We found that the use of the our ERAS protocol was beneficial and safe for elderly patients (> 70 years old) undergoing long-level lumbar fusion surgery. For ERAS group, both the complications and LOS were lower in comparison with control group and without increasing 30-day readmission and mortality rates. We also found that fewer comorbidities and ERAS were associated with incrementally improved complication odds as well as reduced length of stay.
Due to reduced physiologic reserve of vital organs, elderly patients are usually accompanied by significant comorbidities. Therefore, generally considered a minor complication in younger adult patients and may produce only transient adverse effects, may have much more severe consequences in the elderly patients and result in a significantly prolonged LOS(12).
Symptoms of patients with multi-segment degeneration of the lumbar spine often manifest as low back pain and lower limb radiculopathy, which can be accompanied by various degrees of lumbar spinal stenosis, intervertebral disc herniation, scoliosis, and lumbar spondylolisthesis, and often involve multiple segments. Often involves multi-level decompression fusion and internal fixation, so the operation is more difficult, the perioperative risk is greater. Due to the long-level lumbar fusion destroys more paravertebral muscles and facet joints, theoretically, the operation time is longer, the amount of bleeding is more, the risk of potential dural nerve injury is higher and postoperative complications are relatively high.
The key parts of the concept of ERAS include reducing the physical traumatic stress and accelerate rehabilitation, which is of great significance for long-level lumbar fusion. We assessed the association between the level of ERAS component implementation and perioperative complications, length of stay, and overall hospitalization costs. This was based on eight core ERAS protocol components.
The negative effects of traditional kept in bed after surgery may not only increase the risk of thromboembolic and pulmonary complications, but also increased loss of muscle tissue(5). Early mobilization is regarded as a key component of ERAS, consistent with the goals of supporting the early reestablishment of normal function(13). It’s been demonstrated that early ambulation after long-level lumbar surgery significantly reduces the incidence of postoperative complications includes pulmonary complications, thromboembolism and shortens the LOS. (14, 15). Despite the known benefits of early mobility, there is little guidance available on how soon among uncomplicated after long-level lumbar surgery over 70 years old patients should get out of bed and ambulate. Compared with the previous short-level lumbar fusion patients over 65 years old(16), for patients over 70 years old, which have worse physical function, more fusion segments and greater surgical trauma, contribute to the risk for adverse outcomes. Given the complexity of this population, we have extended the patient ambulate and remove the catheter time to 72hours, 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 long-level lumbar fusion surgery.
In addition to muscle wasting, postoperative high catabolism is also an important factor affecting the overall recovery, catabolism is mediated by the surgical stress and postoperative starvation(5). Our ERAS protocols combine many different elements of care in the preoperative, intraoperative and postoperative periods, and aim to reduce surgical stress, the focus is on early recovery, nutrition and pain relief.
Traditional preoperative fasting for at least 8 h and oral feeding on postoperative 1 day were considered to be a necessary to reduce the risk of aspiration during anesthesia induction(17), and ameliorate the postoperative nausea/ vomiting(18). However, a number of studies has been shown that traditionally preoperative and postoperative fasting care may cause the postoperative insulin resistance and electrolyte disorders(19, 20). Clinical observational studies have demonstrated that perioperative hyperglycemia increase the incidence of the development of postoperative complications and death in diabetic and non-diabetic patients(21). In addition, substantial evidence has shown that postoperative electrolyte disorders complications are associated with longer LOS and increased hospital costs in addition to complications such as delirium(22), thromboembolism(23), cardiac and cerebral dysfunction(12, 24, 25). This in turn, shorting fasting and feeding time help reduce catabolism and loss of muscle tissue and function may include stress reduction, decrease the feeling of hunger and anxiety, improve patient comfort(26, 27). Furthermore, avoidance of prolonged preoperative fasting and oral carbohydrate loading can create a positive impact on perioperative glucose control and muscle preservation after major operations(28). One study demonstrated that the mechanism may induces endoplasmic reticulum stress and generates insulin resistance in the skeletal muscle through suppression of Glut4 and inactivation of Ca2+-ATPase, leading to intracellular calcium homeostasis disruption and peripheral insulin resistance.(27). Our studies showed that elderly patients (> 70 years old) who have undergone long-level lumbar surgery minimizing the duration of fasting in surgical patients pre- and post-surgery is safe and can effectively low down the incidence of electrolyte disorders.
However, this study has several limitations. This study is the retrospective design, small sample size. The observation time was limited to the hospitalization period, given the lack of long-term follow-up data, definitive conclusions was unknown. Furthermore, the ERAS and non-ERAS group were assessed at different times, which may have introduced analytical bias. Further multicenter studies with a larger participant population and long-term follow-up are required to confirm the safety and efficacy of our ERAS protocol in elderly patients after long-level lumbar fusion surgery.