If your spine surgeon has recommended an operation, it is completely normal that your first concern is not the name of the technique, but what your recovery will be like. In recent years, programmes called “enhanced recovery” or ERAS (Enhanced Recovery After Surgery) have been developed to make the postoperative period safer, with fewer complications and shorter hospital stays. In this article we explain what this means in practice and what you can realistically expect as a patient.
- ERAS programmes are bundles of measures before, during and after surgery designed to reduce the impact of the procedure on the body and speed up recovery without compromising safety.
- In spine surgery they have been associated with fewer days in hospital, less use of opioids and, in some studies, fewer complications.
- They are not a “miracle technique”: their effectiveness depends on the type of surgery, your general condition and the coordination between the surgical, anaesthesia and rehabilitation teams.
- As a patient, you can actively contribute to ERAS through prehabilitation, stopping smoking, controlling chronic diseases and getting moving early after surgery.
What is an ERAS programme in spine surgery
An enhanced recovery programme is a structured protocol that brings together many small decisions around the time of surgery: how to prepare in the weeks beforehand, which type of anaesthesia and pain control to use, when you can start drinking and eating again, when you should get out of bed, how drains and catheters are managed, and how discharge and later rehabilitation are organised.
Rather than focusing only on the surgical act itself, ERAS looks at the whole perioperative process. The aim is to reduce the body’s stress response, preserve normal function as much as possible and help you regain independence earlier. In spine surgery these programmes have mainly been applied to lumbar and thoracolumbar fusion, complex deformity surgery and, increasingly, to cervical procedures and minimally invasive techniques.
Which types of spine surgery use ERAS
The components of ERAS can be adapted to different procedures, but in practice they are used mainly in:
- Lumbar and thoracolumbar fusions for mechanical pain, deformity or instability.
- Adult deformity surgery involving large corrections.
- Revision spine surgery in patients who have already undergone an operation.
- Minimally invasive techniques such as lateral fusion or endoscopic surgery, where tissue trauma is already reduced and ERAS helps to build on that advantage.
In smaller procedures, such as simple lumbar decompressions, some ERAS measures are applied almost routinely, even if the hospital does not formally label them as such.
Symptoms and indications: when an ERAS programme may help you
ERAS is not an indication in itself, but a way of organising care around an operation that is already indicated. You may benefit particularly from an enhanced recovery programme if:
- You have disabling chronic low back or neck pain that has not improved despite well conducted conservative treatment.
- You have neurological symptoms such as weakness, tingling or difficulty walking due to stenosis or deformity.
- You have been offered a lumbar or thoracolumbar fusion, deformity surgery or a revision of previous spine surgery.
- You live with conditions such as diabetes, obesity, anaemia or osteoporosis, which increase the risk of complications and make global planning even more important.
The goal of ERAS is that, once the decision to operate has been made, the journey is as safe, predictable and focused on your functional goals as possible.
Assessment and workup before surgery
Before entering an ERAS pathway, you undergo the same clinical and radiological assessment as for any spine surgery: full medical history, neurological examination, MRI, dynamic X-rays and, when needed, CT scan or other specific tests. On top of this, ERAS adds several organised steps:
- Structured anaesthetic assessment: review of comorbidities, usual medication, allergies, and cardiac and pulmonary risk.
- Optimisation of chronic diseases: adjusting diabetes treatment, controlling blood pressure, correcting anaemia or malnutrition when present, reviewing osteoporosis.
- Risk stratification: estimating the risk of serious complications and need for ICU, which helps to plan resources and set realistic expectations.
- Preoperative education: explaining the admission pathway, type of anaesthesia, pain management plan, early mobilisation and what variations are normal during the postoperative period.
In some hospitals these interventions are grouped into specific “prehabilitation” clinics where anaesthetists, rehabilitation specialists, nurses and sometimes nutritionists and psychologists are involved.
Prehabilitation: what you can do before surgery
A key part of ERAS is prehabilitation, that is, preparing yourself physically and mentally for the operation. These are not miracle measures, but they do increase the chances of a faster recovery with fewer complications.
- Tailored exercise: gentle aerobic activity (walking, static bike) and moderate strength exercises for trunk and legs are often recommended, as long as pain and your clinical situation allow it. The aim is to reach surgery with the best possible cardiovascular and muscular fitness.
- Stopping smoking: quitting several weeks before surgery reduces the risk of non-union, infection and respiratory problems. Even if complete abstinence is not achieved, any sustained reduction improves the outlook.
- Nutrition and weight: in people who are underweight or malnourished, the goal is to improve protein and calorie intake. In obesity, modest but sustained weight loss can help, but it should not indefinitely delay a necessary operation.
