The introduction of ERAS at our institution for ACDF surgery has resulted in a significant decrease in LOS without causing an increase in postoperative complications and VAS score. The average LOS is 8 days for ACDF in elderly patients. Decrease almost 2 days compared to the conventional protocol. According to our results, it seems applicable to implementation ERAS protocol in elderly patients with ACDF surgery and may helps to reduce costs.
The causes of common diseases related to ACDF surgery (cervical disc herniation, cervical spondylosis, posterior longitudinal ligament ossification, etc.) are various reasons that cause damage to the cervical spinal cord, nerve root compression and irritation trigger corresponding clinical symptoms. The main symptoms of patients with spinal cord and nerve root damage, such as upper limb numbness, pain, fatigue and muscle atrophy, etc. In severe cases, it can be manifested as unstable walking or even paralysis. The purpose of the ACDF surgery is to relieve the compression of the spinal cord and nerve roots, rebuild the stability of the cervical spine surgery segment, promote the recovery of the patient's nerve function and improve the quality of life.
Due to the age-related reduced in physiological reserves and functional capacity are inevitable and affect all organ systems, elderly patients are usually present with many comorbidities(12). Therefore, surgeons are reluctant to perform spine surgery in elderly patients because of the high risk of perioperative complications(13). In addition to normal indications for surgery, the surgeon has to balance the risks of adverse events and expected benefits of surgery according to nutritional state, inflammatory activity and anticipated host response. The whole concept of ERAS first proposed for more than 20 years and is currently extended to spinal surgery. According to ERAS principles, the core parts of classic ERAS is reducing stress, which is significance for elderly patients. Although several studies have been published on ERAS for ACDF(9, 10, 14, 15), there have been limited studies that focused on patients over 60 years old. The pillars of our ERAS protocol are: 1) high patient satisfaction at the center of his or her management, 2) a combination of interventions to nutritional support, reducing the pain and early ambulation.
Nutritional optimization is an essential component of perioperative. Malnutrition is a high risk factor of higher postoperative complications. It thus increases the LOS and burden on healthcare systems(12). The European Society for Clinical Nutrition and Metabolism 2021 guidelines highlighted the significant of the nutrition in ERAS(16). The success of surgery not only depend exclusively on technical surgical skills, but also on nutritional management(17), this is due to the metabolic imbalance response caused by surgery itself. As a spine surgeon, nutritional management is an inter-professional challenge. Preoperative carbohydrate fluids given up to 2 hours prior to surgery in contrast to the traditional midnight preoperative fast can not only reduce surgical stress but also reduce the incidence of postoperative insulin resistance. Clinical observational studies have demonstrated that perioperative hyperglycemia was associated with adverse outcomes in diabetic and non-diabetic(18). In addition, shortening the fasting time before surgery have been proven to enhance patient comfort prior to surgery and have been theorized to reducing patient catabolism, with a positive impact on perioperative muscle preservation(19). Protein catabolism is a considerable feature at postoperative phase, both shorting the fasting time and nutritional therapy as soon as possible may provide the energy for optimal healing and counteract muscle catabolism(20). Previous study have shown that BMI＜24 kg.m-2 is the cut-off for all-cause mortality for older patients(17). However, obscured by obesity reduced muscle mass and malnutrition may be ignored in surgical patients, some studies have shown high rates of malnutrition in older patients(21, 22). Therefore, we routinely supplement protein powder during the liquid phase after surgery，as suggested by Chan(12).
For elderly patients with ACDF, our nutritional program includes prevention and reduction of catabolism before and after surgery. Based on our clinical experience, avoidance of unnecessary prolonged pre-, and post-operative fasting and supplement protein powder during the liquid phase after surgery is safe and reduce the felling of hunger and anxiety in patients.
Multimodal, non-opioid based analgesia has become the cornerstone of our ERAS protocols for effective analgesia after ACDF surgery. Well-managed pain, the so-called “fifth vital sign”, is widely recognized as an important metric for success of surgery and recovery, and even as a surrogate for patient satisfaction(23). Many factors contribute to postoperative pain after spine surgery, in addition to nociceptive pain from surgical incision, these patients experience musculoskeletal pain from surgical traction and manipulation of bone, muscle, ligaments, and joints(24). Although opioids are remains an effective therapy for pain control, substantial evidence has shown the wide range of adverse effects, including nausea, ileus, respiratory depression, hyperalgesia, and delirium associated with opiate analgesia(25). Multimodal analgesia involves use of multiple mechanisms of pain control acting synergistically to improve analgesic effect and reduce the doses of opiates, and thereby reduce risk of side-effects from opioid(26), and may therefore reduce LOS and hospital cost. Our ERAS protocol included oral non-opioid medications preoperatively to help reduce opioid needs postoperatively and the results showed that there was no significant difference between the two groups about the postoperative VAS score.
Early mobilization was another important aspect of our ERAS protocol. Although early mobilization was first proposed by Emil Ries in 1899(27), it was only within the last 20 years that early mobilization became accepted among surgeons and has been significant progress in postoperative care with the development of ERAS. The harmful of traditional prolonged bed rest in postoperative are well-known and it is should not be advocated. Despite the known benefits of early mobility, several questions regarding of this intervention remain unknown. How soon among uncomplicated after ACDF surgery over 60 years old patients should get out of bed and ambulate? And do patients over 60 years old underwent ACDF surgery treated with early mobilization safe? Compared with the previous ERAS study of ACDF(9, 10), for patients over 60 years old, which have worse physical function, given the complexity of this population, we have decided the patient ambulate and remove the catheter time to 24hours, in-bed active/passive limb movement within 4 hours after surgery. Our research results show that this improvement is safe and effective in improving the efficacy of older patients underwent ACDF surgery.
However, this study does have several limitations. This study has a retrospective design, and there is only a small sample size. The observation time was limited to the hospitalization period, and given the lack of long-term follow-up data, definitive conclusions may not be drawn from these results. In addition, the ERAS and non-ERAS groups were assessed at different times, which may have introduced analytical bias into the study. Further multicenter studies with a larger cohort and long-term follow-up are required to confirm the safety and efficacy of our ERAS protocol in elderly patients after ACDF surgery.