Enhanced recovery after surgery clinical pathway in oblique lumbar interbody fusion: overcoming postoperative pain to improve compliance and recovery. A prospective randomized noninferiority trial.

Abstract

Enhanced recovery after surgery (ERAS) has demonstrated benefits across various surgical specialties. However, a significant research-practice gap remains, with fewer than half of spine surgeons incorporating ERAS principles into daily practice. A key barrier to ERAS implementation in spine surgery is postoperative compliance, as patients often express concerns about worsening pain. To address these challenges, the authors developed a standardized, delivery-focused ERAS clinical pathway (CP) for oblique lumbar interbody fusion (OLIF). This study prospectively evaluated whether ERAS-CP can improve postoperative compliance without compromising pain control compared with conventional ERAS. This prospective, randomized noninferiority trial involved 41 patients undergoing OLIF from July 2023 to February 2024. Patients were randomized to either the ERAS-CP group (n = 21) or the control (conventional ERAS) group (n = 20). The ERAS-CP comprised a CP system integrated into the electronic health record system, patient education manual, and dedicated medical personnel support. The control group (conventional ERAS) followed standard ERAS principles but lacked these structured compliance-enhancing interventions. The primary outcome was back pain at discharge measured by the numeric rating scale. Secondary outcomes included ERAS compliance, pain management, and patient satisfaction. Demographics were similar between the groups. The ERAS-CP group demonstrated noninferiority in back pain at discharge compared with the control group in the intent-to-treat analysis (difference -0.1, 95% CI -1.4 to 1.1) and the per-protocol analysis (difference -0.3, 95% CI -1.6 to 1.0). The ERAS-CP group achieved earlier ambulation (median 2 [range 1-9] vs 3.5 [range 2-18] hours, p = 0.011) and longer daily ambulation times (mean 91.7 vs 68.2 minutes/day, p = 0.047). Nonopioid analgesic use was higher in the ERAS-CP group on postoperative days 1 and 2 (p < 0.05), with no difference in opioid use. Both groups reported high satisfaction with pain management (78%). No significant differences were found in complication rates, length of stay, or 3-month clinical outcomes. The ERAS-CP for OLIF demonstrated noninferiority in pain management while improving adherence to key ERAS components. By reinforcing postoperative compliance through structured interventions, ERAS-CP may enhance recovery in lumbar spinal fusion surgery.