Enhanced Recovery With Multi-Modal Analgesia in Spine Surgery

Purpose: Spine surgery is a particularly painful surgery that leaves patients at an increased risk of developing chronic pain. Due to a growing concern of opioid misuse, health care providers are tasked with employing alternative pain-relieving strategies, such as multimodal analgesia to treat perioperative pain. The newest evidence-based practice pathways emphasize the use of multimodal analgesia to treat pain as part of a relatively new clinical pathway known as the Enhanced Recovery After Surgery (ERAS). The purpose of this quality improvement project was to implement multi-modal analgesic techniques for patients having elective spine surgery and evaluate postoperative pain scores, postoperative nausea and vomiting, Post-anesthesia care unit (PACU) length of stay, and postoperative opioid administration compared to the same measures prior to implementation.

Methods: An existing ERAS Clinical Pathway was adapted for use in accordance to latest literature and ERAS guidelines. Retrospective data was collected for patients undergoing elective spine surgery from August 30 – September 30, 2018 and compared to adults who underwent similar surgeries from August 30 – September 30, 2017. Data gathered from the electronic health record included the following variables: postoperative pain scores and postoperative nausea and vomiting, PACU length of stay, and postoperative opioid administration using opioid equivalents. Statistical analysis was performed using descriptive statistics.

Results: During the pre-intervention period, the project sample comprised 12 patients. Post-intervention, the project sample comprised 13 patients. There was a statistically significant difference in preoperative vs. postoperative pain scores for the post-intervention group (6.1 vs. 2.6, p = 0.003). The median value of morphine equivalents decreased by more than 50% post-intervention. There was no difference in post-operative nausea and vomiting (PONV). Median PACU minutes pre-intervention was 125 minutes. This decreased to a median of 120 minutes.

Conclusion: Despite the small number of patients and limited time to implement this project, it is feasible to implement an ERAS clinical pathway in elective spine surgery. Utilization of multimodal analgesia techniques in spine surgery significantly reduces pain scores and total opioid required post-operatively. By standardizing treatment, patients experience less variability in care and an enhanced recovery with less pain and decreased need for opioid analgesia in the post-operative setting. Additional QI projects are needed to expand use of ERAS in elective spine surgery.