Many surgical practices are considered to be tried-and-true; meaning, for years, these guidelines have been tested and were proven to be effective. But even tried-and-true methods can be improved. Despite decades of surgical, technological, medical, and anesthetic enhancements, patients who undergo elective neurosurgical procedures still face the risk of having serious complications after surgery.
Zarina S. Ali, MD, Assistant Professor of Neurosurgery at Pennsylvania Hospital, wants to change that. Ali, and a multidisciplinary team of Penn Medicine specialists have launched a groundbreaking study that seeks to improve patient outcomes through the development of a new protocol for elective spine and peripheral nerve surgery centered around Enhanced Recovery After Surgery (ERAS).
The process of evaluation prior to surgery, hospitalization for surgery, and postoperative care can often be fragmented, requiring patients to visit many different facilities and providers; ERAS is a method of organizing and optimizing this process for the overall benefit of the patient. In addition, the ERAS care pathway enables doctors to evaluate potential risk factors during various pre-, peri-, and post-operative time points to ensure the best possible outcomes.
"ERAS provides the full scope of care packaged into one, evidence-based pathway with the patient at the core,” Ali said. “We dissected each component of an individual’s journey through spine or peripheral nerve surgery, from start to finish, and we continue to work to formalize it in a way that will improve the patient’s overall experience and their clinical care in order to maximize their benefits from surgery."
How the ERAS pathway works?
ERAS was originally developed in the early 1990s by Danish physician Henrik Kehlet with the goal of improving morbidity and mortality associated with colorectal surgery. It has since been adopted in a number of medical disciplines; however, ERAS implementation in neurosurgery has been limited. Penn Medicine has the only comprehensive ERAS program in spine and peripheral neurosurgery in the region and is one of the first such programs in the nation within neurosurgery.
Penn Neurosurgery ERAS pathway focuses on patients that need elective spine or peripheral nerve surgery. According to Ali, these are patients who are recommended for surgery but don’t need surgery immediately, so there is time for their care, before they reach the operating room, to be optimized. Participants will be led through a number of pre-op, peri-op, and post-op evaluations along the ERAS pathway.
The goal of the pre-operative portion of the ERAS pathway is to educate the patient about surgical expectations and to maximize the patient’s physical condition prior to surgery. During this period, patients will engage with physicians who specialize in diabetes care, nutrition management, sleep medicine, pain management and more, to ensure no pre-existing conditions interfere with the success of the surgery.
During this stage in the pathway, for example, a patient who is already taking large doses of opioids before surgery would be paired with a pain management specialist to address any potential opioid dependence issues before surgery.
"We know that the data suggests worst outcomes for patients who have chronic opioid dependency prior to spine surgery. Our goal is to intentionally address some of these comorbid issues, to the best of our ability, in order to limit any untoward effects associated with these conditions that would preclude maximal surgical benefit following surgery,” Ali said.
Ali’s team also screens patients for sleep apnea, a condition that typically goes undiagnosed but could pose serious health risks for patients after surgery.
“People who have obstructive sleep apnea are at a higher risk for developing post-operative complications related to decreased respiratory drive. So, we screen them before surgery and refer them to sleep medicine specialists prior to surgery to determine if they need additional treatment, such as a CPAP device, before undergoing their elective surgery,” Ali explained. “It’s really meant as a way to approach the patient in a 360-degree fashion prior to making an incision."
Reinventing the wheel
During surgery, the medical team will follow specific protocols; some of which reverse long held practices in neurosurgery
Historically, neurosurgery patients had been placed on a controlled analgesia pump with IV opioids and were given access to these medications for at least the first 24 hours after surgery. As part of the new ERAS pathway, patients receive a multi-modal approach to pain management which limits the use of IV opioid medications. Ali says her team is already seeing preliminary benefits of this change in care.
"With this change in practice, we were able to demonstrate that patients required generally less intravenous opioid medication during their surgical hospitalization. This change even persisted at one month after surgery when we observed far fewer patients that remained on opioids following similar surgeries. No increases in pain levels were observed. This obviously has huge implications from a long-term perspective,” Ali said.
Throughout the entire surgery process, the medical team uses a variety of methods to keep patients informed and connected to their surgical care. Patients are enrolled in a text message program that allows them to receive reminders of things to do and look out for following the surgery. According to Ali, ERAS is particularly important for spine surgery because it’s one of the most common and most costly procedures that neurosurgeons perform.
"We approached this from a value-based perspective to both improve the quality of the care we’re providing while also looking to reduce costs in the form of reducing the length of hospitalization, complications and re-admissions,” Ali said. “This is really challenging dogmas of surgery that have been the standard of care for many years. This was an opportunity to take the best practices of medicine and surgery, put them together in one pathway and see if we can improve the process and care of our patients."