Surgical management of pediatric scoliosis has increased in incidence during the past decade. An average of 5000 fusion surgeries are performed each year in the United States.1 Although postoperative hospital length of stay (LOS) has decreased over time, relatively recent reports cite average hospital stays of 5 to 6 days at several centers across the United States.2 Juxtaposed to these historic standards, enhanced recovery protocols (ERPs) have become a topic of great interest across various surgical specialties throughout the past decade. These protocols aim to expedite recovery, reduce the physiological responses to major surgery, decrease hospital stay, and ultimately improve patient outcomes after elective surgeries.3–14 Enhanced recovery protocols rely on various components, including preoperative patient counseling, perioperative administration of multimodal analgesia, and early postoperative mobilization.3–5
While initially focused on colorectal surgery, similar benefits have been reported when ERP principles are applied in other specialties, such as thoracic, vascular, urologic, and orthopedic surgery.3–12,15 Recent adoption of ERPs by pediatric spine centers serves as the impetus for the current review. The aim of this work is to outline the history and general principles of enhanced recovery following surgery. In addition, the authors review the current literature of ERPs in pediatric spinal deformity surgery and discuss the logistics of implementation at their institution.
First Steps to Enhanced Recovery
A brief history outlining the development of enhanced recovery is important to facilitating an understanding of current practices in pediatric spinal deformity. In 1997, Kehlet16 published a review article highlighting various perioperative components of surgery and the effects on patient outcomes. This detailed description of management techniques for postoperative dysfunction has been credited as being one of the earliest reports of enhanced recovery following elective surgeries. With prevention of postoperative functional impairment as the primary goal, the multi-modal approach focused on surgical stress reduction and pain relief to facilitate early ambulation and promote early enteral nutrition. Kehlet and Mogensen17 later reported unprecedented success of early recovery after open sigmoid resection with expedited discharge on postoperative day 2. The postoperative regimen primarily focused on postoperative day 1 mobilization and accelerated diet advancement to include solid food. Additionally, patients were counseled before surgery about the planned postoperative day 2 discharge and the requirements of early mobilization and oral feeding. This work led to the establishment of the Enhanced Recovery After Surgery (ERAS) research group in Europe.
In a systematic review of 512 patients in 6 controlled trials, Wind et al4 determined various ERP elements that were routinely incorporated after colon resection surgeries. While the majority of studies included early postoperative mobilization and oral feeding, other factors included preoperative carbohydrate loading, administration of warmed intravenous fluids, upper body forced air heating to maintain normothermia, and postoperative gum chewing to prevent ileus.4,5,12 The overall conclusion was a significant reduction in LOS and morbidity among the ERP patients. A later study by the ERAS group examined an international, multicenter registry with more than 2300 colorectal patients and found that increased compliance with ERP was correlated with fewer complications and shorter hospital admission.18 Furthermore, Gustafsson et al19 reported, in a retrospective study of 911 colorectal cancer patients, both decreased postoperative complications and improved 5-year survival rate when ERPs were used. The successful integration of colorectal surgery ERPs encouraged the development and implementation of ERPs across other surgical fields, including orthopedic surgery.3–12,15
Enhanced Recovery in Pediatric Spine Surgery
Based on the progress of ERPs after hip and knee arthroplasty, there has been a recent focus on rapid recovery following pediatric spine surgery. Over time there has been an incremental decrease in immobilization and hospitalization. Historically, patients who underwent posterior spinal fusion with non-segmental instrumentation (Harrington rods) were hospitalized for up to 3 weeks and were kept immobile for extended periods.26,27 During this early era of instrumented fusions, independent ambulation did not begin until 6 to 8 weeks, as longer periods of immobilization were believed to contribute to a lower incidence of complications, pseudarthrosis, and hardware failure. Advancements in surgical technique and innovations in instrumentation (ie, segmental fixation) reduced the necessity for immobilization and led to shorter LOS. Additional postoperative enhancements have been made. Although some centers routinely admit patients to the intensive care unit for 24 to 48 hours postoperatively, Shan et al28 found that postoperative care on the general floor after posterior spinal fusion for adolescent idiopathic scoliosis (AIS) had improved patient outcomes and shorter LOS (mean, 5.7 days) when compared with the intensive care unit. More recently, a modest decrease from an average of 6.5 days in 1997 to 5.6 days in 2012 has been observed.2
This trend toward shorter LOS gained further momentum as rapid recovery protocols were implemented after scoliosis surgery.9,13,14,29–31 With the goal of improved safety and efficiency, these protocols were developed to optimize patient outcomes while reducing the overall burden on the health care system. Vigneswaran et al2 analyzed 20,346 AIS patients from 1997 to 2012 through the Kid's Inpatient Database and reported that mean hospital charges for AIS correction surgery significantly increased—from $55,495 in 1997 to $177,176 in 2012. Additionally, they reported an increased rate of posterior spine fusion surgery for AIS throughout the study period—from 1783 patients in 1997 to 5228 patients in 2012.2 As both the costs and frequency of AIS corrective surgery continue to rise, the utility of rapid recovery protocols is becoming more evident, especially as institutions adopt value-based care models. Overall, the 3 key components of ERPs in pediatric spine surgery are preoperative patient counseling, perioperative pain management, and early patient mobilization.
