function-driven model predominantly applicable to spine surgery, where recovery acceleration is the principal objective, and a safety-constrained model characteristic of cranial neurosurgery, where neurological monitoring, intracranial pressure management, and haemorrhagic risk frequently limit implementation of conventional ERAS elements. This distinction provides a physiological and clinical rationale for procedure-specific adaptation rather than uniform application of these principles. The review further argues that the benefits of ERAS arise primarily from pathway standardisation, multidisciplinary coordination, and high protocol adherence rather than from isolated perioperative interventions. By identifying the limitations of current evidence and highlighting the need for neurosurgery-specific outcome measures, standardised reporting, and protocol stratification by surgical pathology, this review offers a framework for future research and more tailored implementation of ERAS pathways within neurosurgical practice.