Enhanced recovery after surgical correction of adolescent idiopathic scoliosis.
This is a retrospective monocentric observational study comparing postoperative recovery data before and after institution of an ERAS (enhanced recovery after surgery) protocol for fusion of adolescent idiopathic scoliosis. The study was done at a tertiary paediatric hospital in Paris in 2015 (82 control patients) and 2018 (81 patients).
Median length of hospital stay was significantly lower in the ERAS group: 4 vs 7 days (95%CI −2 to −4). Median morphine consumption was also reduced by 25% on day 2 and 35% on day 3 in the ERAS group. Incidence of PONV did not differ between the two groups, and the incidence of constipation decreased slightly but significantly in the ERAS group on day 2. Pain intensity at rest and movement were lower in the ERAS group at day 2 and 3.
The concept of ERAS is well-established in adult surgery. In Utopian form it is a beautiful evidenced-based unification of surgery, anaesthesia, allied health and nursing management to create a shared model of how best to standardise perioperative care. However, there is great variability of management because this evidence is lacking for much of the perioperative care for correction of scoliotic spines. Certainly, the ERAS protocol at the study hospital is quite different to our practice: they used sevoflurane in O2/N2O for maintenance, intrathecal morphine, muscle relaxant continuously administered during surgery, oesophageal Doppler monitoring for fluid guidance, dexmedetomidine infusions and a cooling brace was fitted postoperatively to provide non-pharmacological analgesia.
The addition of gabapentin and the elimination of morphine background infusions in the 2018 ERAS group may account for the improved pain parameters and reduced hospital stay, but it’s as likely to be the institution of the protocol itself as any individual intervention. It is well-understood that the collaboration needed to guide an ERAS protocol and its common objective improves multidisciplinary team understanding, standardisation of care, quality measures, and the adherence to management guidelines. Improved patient education, pre-operative clinic education and motivation are also key benefits.
The editorial in the same journal states two truisms: “much more work is needed to ensure that the standard care pathways for spine correction utilized have the requisite amount of scientific rigor” and “use of ERAS pathways for paediatric adolescent idiopathic scoliosis spinal fusion surgery represents another step in the evolution in the care of this challenging patient population.” It may be a call to action for both.
Reviewed by Dr. G. Knottenbelt