Preoperative Patient Counseling
At their institution, the authors have found that preoperative education of patients and their families is paramount and sets the stage for a predictable perioperative experience. Patient counseling during the preoperative visit is specifically focused on expectations regarding perioperative pain management, duration of pain medications, and the significance of early mobilization on postoperative day 1. Despite the authors' experience suggesting the preeminence of patient expectations, literature regarding the impact of patient counseling prior to scoliosis surgery is scarce. There are, however, reports of the direct benefits to preoperative counseling within the realm of hip and knee arthroplasty. In a prospective study of 72 patients examining the effects of preoperative patient education, Yoon et al32 reported that a voluntary 1-on-1 patient education session prior to elective total hip or knee arthroplasty significantly decreased LOS by 1 day. They highlighted the necessity of an in-person preoperative counselor, as opposed to the use of bedside videotapes or booklets.32 Similarly, Jones et al33 reported, in a prospective study of 322 total knee arthroplasty patients, that preoperative counseling by a dedicated joint arthroplasty nurse provided an advanced notification of clearly defined goals, such as mobilization within 24 hours. The current authors' institutional experience supports these findings: one of the surgeons meets patients in the clinic approximately 2 weeks prior to the scheduled surgery (during the preoperative testing day) with the purpose of setting perioperative and postoperative expectations, resulting in an average LOS 1 day less than that of other surgeons within the group who do not visit with patients on the preoperative testing day.
Preoperative patient education was found to have a significant impact on patient satisfaction, specifically by reducing anxiety regarding postoperative pain. In a retrospective analysis of 77 patients, Papanastassiou et al34 found that implementation of a multidisciplinary preoperative “spine class” had a positive impact on patient satisfaction, especially regarding pain management. Sanders et al35 mentioned the benefits of preoperative counseling in combination with a rapid recovery protocol after scoliosis correction surgery. Further studies implementing formalized preoperative education in spine deformity are warranted, as the benefits are clearly demonstrated in the orthopedic joint literature.
Multimodal Analgesia and Early Mobilization
Multimodal analgesia incorporates an assortment of non-opioid agents acting synergistically with opioids to accelerate recovery time, lower pain levels, and reduce total opioid consumption.36 Multimodal practices have received praise in joint arthroplasty.37,38 Furthermore, several investigations have documented success after pediatric spine surgery using a variety of multimodal methods, including the use of nonsteroidal anti-inflammatory drugs, intravenous acetaminophen, gabapentin, bupivacaine, transdermal cloni-dine patches, and combinations of operative spinal and epidural analgesia.39–44 Raudenbush et al45 used a combination of gabapentin, intravenous acetaminophen, intravenous ketorolac, local liposomal bupivacaine injection, and 2 hydromorphone epidural catheters for 48 hours postoperatively and reported significant reduction of LOS (from 4.2 to 3.3 days). Choudhry et al44 examined the efficacy of combined gabapentin and intradermal clonidine in conjunction with patient-controlled analgesia (PCA) compared with PCA alone. They reported a reduced morphine consumption on postoperative day 1, increased PCA demand-free hours, earlier ambulation, and shorter LOS in the multimodal group.44 A prospective analysis by Rajpal et al36 compared the efficacy of PCA with perioperative oral multimodal analgesia (extended-release oxycodone, gabapentin, acetaminophen, and as-needed postoperative short-acting oxycodone) in an adult spine population. Patients receiving the oral multimodal regimen had significantly less opioid consumption, improved pain scores, and fewer opioid-related side effects, such as nausea, drowsiness, and respiratory compromise.36 The current authors have similarly observed a benefit to early transition away from PCA in favor of oral pain medication, and they do so early on postoperative day 1. Future studies applying an oral multimodal approach after posterior spinal fusion for AIS may prove that it is beneficial based on these positive results.