- Mental health and realistic expectations: anxiety and unrealistic expectations increase the perception of pain and the likelihood of dissatisfaction. Education and, where needed, psychological support are part of ERAS.
- Medication review: some drugs, such as anticoagulants or antiplatelets, require a specific plan before and after surgery, while others, such as certain painkillers, can be adjusted to improve postoperative pain control.
All of this should be personalised. Never change important medication on your own without talking to your medical team.
What changes during surgery in an ERAS programme
In the operating room, ERAS does not mean one single technique, but a different way of combining anaesthesia, analgesia and monitoring to reduce surgical stress. Common elements include:
- Anaesthesia adapted to the protocol: use of drugs that allow quick awakening, strict control of body temperature and careful management of fluid volumes.
- Multimodal analgesia: combining several drugs and techniques (non-opioid painkillers, regional anaesthesia, local infiltrations) to reduce the need for strong opioids.
- Active prevention of nausea and vomiting: this reduces discomfort and makes early mobilisation and feeding easier.
- Advanced monitoring: depending on complexity, this may include neuromonitoring and close haemodynamic monitoring to minimise neurological and cardiovascular risks.
The specific surgical technique (for example, a thoracolumbar fusion or a minimally invasive lateral fusion) is chosen according to the clinical indication, not because of the ERAS protocol. However, when the surgery is less aggressive to the tissues, the benefits of ERAS usually become more evident.
Postoperative recovery: what you can realistically expect
Every case is different, but the literature on ERAS in spine surgery shows that, in comparable groups, patients tend to have shorter hospital stays (often one or two days fewer in fusion surgery) and better pain and function scores in the first days or weeks, without an increase in complications. Some studies also report reduced opioid consumption.
A rough timeline for a lumbar or thoracolumbar fusion within an ERAS setting might be:
- First 24 to 72 hours: intensive pain control with multimodal analgesia, getting out of bed and walking with help on the first day whenever it is safe, early oral intake if there are no contraindications.
- Weeks 1 to 2: daily walks, posture care, gentle exercises prescribed by rehabilitation. Tiredness and stiffness are common, but the goal is to gradually increase independence.
- Weeks 3 to 6: many patients with office-based jobs can consider a phased return to work, provided pain is controlled and they are not taking sedating medication. Core strengthening exercises are added.
- Months 3 to 6: functional consolidation, more freedom for leisure activities and low impact sports. Physically demanding jobs and high impact sports require more time and individual assessment.
These timeframes are approximate. Factors such as age, number of levels operated, bone quality, previous surgeries or associated diseases can markedly shorten or lengthen them.
Benefits compared with risks and side effects
The potential benefits of ERAS in spine surgery include:
- Fewer days in hospital for many elective procedures.
- Earlier mobilisation, which reduces the risk of thromboembolic complications and supports functional recovery.
- Less reliance on opioids thanks to multimodal analgesia.
- A greater sense of control for the patient by understanding the process and its goals better.
However, ERAS also has limitations and possible risks if applied without judgement:
- Not all patients or surgeries are suitable for very early discharge; pushing for it can increase readmissions.
- If information is not well coordinated, patients may feel pressured to “tick boxes” that are not realistic in their situation.
- In people with significant comorbidities, overly aggressive mobilisation may lead to falls or cardiovascular complications.
Protocols are therefore tailored to each risk profile, and safety must always come before speed.
Criteria for considering surgery within an ERAS pathway
There is no single universal list, but in general your team may consider an ERAS approach if several conditions are met:
- The surgery is planned, not urgent, and there is time to prepare properly.
- A clear pathway exists between surgery, anaesthesia, nursing, rehabilitation and primary care.
- Your overall condition allows some degree of early mobilisation, even with help.
- You understand the plan and can take an active role in prehabilitation and in following postoperative advice.
Although ERAS provides advantages in many contexts, it is not essential for spine surgery to have a good outcome. Many patients also do well in settings without a formal protocol but with well individualised care.
When to go to the emergency department after spine surgery
Whether or not ERAS is used, there are situations after spine surgery in which you should go straight to the emergency department or contact your team:
- Sudden or progressive loss of strength in arms or legs.
- Difficulty controlling urine or stools, or complete loss of sensation in the perineal area.
- Sudden severe pain that does not improve with the prescribed medication.
- High fever together with significant back pain or redness at the wound site.
- Shortness of breath or sudden chest pain.
These warning signs may point to potentially serious complications such as haematomas, deep infections, cauda equina syndrome or thromboembolic events. Do not wait for your next scheduled appointment if they occur.
