Dr. Smith received his medical degree from Rush Medical College and has been in practice for nearly 10 years. He is passionately concerned about the care of his patients and personally speaks with every patient during consultation and before surgery. He is committed to the wellness of each of his patients and continuously offers the highest level of patient care at Rocky Mountain Brain and Spine Institute. To schedule an appointment with Dr. Smith and learn how he can help you, contact us at (303) 471-4690.
Spine surgery, even using tubular minimally invasive techniques, is associated with reasonable pain postoperatively. Even though most patients are happy their preoperative symptoms are improved, and this pain tends to be different, pain management is often required.
With the ongoing opioid epidemic and inevitable temporary disability from spine surgery, significant investment and research has been geared toward non-opioid pain management and quicker recovery with return to function.
ERAS, enhanced recovery after surgery, was originally developed in the 1997 in Europe for abdominal surgery. Patients reported less pain and their hospital stays were shortened. Other outcomes were similar. ERAS has now expanded into many different surgical subspecialties, including minimally invasive spine surgery.
ERAS involves preoperative, perioperative and postoperative periods.
In the preoperative period, patients are counseled about the surgical procedure and the potential complications. It has been found that well-informed patients have a better postoperative outcome with less pain, so expectations are set to minimize unsatisfactory results. One of the unique changes to the preoperative protocol is permitting eating up to 6 hours before surgery and carbohydrate supplementation. Prolonged fasting may have a negative effect on metabolism, promoting constipation and muscle loss. Preoperative acetaminophen (Tylenol), celecoxib (non-steroidal anti-inflammatory) and gabapentin may be given and resumed immediately postoperative. Gabapentin, in particular, may suppress pain perception, have anti-inflammatory properties, and may suppress nausea.
In the peri-, or intraoperative, period, minimal sedation, warming, and improved hydration is sought to avoid complications of anesthesia and prevent dehydration. Less sedation encourages the surgeon to work faster, as shorter surgeries may result in improved outcome. Some surgeries, although not all, can be performed with regional blocks or conscious sedation, in which the patient is anesthetized but not completely unconscious. Shorter surgeries tend to have less blood loss and lower infections.
This fits well with tubular minimally invasive spine surgery (MIS), in contrast to open spine surgery, in that MIS is associated with shorter surgery, lower blood loss, lower infection rates, less muscle damage, and less pain. ERAS intraoperative protocols also try to avoid foley catheters (bladder catheter) which may contribute to urinary retention. On occasion intraoperative lidocaine (non-opioid pain medication) infusions can be given for pain control. At the end of the procedure, a liposomal bupivacaine medication catheter can be placed around the incision to improve incisional pain. Newly being explored is “opioid-free anesthesia”, in which no intraoperative opioid is administered by any route.
In the postoperative period, early eating, drinking and mobilization is encouraged. Non-opiate pain management including meditation, ice/heat, lidocaine patches, Toradol (nonsteroidal pain medication), etc… is preferred as this avoids sedation and constipation associated with narcotics. Early evaluation by physical and occupational therapy encourages mobilization. Rapid discharge home has been shown to improve outcomes.
ERAS principles are newly being implemented in spine surgery, but shows promise of less postoperative pain and earlier return to function. ERAS seems to fit well with MIS spine techniques, as both are designed to achieve the same goals. ERAS seems to also lower healthcare costs.