The importance of early ambulation after AIS surgery was emphasized by Leider et al46 in 1973; however, since then, there have been limited reports specifically assessing the role of early mobilization following surgery for AIS. In the clinical pathway described by Fletcher et al,9 an emphasis on early mobilization was attributed as an impetus for development of the ERP. Patients in the accelerated discharge pathway were mobilized with physical therapy 3 times daily beginning on postoperative day 1 and had a shorter LOS by 32.6 hours.9 However, due to the retrospective nature of their study, it was difficult to clearly determine the impact of early mobilization. Rao et al47 compared two ERPs with their standard discharge protocol and reported shorter LOS by 15 hours when the adopted protocol included earlier removal of the Foley catheter in addition to accelerated physical therapy milestones.
Pediatric Spine Enhanced Recovery Protocols
Fletcher et al13 described an accelerated discharge protocol after posterior spinal fusion for AIS. In this protocol, PCA was switched to oral pain medication on postoperative day 1. Additionally, patients were mobilized and transitioned to a solid diet on postoperative day 1. These authors reported shorter LOS (discharge on postoperative day 2 or 3) when using the accelerated protocol compared with a traditional pathway (PCA until postoperative day 3, walking on postoperative day 1, and solid oral diet on postoperative day 2) without any difference in complications or readmission rates.13 In addition, the implementation of an accelerated discharge protocol led to a small but significant decrease in hospital cost when compared with the traditional pathway.9
Muhly et al14 described a standardized ERP after posterior spinal fusion for AIS that included PCA only on the day of surgery (postoperative day 0), followed by oral pain medication with intravenous hydromorphone for breakthrough pain. Oral diazepam and gabapentin were also included in the oral medication regimen. Intravenous ketorolac was added at the discretion of the surgeon. In this ERP, patients began walking on postoperative day 1 with the help of physical therapy to perform out of bed activities. Preparation for discharge started once the patient tolerated oral pain management and cleared physical therapy milestones. These authors reported a significant decrease in hospital stay and in numerical pain score after surgery.14
Sanders et al35 described another accelerated protocol, which started with preoperative education about the surgery, postoperative protocol, and recovery. Nursing staff helped patients sit upright in the bed or stand at bedside on the evening of postoperative day 0 and the morning of postoperative day 1, while physical therapy facilitated ambulation by noon on postoperative day 1. Foley catheter and PCA were discontinued on postoperative day 1 in the afternoon and patients were transitioned to oral pain medication. A solid fiber diet was instituted on postoperative day 1. With this protocol, the average LOS was 3.7 days and there was a 22% decrease in postoperative hospital charges with no significant changes in wound complications and readmission rates.
Rao et al47 described a similar protocol in a retrospective study consisting of 190 patients with AIS. The key features were discontinuing the Foley catheter on postoperative day 1, discontinuing PCA on postoperative day 2, and mobilizing the patient (up in chair, short walks) and starting a regular diet on postoperative day 2. These authors also used an epidural catheter for pain control that was discontinued on postoperative day 2. They compared patients who were placed under this protocol with two other groups. The first group did not have a protocol (pre-protocol), and the second group (protocol 1) differed slightly from the enhanced protocol (protocol 1 discontinued the epidural catheter and Foley catheter on postoperative day 3). They found that the average pain score was similar in all three groups. The time to sitting and time to discharge was significantly decreased (15 hours) in the enhanced protocol group (P<.05). They also found a decrease in total complications (from 14% to 3%) in the enhanced protocol group.
