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E recovery after surgery (ERAS) was initially introduced by Henrik Kehlet as a multimodal approach focused on modulating the surgical stress response to reduce the impact of surgery on patients and improve recovery time.1 A wealth of evidence confirms the clinical and economic benefits of ERAS protocols in numerous fields.2 A meta-analysis conducted by Adamina et al3 on the use of ERAS protocol in colorectal surgery aided in the international recognition and interest in the adoption of enhanced recovery pathways into other complex surgical specialties including pancreaticoduodenectomy, gastrectomy, elective colonic, and pelvic surgery.3 ERAS protocols are adopted specifically for particular surgeries; however, all pathways are multimodal and involve preoperative assessment and optimization, attenuation of surgical stress, pain relief, early mobilization and exercise, and enteral nutrition to achieve an accelerated postoperative recovery and reduction in morbidity.4 Adoption of ERAS protocols into orthopedic surgery has likewise resulted in fewer postoperative complications, decreased opioid use, shorter length of stay (LOS), and greater overall cost savings.5,6 By implementing ERAS, the mortality for total joint arthroplasty decreased from 0.44% to 0.07% despite no alteration in surgical technique.5 Furthermore, meta-analysis depicted fewer complications in the ERAS group (P= 0.03) and a decreased LOS in comparison to non-ERAS groups (P< 0.01),6 suggesting the applicability to spinal operations. Conditions affecting the spine are some of the most prevalent medical conditions, with lower back pain affecting ∼80% of people at some point in their life.7 It is estimated that 1%–2% of disability in the US adult population is attributed to lower back pain, making it the second most common cause of adult disability.7 As health care cost increases in the United States, currently approximated at $2.8 trillion or 18% of the GDP, cost-effective analysis on the value of health care interventions have produced a critical debate.8 Back pain in the United States is estimated to consume ∼9% of total health care costs, with the cost exceeding $100 billion per year.7 Although advances have been made regarding surgical techniques and perioperative care, major spine surgery is still associated with significant postoperative morbidity in regards to neurological dysfunction and prolonged LOS in hospital.9 The increased metabolic demands on the body modulated by the surgical stress response is significantly influential to postoperative morbidity rates. In addition, certain spinal procedures are associated with pronounced postoperative pain. A review of 179 surgical procedures by Gerbershagen et al10 ranked lumbar fusion (1–2 vertebrae, 3+ vertebrae) and complex spinal reconstruction as 3 of the top 6 procedures for pain intensity experienced on the first postoperative day. Postoperative complications and morbidity are intensified by the metabolic demands placed on the body by the surgical stress response, as studies show preoperative malnutrition (serum albumin level <3.5 g/dL) is an independent risk factor for readmission within 30 days of spine surgery.11 Such recurring issues justify the construction of an efficient protocol to improve postoperative recovery for spinal procedures. Despite the added complexity of spinal surgery, several preliminary studies regarding the implementation of ERAS protocols in spinal surgery have been successful, suggesting the need for system-wide implementation.9,12 A recent study compared the surgical outcomes of preimplementation and postimplementation of ERAS protocols for patients who underwent surgery for metastatic spine tumors and found improvements in postoperative pain scores, opioid consumption, and LOS.9 Comparison between cohorts showed decreased total morphine use in ERAS groups with a statistically significant Spearman rank correlation (ρ= 0.47, n= 78, P< 0.001), and a LOS of 6.3 ± 2.2 days compared with the non-ERAS group LOS of 6.8 ± 1.9 days (P= 0.590).9 In addition, ERAS Received for publication April 6, 2019; accepted August 17, 2019. From the *Royal College of Surgeons in Ireland, St. Stephen’s Green; †Spine Service, Department of Trauma & Orthopaedic Surgery, Tallaght University Hospital; ‡School of Medicine, Trinity College Dublin; and §National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland. The authors declare no conflict of interest. Reprints: Daniel P. Ahern, MRCSI, Department of Surgery, School of Medicine, Trinity Centre for Bioengineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, 152-160 Pearse Street, Dublin 2, Ireland (e-mail: [email protected]). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. CONTROVERSIES IN SPINE SURGERY