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      Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

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          Abstract

          Background

          Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review.

          Methods

          We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway.

          Results

          We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components.

          Conclusions

          We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS.

          Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

          Supplementary Information

          The online version contains supplementary material available at 10.1186/s12871-021-01281-1.

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          Most cited references241

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          RoB 2: a revised tool for assessing risk of bias in randomised trials

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            ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions

            Non-randomised studies of the effects of interventions are critical to many areas of healthcare evaluation, but their results may be biased. It is therefore important to understand and appraise their strengths and weaknesses. We developed ROBINS-I (“Risk Of Bias In Non-randomised Studies - of Interventions”), a new tool for evaluating risk of bias in estimates of the comparative effectiveness (harm or benefit) of interventions from studies that did not use randomisation to allocate units (individuals or clusters of individuals) to comparison groups. The tool will be particularly useful to those undertaking systematic reviews that include non-randomised studies.
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              AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both

              The number of published systematic reviews of studies of healthcare interventions has increased rapidly and these are used extensively for clinical and policy decisions. Systematic reviews are subject to a range of biases and increasingly include non-randomised studies of interventions. It is important that users can distinguish high quality reviews. Many instruments have been designed to evaluate different aspects of reviews, but there are few comprehensive critical appraisal instruments. AMSTAR was developed to evaluate systematic reviews of randomised trials. In this paper, we report on the updating of AMSTAR and its adaptation to enable more detailed assessment of systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. With moves to base more decisions on real world observational evidence we believe that AMSTAR 2 will assist decision makers in the identification of high quality systematic reviews, including those based on non-randomised studies of healthcare interventions.
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                Author and article information

                Contributors
                analicina@hotmail.com
                silversaj@me.com
                drharrylaughlin@gmail.com
                Jeremy.russell@austin.org.au
                cwan@sent.com
                Journal
                BMC Anesthesiol
                BMC Anesthesiol
                BMC Anesthesiology
                BioMed Central (London )
                1471-2253
                10 March 2021
                10 March 2021
                2021
                : 21
                : 74
                Affiliations
                [1 ]GRID grid.410678.c, Austin Health, ; 145 Studley Road, Heidelberg, Victoria 3084 Australia
                [2 ]GRID grid.1002.3, ISNI 0000 0004 1936 7857, Monash Health, Clayton, Australia, , Faculty of Medicine, Nursing and Health Science, Monash University, ; Melbourne, Victoria Australia
                [3 ]GRID grid.416131.0, ISNI 0000 0000 9575 7348, Royal Hobart Hospital, ; Hobart, Tasmania, Australia
                [4 ]GRID grid.410678.c, Department of Neurosurgery, , Austin Health, ; Melbourne, Victoria, Australia
                [5 ]GRID grid.413105.2, ISNI 0000 0000 8606 2560, St Vincent’s Hospital, ; Melbourne, Australia
                Author information
                http://orcid.org/0000-0001-8897-0156
                Article
                1281
                10.1186/s12871-021-01281-1
                7944908
                33691620
                c9b8fb24-789d-426b-8586-afc20878ea21
                © The Author(s) 2021

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 16 June 2020
                : 16 February 2021
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2021

                Anesthesiology & Pain management
                enhanced recovery after spinal surgery (erss),perioperative pathway,perioperative outcomes,systematic review;

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