We'll begin the session with an abstract entitled enhanced recovery after surgery decreases post-operative opioid use in elective Spinal and peripheral nerve surgery by Dr. Zarina Ali our statistical discussant will be ab kulkarni and The paper discussant Michael Wang Let me also remind our speakers that the microphones will automatically go silent when your time allotment is over and your session Will end thank you You Thank you to the Scientific Program Committee for giving me this opportunity to talk to you about our enhanced recovery after surgery or ERAS at The University of Pennsylvania, I have no disclosures The widespread abuse of prescription opioids and a dramatic increase in the availability of illicit Opioids has been implicated in the national opioid epidemic Opioid overdoses in large cities has increased by 54 percent in 16 states I happen to practice in Pennsylvania where the overdose death rate is more than twice the national average not surprisingly increasing legislation around opioid prescribing is on the rise and worrisomely may not include the surgeons perspective There has been more recent evidence in the medical literature to suggest that many surgical procedures are Associated with an increased risk of chronic opioid use in the post-operative period In recent years enhanced recovery after surgery protocols have emerged as multimodal approaches designed to improve clinical outcomes in surgical patients These protocols often emphasize multimodal pain management regimens ERAS has already gained interest in the lay media and there have been more recent reports within the neurosurgical literature Most notably from Michael Wang's group in Miami that has reported successful implementation reduction in acute care costs and Improvement in patient outcomes following adoption of ERAS elements in minimally invasive spinal fusion surgery at Penn We developed an neurosurgery ERAS pathway aimed to optimize the pre peri and post-operative care of our elective Spine and peripheral nerve surgery patients. We hypothesized that this 360 degree care approach which includes a focus on multimodal opioid sparing pain management Inherent to ERAS had the potential to decrease overall opioid use here I'll present our institution's initial experience with implementation of ERAS and discuss the outcomes associated with post-op opioid use So our Penn neurosurgery ERAS pathway includes 16 domains of care with multiple interventions Which I will unfortunately not have time to go into great detail However briefly in the pre-op setting patients receive formal education about the ERAS care pathway Including enrollment in our engaged recovery at Penn text message reminder system It in it encourages patients to perform ERAS behavior such as preoperative skin Washings among other reminders in addition patients are recommended to seek additional Consultations prior to surgery when appropriate including pain management for chronic opioid users sleep medicine Consultation for patients who score greater than two on the stop-bang sleep apnea screening questionnaire smoking cessation counseling and diabetes management All patients receive information provided by our nutritionist about preoperative protein intake as well ERAS patients also complete a risk assessment and prediction tool pre-op as a means to educate Patients and their families about their discharge disposition in The perioperative setting patients undergo a carbohydrate load the day prior to and on the day of surgery Pain management is achieved via a robust opioid sparing Multimodality regimen which includes standing doses of around-the-clock acetaminophen peri-op gabapentin Loga local anesthetic and and opioids only as needed Surgery is performed using a safe spinal surgery checklist Which was designed to engage all operating room staff just prior to closure of the wound to ensure completion of all necessary elements of the desired procedure Post-op nursing instructions include an aggressive early post-op mobilization program Foley catheters outside the OR are used only in select patients and Finally a standard wound care regimen was also established and implemented in The post-op setting our ERAS pathway includes a continuity of medical care plan and a post-acute resource triage pathway Designed for nursing facilities and rehab centers to prevent immediate return of patients to the hospital ER when avoidable Patients are also provided with a web link by a text message with resources on post-op exercises and nutrition So as part of a major quality improvement effort at our single institution We prospectively enrolled 201 consecutive patients into our ERAS pathway and retrospectively analyzed our data both before ERAS implementation and after ERAS a Historical control of 74 patients who underwent elective spine and peripheral nerve surgery were identified as the control group These patients underwent traditional surgical care in a non standardized fashion including routine Foley catheter placement routine post-op pain control via PCAs out of the OR among other routine parameters Inclusion criteria consisted of clinical history and diagnostic imaging supporting the need for elective spine or peripheral nerve surgery Age over 18 and the ability to understand and participate in the program Exclusion criteria included contraindications to elective spine or peripheral nerve surgery as deemed by the attending neurosurgeon diagnosis of liver disease or pregnancy Primary and secondary outcomes are listed here and standard statistical techniques were used to perform analysis of data with the collaboration of a biostatistician So the two groups were similar in respect to age gender BMI history of prior spinal surgery pre-op narcotic use and smoking status medical comorbidities Including OSA diabetes COPD in each group was also not statistically different The distribution of surgical procedures was also similar with the majority of surgeries consisting of open lamies Dyskectomies and for a monotony less than 10% of the surgeries in both groups consisted of other surgeries including peripheral nerve surgeries and hardware removal and benign tumor resections less than 10% of cases in both groups consisted of outpatient surgery in Terms of process metrics a multimodal pain management pathway was effectively implemented in which a greater proportion of ERAS patients received three or more non opioid agents In addition PCA use was almost completely