Myths and facts about ERAS in spine surgery
- Myth: ERAS means you will always go home the day after surgery. Fact: in some smaller procedures, very early discharge may be possible, but in complex surgery the stay is still measured in days. The aim is to avoid unnecessary days in hospital, not to break a record.
- Myth: if you are in an ERAS programme you will have less pain because they use stronger drugs. Fact: the idea is to use smarter combinations of medicines to control pain with fewer side effects, not to increase the strength of the drugs without limit.
- Myth: ERAS replaces the need for rehabilitation. Fact: structured rehabilitation is a key part of enhanced recovery, not a substitute for it.
- Myth: if your hospital does not have an official ERAS protocol, your surgery will go worse. Fact: many ERAS principles are applied implicitly in centres that do not use that name. What really matters is the overall quality of the team and follow up.
- Myth: ERAS is only for young, healthy patients. Fact: higher risk patients can benefit greatly from more careful preparation, although goals and timelines need to be adapted.
Frequently asked questions
What does being in an ERAS programme “really” change for the patient?
You will mainly notice that everything is explained more clearly, you are encouraged to get up and walk early, you can drink and eat sooner than with older protocols, and several pain control strategies are used at the same time to make discomfort more manageable. It is also common for discharge to be planned from the start, with clear instructions for home.
Are ERAS programmes as safe as traditional protocols?
Published studies have not shown an overall increase in complications when protocols are well designed and adapted to the type of surgery and patient. In many cases there is even a reduction in some complications and in length of stay. There is always some risk, though, because any major spine operation carries risk.
Can I ask for an ERAS protocol if my hospital does not formally have one?
You can ask which measures are used to promote fast recovery and discuss them with your team. Many elements of ERAS, such as early mobilisation or multimodal analgesia, can be incorporated even if the hospital does not have a formally named programme.
Do ERAS programmes eliminate pain after surgery?
No. The goal is for pain to be tolerable so that you can move, sleep reasonably well and progress with rehabilitation. It is normal to have discomfort for several weeks. What matters is that pain gradually improves and there are no signs of complications.
If I have osteoporosis or other illnesses, is ERAS still an option?
For many people with fragile bone or comorbidities, enhanced recovery programmes are particularly helpful because they ensure treatment optimisation and better planning of the postoperative period. Not every component will be the same and, in some cases, hospital stay or activity progression will need to be more cautious.
Who decides whether I enter an ERAS programme?
The decision usually lies with the spine and anaesthesia teams, based on hospital resources and your clinical situation. As a patient you can and should ask which specific measures will be used to support your recovery and how you can play your part.
Glossary
- ERAS: acronym for Enhanced Recovery After Surgery, programmes that bundle measures to improve recovery after an operation.
- Arthrodesis: surgical fusion of two or more vertebrae using implants and bone to stabilise the spine.
- Spinal deformity: significant change in normal spinal alignment, such as severe scoliosis or kyphosis.
- Multimodal analgesia: combined use of different types of painkillers and techniques to control pain.
- Prehabilitation: set of measures before surgery to improve physical and mental condition and thus facilitate recovery.
- Comorbidity: chronic disease that exists alongside the main problem, such as diabetes, high blood pressure or obesity.
References
1. Bansal T, Sharan AD, Garg B. Enhanced recovery after surgery protocol in spine surgery. J Clin Orthop Trauma. 2022. Available at: pubmed.ncbi.nlm.nih.gov/35865326
2. Naftalovich R, et al. Enhanced Recovery After Surgery (ERAS) protocols for spine surgery – review of literature. Anaesthesiol Intensive Ther. 2022. Available at: ait-journal.com (Enhanced Recovery After Surgery protocols for spine surgery)
3. Elsarrag M, et al. Enhanced recovery after spine surgery: a systematic review. Neurosurg Focus. 2019. Available at: thejns.org (Neurosurgical Focus, volume 46, number 4)
4. Álvarez-Galovich L, et al. Recommendations for optimised postoperative recovery in spine surgery (REPOC). Rev Esp Cir Ortop Traumatol. 2023;67:T83–T93. Available at: elsevier.es (Revista Española de Cirugía Ortopédica y Traumatología)
5. Debono B, et al. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS) Society recommendations. Spine J. 2021. Available at: erassociety.org (Guidelines)
6. Tong Y, et al. Enhanced recovery after surgery trends in adult spine surgery: a systematic review. Int J Spine Surg. 2020. Available at: pubmed.ncbi.nlm.nih.gov/32986587
This text is for information only and is not a substitute for an individual medical assessment or the recommendations of your healthcare team. If you develop new or worrying symptoms, always consult health professionals or go to the emergency department.
