Perioperative care in lumbar spinal fusion: Consensus statement from ERAS Society

Preoperative recommendations

• Preoperative patient education is recommended
• Patients undergoing lumbar fusion should undergo a preoperative nutritional assessment.
• Preoperative nutritional interventions should be offered to patients identified as malnourished.
• A combined smoking cessation therapy at a minimum of 4 weeks before surgery is recommended.
• Alcohol cessation programs 4 to 8 weeks before surgery can reduce postoperative complications.
• Clear fluid should be permitted up to 2 hours and solid foods up to 6 hours before the induction of general anesthesia.
• The routine administration of sedatives to reduce anxiety preoperatively is not recommended.
• The routine preoperative administration of acetaminophen, NSAIDs, and gabapentinoids as part of a multimodal opioid-sparing analgesia strategy is recommended.
• Preoperative anemia should be assessed and corrected before lumbar fusion.

Intraoperative recommendations

• A care bundle should be implemented, including administration of a broad-spectrum antibiotic covering S. aureus, and skin preparation using either alcohol-based iodine or chlorohexidine solution.
• Antiseptic dressing the night before surgery.
• Skin preparation using use of either alcohol-based iodine or chlorohexidine solution.
• Modern general anesthesia, including the use of neuromuscular blockade and neuraxial techniques should be used as part of multimodal anesthetic strategies follow local policy and availability.
• Normothermia should be maintained peri- and postoperatively through prewarming and active warming of patients intraoperatively.
• Surgical techniques should be decided on a case-by-case basis, factoring surgery goals, training, and experience of the surgeon, and the availability of technology at the local institution.
• Use of intrathecal morphine, epidural analgesia, locoregional blocks, or wound infiltration with long-acting local anesthetics should be used to improve postoperative pain management.
• Intravenous fluids should be maintained near-euvolemic status.
• Goal-directed fluid management is not needed for 12 level lumbar fusion but should be considered if signifi- cant patient comorbidities exist.
• An early return to a normal diet is recommended and should be promoted.
• The routine use of urinary catheters is not recommended for short-segment elective lumbar spinal fusions with or without concomitant decompression. When used, they should be removed within hours of surgery with close monitoring.

Postoperative recommendations

• The routine use of multimodal analgesic regimens to improve pain control and reduce opioid consumption is recommended.
• Risk assessment for PONV, routine use of multimodal PONV prophylaxis based on assessment and PONV rescue with a different class of anti-emetic, is recommended.
• Routine wound drainage is not recommended for shortsegment lumbar fusion surgery.
• Early ambulation and the use of mechanoprophylaxis should be encouraged in all patients after spinal surgery.
• Pharmaceutical antithrombotic prophylaxis should be reserved for specific risk groups, while no recommendation can be made concerning standardized use.
• Early mobilization and early physical therapy are recommended.
• Routine auditing and feedback are necessary for implementing ERAS protocols, maintaining high compliance with ERAS protocols, and realizing quality improvements.

Reference:

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS
) Society recommendations, published in the Spine Journal.

DOI: https://www.thespinejournalonline.com/article/S1529-9430(21)00002-4/fulltext