Chan et al48 reported the results of an accelerated recovery protocol in a prospective study of 74 patients undergoing posterior spinal fusion for AIS. This protocol included three primary elements. The first component was a preoperative regimen that involved instructing patients to do aerobic/back strengthening exercises and connecting patients with a scoliosis support group 6 weeks before surgery. The second component was an intraoperative strategy that included dual attending involvement, tranexamic acid administration, and the use of cell salvage. In the postoperative stage, PCA was discontinued once consumption was less than 5 mg within 24 hours, Foley catheter/ drains were removed by 18 to 24 hours, and ambulation was started by 24 to 48 hours. With this protocol, 81% of patients discontinued PCA by 36 hours, average LOS was 3.6 days, and the overall complication rate was 1.4%.48Table 1 summarizes key components and outcomes of the various ERPs published in the pediatric spine literature.
Studies on the Effect of Enhanced Recovery Protocols for Patients Undergoing Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis
At their institution, the current authors use aspects of published protocols while tailoring the postoperative regimen to the hospital's context in collaboration with both anesthesia and nursing staff (Figure 1). On postoperative day 0, patients receive PCA, which is managed by the anesthesia team. At 6:00 am on postoperative day 1, PCA is discontinued and patients begin oral hydrocodone and diazepam with intravenous ketorolac for breakthrough pain. The Foley catheter is removed on postoperative day 1 and patients ambulate 3 times a day with assistance. Specifically, the goal is for patients to ambulate in the room and sit in a chair by 9:00 am for at least 30 minutes and to then ambulate in the hallway after lunch and in the evening. Drains are removed on postoperative day 1 or 2, based on surgeon discretion. Patients' diet is advanced beginning on postoperative day 1. Patients are routinely discharged by noon on postoperative day 3.
Perioperative enhanced recovery protocol at the authors' institution for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis. Abbreviations: PCA, patient-controlled analgesia; PO, oral; POD, postoperative day; TID, 3 times a day.
Importance of Nursing Staff to Successful Implementation
The input of nursing staff is vital for successful implementation of an ERP. The literature on ERP emphasizes the importance of buy-in from involved departments (ie, nursing staff and therapists).9,29,47 Rao et al47 formalized this process through comprehensive nurse-guided teaching modules that were mandated to be completed during a 1-month period. In addition, a designated orthopedic clinical nurse specialist was available to instruct nursing staff and provide new preoperative and postoperative patient education packets. Dedicated nursing staff are essential for reinforcing expectations, which helps to keep patients on track and to avoid confusion about expected progression along the postoperative pathway. In a study by Jones et al,33 successful implementation of a patient education program was attributed to a dedicated arthroplasty nurse ensuring that patients clearly understood the postoperative milestones.
At their institution, the current authors have found the integration of nursing staff to be instrumental in proper implementation of their ERP. One initial challenge they faced was ensuring that patients were ambulating on the morning of postoperative day 1. By engaging feedback from their nurse partners, the current authors identified that the nurses were not comfortable ambulating patients with a PCA and arterial line in place. This led the authors to modify the time of PCA/arterial line discontinuation to 6:00 am on postoperative day 1, which was completed by the night shift nursing staff. As a result, the day shift nursing staff were able to focus on ensuring that patients met their postoperative mobilization milestones. Similar to Rao et al,47 the current authors have had success through the use of dedicated spine nurses to assist in hospital floor transitions and to instruct additional nursing staff.
Summary of Key Elements
To summarize, ERPs for pediatric spine surgery start with preoperative counseling, preferably in person by the surgeon or a trained nursing instructor. The key components of discussion include details about the surgical plan and postoperative expectations for both pain management and mobilization protocols. Postoperative pain management primarily involves early discontinuation of the PCA and transition to oral pain medications as early as postoperative day 1. The final component is early mobilization with the goal of ambulation on postoperative day 1. This process is primarily carried out by nursing staff at the authors' institution, whereas others have used physical therapy to do so. Other factors to be considered are early drain/catheter removal and an aggressive bowel regimen.