To the best of our knowledge, this is the first study focusing on the implementation of ERAS program in elderly patients undergoing lumbar arthrodesis. Similar to the results of ERAS program in minimal invasive lumbar surgery[13, 14], this study found that the ERAS program significantly reduced the incidence of complications and LOS, and the majority of elderly patients could complete the pathway. The standardized multimodal analgesia significantly reduced postoperative pain levels in the ERAS group. Only patients undergoing lumbar arthrodesis were included in this study to avoid the bias caused by surgical types.
Due to the influence of non-clinical factors such as culture, doctor-patient relationship, and insurance system, although the LOS of patients in the ERAS group was significantly shortened in our study, it was still longer than that in other studies[15–17]. Our study showed that higher preoperative ODI was associated with prolonged LOS, because worse preoperative motor capacity usually leads to longer time for first ambulation. The implementation of ERAS can reduce occurrence of complications, and provide adequate pain control, which are important components of our discharge criteria.
Similar to previous studies[18–20], our results showed that the implementation of ERAS program was associated with lower complications. We believe that there are several factors in the study contributing to the decrease in complications. Early removal of bladder catheter and standard antimicrobial prophylaxis reduce the risk of infectious complications such as urinary tract infection and wound infection[21–23]. Thrombosis-related complications can be decreased by active/passive limb movement, antithrombotic stockings and early ambulation. Notably, advanced age is one of the main risk factors for postoperative delirium, and the incidence of postoperative delirium after elective lumbar surgery can be as high as 15%, which can lead to nursing difficulties and lower compliance with the ERAS protocols[24–26]. Postoperative delirium has rarely been discussed in ERAS studies, but it is extremely important for the prognosis of patients, especially in elderly patients[10, 27]. In this study, no patients in the ERAS group suffered from postoperative delirium in contrast to 4 cases in none-ERAS traditional care group. Early recovery of normal life, multimodal analgesia and depth of anesthesia monitoring in the ERAS program can effectively reduce surgical stress and the risk of delirium. Opioids are considered to be the cornerstone of analgesics for severe pain, but opioid abuse increases the risk of postoperative delirium.
Improved pain control has been proved to be correlated with decreased risks of wound healing and Infectious complications, delirium, delayed mobilization, and prolonged LOS[29, 30]. Multimodal analgesia was applied in our ERAS program, and a standardized analgesic strategy was established based on patient-reported pain VAS score. Significantly lower back pain scores on POD 1-2 and shortened LOS suggested improved pain control in the ERAS program. And nonopioid-preferable pain management can reduce opioid side effects and long-term dependence. It is necessary to weigh the side effects against the strong potency of opioids. Although some guidelines and reviews mentioned about multimodal analgesia in ERAS program, there are still some controversies, such as the application of patient-specific multimodal analgesia programs for elderly patients and multimodal analgesic management for pre-operative opioid users[10, 28, 31, 32].
Preoperative education helps elderly patients gain a clear understanding of the expectations of surgeries and build confidence in perioperative recovery. Due to the decline in visual and auditory functions of elderly patients, the education was through verbal and handouts, with an emphasis of involvement of family members. Understanding the patient's expectations, preferences and the burden of postoperative care can help medical teams determine better treatment options to truly improve quality of life.
A growing number of studies have recognized that malnutrition can lead to adverse outcomes of spinal surgery, especially for elderly patients[34–37]. Increased risk of malnutrition in aging population is due to living alone, chronic diseases and poor dietary habits. Dietitians participated in daily rounds and identified the patients who were malnourished or at risk of malnutrition through nutrition screening tools and laboratory tests. Personalized diet guidance and nutritional supplement were provided to patients in need. Unlike other studies, economic factors and medical insurance system were taken into consideration and no additional nutritional supplements were provided for elderly patients with good nutritional status, but instead professional guidance on perioperative diets was given. Our results showed a significant increase in the proportion of patients receiving nutritional supplements in the ERAS group, indicating that previous malnutrition or risks in the none-ERAS traditional care group may be ignored or not intervened.
The neglect of compliance leads to doubts about the impact of ERAS program on the prognosis. Our results illustrated that the overall ERAS compliance was as high as 94%, and the compliance of preoperative and intraoperative items was better than postoperative items. We considered that the postoperative ERAS procedures are affected by the patient's subjective consciousness and the actual condition, while the preoperative and intraoperative steps depend more on the executive capability of the medical team. The close and timely communication of the ERAS team helps to identify potential difficulties and optimize ERAS procedures. Recent studies have shown that continual auditing of the protocol can help to improve compliance.
Although the compliance of early ambulation was only 70% in our study, the overall time until ambulation postoperatively was greatly shortened. Previous studies have shown that early ambulation is associated with decreased morbidity and adverse events after elective lumbar spine surgery. However, preoperative deterioration of motor function, endurance and coordination makes early ambulation more difficult. And early ambulation is often accompanied by orthostatic intolerance, such as dizziness and nausea, which increases the risk of aspiration and fall[40, 41]. Therefore, for elderly patients, early ambulation should be encouraged rather than enforced, and should be accompanied by the presence of professional caregivers and patient confirmation of no obvious discomfort after sitting up.
In this study, 86.7% of patients complied with early removal of bladder catheter. While early removal of bladder catheter may increase the risk of reinsertion and urinary retention[23, 42]. It significantly reduces the risk of urinary tract infections and gives patients confidence to return to normal life, which is helpful in shortening LOS. Patient's urination should be closely monitored after early removal of the bladder catheter. Prudence should be taken to determine whether reinsertion is required if there is a possibility of urine retention. Prolonged bladder catheter carrying may be justified for elderly patients with prostate disease.
Although we developed detailed discharge criteria, the compliance was only 78.3%. Geriatric syndromes (such as constipation, incontinence or pressure sores) may cause the elderly not to be discharged even if the discharge criteria are met. In addition, due to inadequate conditions in community medical care facilities and nursing homes, inconvenience of life after discharge and concerns about readmission, some of the elderly patients were reluctant to be discharged[7, 10, 44]. Therefore, we should proactively address the psychosocial problems that the elderly may encounter. Detailed guidance on comorbidities and fostering trust between patients and medical teams can help patients relieve their anxieties. Rehabilitation guidance and telephone follow-up allow patients to be discharged safely. The ERAS program is based on “first better, then faster”, and extension of LOS in elderly patients with special comorbidities should be granted on a case by case basis.