Cervical spine surgery is a “team sport” involving you and your surgeon. Significant opportunity exists pre-operatively, intra- operatively, and post-operatively to provide for maximal recovery and minimize complications. This article delineates some of the aspects that a wise patient should consider before “going under the knife.”
Statistics show that the number of spine surgeries and especially spinal fusions have increased significantly over the past 20 years. In addition, the average age of the person undergoing spine surgery has increased. These facts point to the potential for higher complication rates, greater use of opioid analgesics, longer hospital stays, and increased costs overall after spine surgery, emphasizing the importance of a multimodal approach to improve outcomes.
In general, multiple factors after surgery lead to tissue damage and an activation of the inflammatory response similar to that which occurs as a result of trauma. It makes sense to alter these pathologic processes in a multimodal approach if we are to minimize their effects to promote a quicker, safer, more complete, and more cost-effective recovery. As a team, surgeon and patient can intervene in the pre- operative, intra- operative and post-operative periods to provide for Enhanced Recovery After Surgery (ERAS).
The first and foremost aspect of ERAS is patient education.
Realistic expectations of pre- and post-op events including pain control, early ambulation, elimination of unhealthy practices, etc. have been shown to decrease patient anxiey and lead to better healing. All patients should understand their critical role as a partner with their surgeon in the process of their own recovery. Communication is the key to initiating change in behavior of unhealthy practices such as alcohol abuse, excessive use of narcotics, etc. and reinforcing those that lead to better outcomes.
All patients must discontinue use of all tobacco products (including nicotine gum, etc.) 30 days prior to proposed surgery. Nicotine and many chemicals in tobacco smoke have been shown to significantly impair bone formation leading to poor bone fusions (pseudoarthroses). In addition, the chemicals cause impaired wound healing, pneumonias, blood clots, etc. and lead to accelerated disc and ligament degeneration. If quitting smoking is anticipated to be difficult for you, ask your surgeon for help, such as an appointment to a smoking cessation clinic.
Aspirin, nonsteroidal anti-inflammatory agents, Vitamin E supplements, and all fish oil supplements should be discontinued at least 7 days prior to surgery as they inhibit platelets and can lead to increased risk of bleeding. Certain agents such as excessive use of gingko biloba can cause excessive bleeding as well; these should all be reviewed in detail with your surgeon pre-operatively. In addition, these agents can cause impaired bone formation after surgery.
All medications causing bleeding such as Coumadin®, Plavix®, Lovenox®, Pradaxa®, Eliquis®, Airixtra®, Xarelto®, Acova®, Savaysa®, heparin, etc. must be discontinued for obvious reasons, usually 5-7 days before anticipated surgery. Check with your prescribing doctor for specific directions.
We recommend showering with an antibacterial soap such as Dial® for 7 days prior to surgery to limit the bacterial skin load and decrease the risk of wound infection.
Your overall health needs to be maximized prior to submission to the stresses of surgery and general anesthesia. Your surgeon may request formal evaluations and clearances from a cardiologist, pulmonologist, hematologist, or any number of specialists.
Vitamin and mineral supplements such as Vitamin C, Vitamin D, calcium, and a daily multivitamin tablet may be recommended before and after surgery. Check with your surgeon.
Make sure you maintain a normal diet and adequate hydration before your surgery with normal fluid intake until the prescribed time to stop eating and drinking. This is especially important for an outpatient surgery scheduled later in the day (with nothing to eat or drink after midnight) to avoid complications associated with dehydration.
Robotic-assisted, minimally invasive procedures, and procedures using microsurgery can potentially lead to smaller incisions, less blood loss, and less post-op pain with limited use of narcotics and earlier ambulation.
Local infiltration of the operative site with anesthetic agents such as bupivacaine, lidocaine, and in particular, liposomal bupivacaine (Exparel®) has proven to be very effective in our experience with post-operative pain control, leading to earlier ambulation and less risk of pulmonary complications, deep venous thrombosis, etc. We use these agents in essentially every surgery.
Liberal use of intravenous nonopioid agents such as steroids (including dexamethasone), acetaminophen, etc. can likewise lead to decreased use of narcotics, resulting in diminished post- op sedation and earlier ambulation. As indicated, patients can also be given the option of non-narcotic analgesic agents for post-op use, especially after outpatient procedures.
Consideration should be given to performing your procedure as an outpatient if clinically indicated. This decision is obviously surgeon- and patient-dependent, but less time in a standard hospital (with its significant bacterial contamination) is obviously in your best interest.
Early ambulation is critical to your recovery after spine surgery and has many benefits, including diminishing risk of respiratory complications, infection, muscle spasm, thromboembolic disease (blood clots), etc. as well as leading to a decreased length of hospital stay. You may be a candidate for formal physical therapy (outpatient or inpatient), if needed. Judicious chiropractic intervention may also be indicated.
As mentioned previously, decreased usage of opioid analgesics allows for diminished sedation and early mobilization especially after complex cervical and lumbar surgeries. Pre-operative education is critical to you as a patient in meeting your expectations for pain control while minimizing narcotic usage. Steroids, antinflammatories (when indicated), neuromodulating agents like Lyrica® or Neurontin® , muscle relaxants, acetominophen, Tramadol®, anti-nausea medications, etc. all play a role in this multi-modality approach to early ambulation.
Have a low threshold to communicate post-op problems and concerns to your surgeon. Maintain close communication for the best outcome. To that end, we call each of our patients directly the first day after discharge to keep communication open and to minimize anxiety and complications associated with post-op concerns.
At this time, there are no official guidelines for Enhanced Recovery After Spine Surgery. However, as evidence-based data becomes available for pre-, intra-, and post-op multi-modality interventions, pathways to improve overall outcomes, lessen patient stress and anxiety, speed overall recovery, and reduce stress for spine surgery patients will evolve. As a consumer of spine surgery, it makes perfect sense for you the patient to be actively involved in the evolution of those pathways. Call us at +1-(855)-854-9274 if you have questions regarding optimizing your spine surgery experience.