Enhanced Recovery After Surgery

The effects of a novel enhanced recovery after surgery (ERAS) protocol on clinical outcomes for patients undergoing elective spine or peripheral nerve surgery.

Zarina S. Ali, MD, MS
Principal Investigator
Tracy M. Flanders, MD


Enhanced recovery after surgery (ERAS) protocols address pre-, peri-, and postoperative factors of a patient’s surgical journey. ERAS engages all healthcare providers in a longitudinal fashion, with an underlying theme of reduction of the dramatic stress response due to surgery.The authors sought to assess the effects of a novel ERAS protocol on clinical outcomes for patients undergoing elective spine or peripheral nerve surgery.

Intervention and Design

This is a prospective cohort analysis to evaluate the impact of a novel ERAS protocol for patients undergo- ing elective spine or peripheral nerve surgery by the same attending neurosurgeons who operate at a single hospital (Pennsylvania Hospital) within the University of Pennsylvania Health System. The 2 cohorts underwent treatment at a single institution before ERAS implementation (September–December 2016) and after ERAS implementation (April–June 2017).

Intervention - The authors conducted a prospective cohort analysis comparing clinical outcomes of patients undergoing elective spine or peripheral nerve surgery after implementation of the ERAS protocol compared to a historical control cohort in a tertiary care academic medical center. Patients in the historical cohort (September–December 2016) underwent traditional surgical care. Patients in the intervention group (April–June 2017) were enrolled in a unique ERAS protocol created by the Department of Neurosurgery at the University of Pennsylvania.

Main Outcomes and Measures - Primary objectives were as follows: opioid and non-opioid pain medication consumption, need for opioid use at 1 month postoperatively, and patient-reported pain scores. Secondary objectives were as follows: mobilization and ambulation status, Foley catheter use, need for straight catheterization, length of stay, need for ICU admission, discharge status, and readmission within 30 days.

Way to Health Use

  • Study Enrollment: Enroll and randomize participants in the study
  • Discharge Date Finder: Collect data from EPIC regarding patient’s discharge date
  • Text Message Reminders: Text reminders sent throughout the intervention

Findings and Conclusions

The 2 groups were similar in baseline demographics. Intravenous opioid medications postoperatively via patient-controlled analgesia was nearly eliminated in the ERAS group (0.5% vs 54.1%, p < 0.001). This change was not associated with an increase in the average or daily pain scores in the ERAS group. At 1 month following surgery, a smaller proportion of patients in the ERAS group were using opioids (38.8% vs 52.7%, p = 0.041). The ERAS group demonstrated greater mobilization on postoperative day 0 (53.4% vs 17.1%, p < 0.001) and postoperative day 1 (84.1% vs 45.7%, p < 0.001) compared to the control group. Postoperative Foley use was decreased in the ERAS group (20.4% vs 47.3%, p < 0.001) without an increase in the rate of straight catheterization (8.1% vs 11.9%, p = 0.51).

Implementation of this novel ERAS pathway safely reduces patients’ postoperative opioid requirements during hospitalization and 1 month postoperatively. ERAS results in improved postoperative mobilization and ambulation.


Enhanced Recovery After Elective Spinal and Peripheral Nerve Surgery: Pilot Study from a Single Institution