Optimising Postoperative Spine Outcomes: An Umbrella Review of Enhanced Recovery After Spinal Surgery (ERASS) Protocols

Introduction: Enhanced Recovery After Surgery(ERAS) protocols aim to accelerate recovery, reduce complications, and enhance surgical outcomes through a multimodal approach that spans preoperative, intraoperative, and postoperative phases. Given the complexity and extended recovery associated with spinal surgery, ERAS protocols hold significant potential to improve outcomes. We aimed to conduct an umbrella review that synthesizes all published systematic reviews(SRs) on Enhanced Recovery After Spinal Surgery(ERASS) protocols.

Methods: This umbrella review followed PRISMA and PRIOR guidelines including SRs and meta-analyses(MAs) that evaluated the impact of ERAS protocols on spinal surgery outcomes. The search spanned databases such as Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, Centre for Reviews and Dissemination and Web of Science from January 1990 to May 2024. The AMSTAR-2 and ROBIS tools were used to assess the quality and risk of bias in the included SRs. Meta-analytic estimates were recalculated from primary studies using random-effects models to account for heterogeneity, with Egger’s test used to assess publication bias.

Results: Fifteen SRs, representing 224 primary studies and over 51,000 participants, were included in this
umbrella review. Qualitatively, ERASS protocols consistently reduced hospital stays, postoperative
complications, opioid use, and healthcare costs. Meta-analysis showed a reduction in hospital stay by
1.54 days(95% CI: 1.26–1.82), healthcare costs by $941.24 per patient(95% CI: $168.12–$2050.59),
patient-reported pain scores by 0.27(95% CI: -0.13, 0.66) and opioid consumption by 7.26 mg(95% CI:
3.70–10.82). Postoperative complication rate had a relative risk (RR) of 0.63 (95% CI: 0.53–0.74), while
readmission rate was RR 0.79(95% CI: 0.59–1.06). Study quality ranged from low to high(AMSTAR-2),
with low risk of bias(ROBIS).

Conclusion : This umbrella review is the first to evaluate ERAS protocols in spinal surgery, demonstrating
significant reductions in complications, readmission rates, hospital stay, opioid use, and healthcare
costs, ultimately enhancing patient outcomes. Overall, this review supports the widespread
implementation of ERAS protocols in spinal surgery, with potential benefits for both patients and
healthcare systems. Future studies should focus on standardizing ERAS interventions and addressing
gaps in current research.