How and Why ERAS Protocols in Neurosurgery Are Lagging

Despite success in other specialties, implementation of Enhanced Recovery After Surgery (ERAS) protocols in neurosurgery has lagged. Why?

According to a 2021 study published in the Journal of Neuroscience, it’s a combination of factors, including:

• • A lack of coordination among team members providing care from the pre-operative through post-operative phases
  • The challenging nature of urgent and emergent cases
  • A focus on perioperative procedural design vs. holistic, interdisciplinary implementation of patient care

To better understand the current practice of neurosurgical ERAS protocols, Agarwal et al. conducted a survey of implementation of and satisfaction with such protocols at individual institutions, ultimately to advocate for increased use in the specialty going forward.

Neurosurgeons’ Experience with Neurosurgical ERAS Protocols

Agarwal et al. distributed a 15-question survey through the College of Neurological Surgeons’ conference and webpage from November 2019 to April 2020. Thirty-nine responses were collected from 38 institutions.

Here are some key findings about ERAS protocols in neurosurgery:

• • Who uses ERAS protocols in neurosurgery?

58.9% of neurosurgeons reported using them. Those who did represented a near even split between academic and private-practice providers (52.1% vs. 47.8%).

• • When do neurosurgeons use ERAS protocols?

All respondents who use ERAS protocols reported using them in spine surgery, but only 17.3% use them in cranial cases.

• • Who designs the ERAS protocols in neurosurgery?

Nearly 70% reported that design and implementation was a multidisciplinary effort across many departments, including neurosurgery, anesthesia and pharmacy. 17.3% reported design was by the institution, 8.6% reported design by the neurosurgery department and 4.3% reported design by individual surgeons.

• • At what stage of care are ERAS protocols used?

• • • Pre-operative (91.3%)
    • Post-operative (86.9%)
    • Peri-operative (82.6%)
    • Pre-admission patient education, anesthesia, early patient mobilization (78.2%)
    • Antibiotic prophylaxis (73.9%)
    • Nutritional management (56.5%)

• • What are the challenges of implementing ERAS protocols in neurosurgery?

• • • Difficulty obtaining consensus on ERAS protocols
    • Achieving widespread adoption across all neurosurgical providers
    • Slow adoption to new protocols by non-surgical providers, including nurses and support staff
    • Difficulty implementing ERAS into electronic medical records system

• • How do neurosurgeons evaluate the effectiveness of neurosurgical ERAS protocols?

• • • Post-operative complication rate (78.2%)
    • Assessing patient pain control and decreased opioid usage during admission (69.5%)
    • Cost savings (47.8%)
    • Postoperative time to ambulation (43.4%)
    • Peri-operative blood loss (30.4%)

• • What improvements would neurosurgeons like to see with ERAS protocols?

• • • Improvements in patient opioid usage, postoperative infection rate and time to return to work
    • Application to other neurosurgical subspecialties
    • Continued refinements to ERAS algorithms
    • Focus should be patient-centric rather than cost-centric
    • Compensation for improved quality outcomes

Neurosurgery Specialty Still Lags Behind in ERAS Implementation

Since Enhanced Recovery After Surgery (ERAS) guidelines were first introduced in 1997, they have been implemented across multiple specialties to deliver care at a lower cost while improving both quality and patient outcomes.

For example, ERAS protocols in preoperative abdominal surgery have been associated with improved clinical outcomes for patients, shorter hospital stays, faster return to bowel function and a 50% reduction in surgical site infections. Likewise, in colorectal surgery, protocols have been associated with significantly shorter hospital stays, lower costs and lower rates of severe complication.

And yet, despite two decades of ERAS proliferation across multiple specialties and six continents, ERAS protocols in neurosurgery are behind. “There has been a disconnect between many healthcare institutions and their spine surgeons due to a lack of data on how to begin or to implement a spinal ERAS program,” a neurosurgeon at the University of Miami wrote in 2019.

There is a lack of standardization across the specialty. For example, the Cleveland Clinic’s ERAS protocol for spine surgery significantly decreased the peri-operative blood transfusion rate from 20.1% to 7.7%, yet only 30.4% of surveyed neurosurgeons reported using peri-operative blood loss as a metric for assessing ERAS protocols.

Agarwal et al. recommend that future research focus on optimizing elements of ERAS algorithms, investigating barriers to implementation and recommending strategies to overcome them. Given that less than 70% of their survey’s respondents reported a multidisciplinary approach to ERAS protocols in neurosurgery, the authors note that perhaps the most important challenge is building consensus and garnering acceptance from both neurosurgeons and support staff.