Eliminated in the ERAS group while over half of patients in the control group were using PCA's the true consumption of opioids Via PCA in the control group was unable to be determined due to a lack of complete drug usage totals in the control group And but a trend for reduced total morphine equivalent dosage usage was observed Importantly at the one month post-op time point without any changes to the Discharge prescription of opioids we found a reduction in Opioid use in our patients as compared to the control group When we looked at maximum pain scores during the inpatient admission we found no increase in pain scores associated with the near elimination Of PCA and adoption of the multimodal opioid sparing regimen with respect to resource utilization implemented Implementation of ERAS trended towards a reduction in overall hospital length of stay There was no difference in terms of ICU admission and ERAS patients Trended towards being discharged to home more likely than the control group Readmission rates at 30 and 90 days were not found to be statistically different different in our small cohort So in conclusion the major goals of our ERAS pathway are to optimize the surgical experience for patients and improve their clinical outcomes This care paradigm relies on the multidisciplinary and collaborative care of all individuals Involved in the patient's surgical journey in a relatively standardized fashion The present study has shown that our ERAS protocol and in particular our ERAS pain management protocol has the potential to safely reduce Opioid use in both the peri-op period as well as one month after surgery For example three-quarters of our institution's fine and profo nerve surgical population represents opioid naive patients And there's increasing data to support that between three to seven percent of opioid naive patients undergoing surgery Continue to take opioids at one year later Further long-term data with a larger group and potentially randomization is required to address whether this reduction in opioid use is durable There are several limitations to our study This is a prospective cohort analysis Which is limited by a moderate sample size the control group is a historical one and the data was reviewed retrospectively Randomization and blinding was not performed Data collections limited to the information provided in the medical records and minor protocol deviations from this multimodal pathway are not well-documented And difficult to assess however no selection bias was encountered Despite these limitations the study demonstrates the safety and efficacy of our pen neurosurgery ERAS protocol We continue to iterate on our pathway and monitor outcomes We believe that an ERAS pathway similar to this can be safely incorporated in other centers Performing spine and peripheral nerve surgery and based on the data has the potential to improve outcomes Thank you So Ali at all provide an example of a before-and-after study of the implementation of ERAS at their institution Strengths of this study include prospective data collection within the after group a before group that came from the same institution with the same surgeons and The fact that they were able to demonstrate large effects for some but not all of their outcomes Important considerations in this before-and-after study design however include the possibility of regression to the mean and in particular Did an unusually high rate of opioid use in 2016 lead to implementation of the ERAS? protocol in 2017 did other institutional changes coincide with the implementation of ERAS that might have also affected the results and Finally there were far fewer before subjects compared to after subjects Despite having been recruited over a similar period of time and so this does raise the possibility of an unintentional selection bias These and other considerations force us to temper our enthusiasm for these otherwise promising results Great well, I congratulate you on your paper. If you haven't heard about ERAS yet I strongly encourage you to go home and talk to your general surgeons about it This is a massive movement and I was lucky enough to be introduced to this by one of our young residents Karthik Madhavan about seven years ago and This is I think the first paper ever discussed on ERAS and spine So has been indicated ERAS is a comprehensive pathway program That's been implemented just as they have at Penn and this is you've even heard of it At Penn and this is to give you an idea Colorectal surgery look at all the iterative changes that have been made and this is the oldest standing Surgical iterative change which is in the colorectal region and please take a look at that literature It's really fascinating in terms of what it involves now Penn and I believe HSS and us We've been leading the way in terms of doing studies on ERAS And I know many of you at home are starting to do a similar concept so going over the study design again It's a comparative group. So this is how ERAS is different It is an iterative process where you measure you change your your practice and you measure again And you see what works, and you see what doesn't works work And I think that the bottom line is that in this paper They were really able to document a significant decrease in PCA usage and total narcotic consumption by instituting some very basic and simple implementations as you can see in their paper and What they found was that they reduced narcotics significantly and patients were much less likely to use narcotics one month after surgery So it was a lasting benefit, but unfortunately they didn't see a difference in pain scores They didn't see shorter length of stay and they didn't see any changes in terms of long-term discharge here a couple flaws they had a very heterogeneous population, but it is a real-world group and It's it's unclear exactly how the changes were instituted I think a lot of this is really process improvement, which is important to any ERAS program so in conclusion. I really can crash Congratulate dr. Ali dr. Welch and their group at Penn for being the first to publication on this this is an iterative process So I'm sure they're going to continue to improve it And there's a lot of room for improvement like local analgesia fluid management surgical technique modification and prehab. Thank you

enhanced recovery after surgery

ERAS protocol

opioid use reduction

multimodal pain management

surgical outcomes improvement