An Enhanced Recovery Program Significantly Reduces Postop Opioid Use in Spine Surgery Patients

The majority of elective spinal and peripheral nerve surgery patients who followed an Enhanced Recovery After Surgery (ERAS) protocol did not need opioids for pain management at multiple time points following their procedure, according to a study from the Perelman School of Medicine at the University of Pennsylvania. Researchers found that when an ERAS protocol was employed to optimize patients perioperatively, fewer patients needed pain medications at 1, 3, and 6 months after surgery.

Preliminary findings summarizing opioid use after 1 month of the ERAS protocol were published in the Journal of Neurosurgery: Spine in 2019. [1] The new paper, published online ahead of print by Pain Medicine, reports on continued benefits over an 18-month period utilizing the ERAS pathway.

The ERAS protocol developed at Penn (Figure 1) includes a personalized, safe, and effective pain management plan to help prevent opioid addiction, an ongoing public health crisis in the US. ERAS engages patients in their care before, during, and after their hospitalization and includes patient education, text reminders, nutrition information, early mobilization, and recovery plans. ERAS also relies on collaborative care among all individuals involved in the patient’s surgical journey, including anesthesiologists, rehabilitation therapists, nurses, and surgeons, to improve clinical outcomes and optimize a safe recovery.


Figure 1. Enhanced Recovery After Surgery (ERAS) protocol for elective spine and peripheral nerve surgery decreases opioid use and length of stay. Image courtesy of Penn Medicine.


“We know from our clinical experience and previous literature that programs like ERAS work, but we didn’t expect the impact on opioid use to be so sizeable,” said senior author Zarina S. Ali, MD, an assistant professor of neurosurgery at Penn. “The most important outcome from this study is the decrease in opioid use. Furthermore, patients following the ERAS protocol reported less opioid use without higher pain scores. This represents an important advance in the context of the current nationwide opioid epidemic.”

For this study, a total of 1141 patients were enrolled in the ERAS protocol and compared with 149 historical controls who received the standard of care. Both groups had similar surgical procedures and demographics.

The researchers found a significant reduction in use of opioids by following the ERAS protocol at 1, 3, and 6 months following surgery:

  • 6% of patients following the ERAS protocol needed pain medications 1 month after surgery, compared with 70.5% of patients in the control group
  • 5% in the ERAS cohort needed pain medication at 3 months after surgery, compared with 70.9% of the controls
  • 6% of the ERAS cohort needed pain medication at 6 months after surgery, compared with 51.9% of controls

In addition, use of patient-controlled analgesia (PCAA) was nearly eliminated in the ERAS group compared with patients in the control group: 1.4% versus 61.6% ERAS patients were up and moving faster compared with control patients, were less likely to need postoperative catheterization, and had shorter hospital stays.

“Previous publications have demonstrated ERAS implementation in neurosurgery practices primarily through minimally invasive spinal surgery, but our neurosurgical practice has been actively applying ERAS principles to elective spine and peripheral nerve surgery since 2017, in coordination with a variety of departments across the health system,” said Tracy M. Flanders, MD, first author and neurosurgery resident at Penn. “This study captures the exciting benefits of this protocol for minimizing opioid use, decreasing length of stay, and more—without impacting patient satisfaction.”



Flanders TM, Ifrach J, Sinha S, et al. Reduction of postoperative opioid use after elective spine and peripheral nerve surgery using an enhanced recovery after surgery program. Pain Med. 2020 Aug 6;pnaa233. doi: 10.1093/pm/pnaa233. Online ahead of print.



  1. Ali ZS, Flanders TM, Ozturk AK, et al. Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution. J Neurosurg Spine. 2019 Jan 25;1-9.

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