Nursing care in enhanced recovery after surgery (ERAS): Pathways for patients undergoing spinal surgery

Spinal surgery encompasses surgical procedures that are performed in the cervical, thoracic, lumbar and sacral regions (Pahwa et al., 2024). While spinal surgery is practiced worldwide, there are varying strategies used by clinicians to manage pain among patients who undergo this form of surgery. The experience of pain post-surgery is unique for each patient and hence the challenges for pain management are complex for clinicians to address (Wijgert et al., 2025).

Recent innovations in post-spinal surgical pain management have led to the inception of multidisciplinary teams that design and implement Enhanced Recovery After Surgery (ERAS) programs which are multimodal strategies targeted at enhancing patients’ postoperative experiences by moderating physiological strain resulting from surgery (Pahwa et al., 2024).

The aim of this paper was to explore nursing roles and what constitutes pre-operative risk factors, information requirements for enhanced recovery and effective medications for patients after spinal surgery. An understanding of enhanced recovery following spinal surgery can empower neurosurgical nurses to prioritise interventions that optimise quality of care and maximise positive outcomes for surgical patients.

Patients’ pre-operative function, risk factors and pre-operative education and support can affect their post operative recovery. Patients should have a clear understanding of expected post-operative pain before surgery. Pre assessment is important to identify patients taking high doses of opioids or chronic pain as these may be more difficult to manage post operatively (Bhatia & Buvanendran, 2019). Pre-operative risk factors for postoperative pain include catastrophizing, anxiety, depression, preoperative opioid use, pain sensitivity and females (Prabhakar et al., 2022). Fear of movement can occur pre-operatively and is associated with impaired mobility post operatively and should be addressed early to prevent immobility post-operatively (Ali, 2018). The patients’ psychological state and high/low expectations have been linked to less optimal results post operatively in spinal surgery and are associated with increased pain sensation and immobility (Licina et al., 2021). Patients require different levels of information to support their surgical journey, and a balance of pre-operative information is important as too little or too much can increase anxiety (Wongkietkachorn et al., 2018).

Waiting time for spinal surgery may significantly impact patient post operative pain experience and their recovery. Longer waiting times may be more apparent with competing priorities such as brain tumours and trauma, as often spinal surgery is not considered as an emergency and occurs electively. Evidence suggests that patients who experienced pain for more than a year before surgery, were associated with poorer outcomes post-operatively (Hamilton et al., 2023). The outcomes assessed included pain, patient satisfaction and return to work. Patients who waited less than three months for surgery had the best outcomes which may be why patients take longer to recover or experience more pain post operatively with longer waiting times.

The experience of post-operative pain is unique for every patient and is influenced by compounding factors, some of which may be inherent or external to the person (Waelkens et al., 2021). Inadequately controlled early post-operative pain after spinal surgery can have significant effects on patient outcomes such as delayed mobility, sleep deprivation, inadequate nutrition, incontinence, constipation or increased length of hospital stay (Ali et al, 2018; Ali et al 2019; Licina et al, 2021).

Inadequately managed pain post-operatively can lead to prolonged bedrest.

However, there are several complications that are associated with prolonged bedrest including risk for pneumonia, muscle atrophy, venous thromboembolism, and delayed rehabilitation (Rajan et al., 2022). Therefore, it is important for nurses to ensure that patients are provided adequate pre-preoperative information to enhance the post-operative experience following elective spinal surgery and post operative pain is acknowledged and treated early through nursing assessments.

Patients following spinal surgery may be restricted in their mobility due to multiple factors. These include clinical attachments, such as intravenous fluids, patient-controlled analgesia, indwelling urinary catheter, sequential compression devises, cervical collar, surgical drains and their post-operative functional level (Rupich et al., 2018). Delayed mobilisation can also be associated with some neurosurgical protocols where, for instance, patients are to wait for a follow up CT scan prior to mobilisation (Licina et al., 2021). Fear of pain or anticipation of pain on movement may contribute to increased anxiety resulting in delayed mobilisation and some patients may require support from physiotherapists or a mobility aid to mobilise post-operatively which can cause significant delays. Therefore, facilitating early safe patient mobilisation is a fundamental intervention that nurses should prioritise to safeguard against complications associated with prolonged bed rest (Rupich et al., 2018; Smith et al., 2019). Every patient’s surgical journey is unique and is dependent on factors such as the region of the spine being operated on, invasiveness of the surgery, level of pre-operative pain, mobility pre- and post-operatively, co-morbidities, tolerance of medications and pain (Waelkens et al., 2021).

Several types of medications are used as strategic interventions in the management of pain for spinal surgical patients. Opioids are frequently prescribed during the pre-operative period for patients, but this may create drug tolerance making post-operative pain management challenging (Yerneni et al, 2020). The utilisation of opioids has traditionally been the preferred choice of pain relief following spinal surgery, but they are associated with a number of side effects including nausea, vomiting, drowsiness, urinary retention, constipation and respiratory depression (Rajan et al., 2022). This leads to longer hospital stays, difficult to manage pain cycles, and delayed rehabilitation. More recently practice has moved to a multimodal pain relief approach throughout the patient journey from pre-operatively, intra-operatively and post-operatively with the avoidance of opioids (Ali et al, 2018; Bae et al., 2022; Debono et al, 2021; Lucina et al, 2021). Triple pharmacy consisting of paracetamol, nonsteroidal antiinflammatory drugs, and either a gabapentanoid or an adjunct such as duloxetine, epidural clonidine, lidocaine infusion dexamethasone, or magnesium infusion has been shown to reduce the use of opioids and improve the level of pain post-operatively (Bae et al,2022). Dehkordy et al. (2020) note that peri-operative magnesium infusion improves the post-operative analgesia, decreases the amount of morphine consumption following surgery and does not change the intraoperative bleeding in patients undergoing posterior spinal fusion surgery. Through ERAS programs, evidence has become clear that limiting the use of opioids and focusing on multimodal pain relief can be effective in attaining positive post-operative outcomes for patients (Naftalovich et al, 2022).

ERAS Programs are evidence based holistic protocols for the whole patient surgical journey and have led to improvements in outcomes for numerous surgical procedures through multimodal optimization of the patient pathway (Enhanced Recovery After Surgery [ERAS] Society, 2025). Originally, ERAS were popularised in the 1990s, as a systematic multi-model approach to managing perioperative patients via what was then referred to as Fast-Track Surgery (Debono et al., 2021).

The ERAS Society (www.erassociety.org) was founded in 2010 and continues to develop a range of guidelines that inform various types of surgeries worldwide (Debono et al., 2021; The ERAS Society, 2025). ERAS programs improve clinical outcomes, reduce complications, accelerate patient recovery, reduce hospital length of stay as well as improving patient satisfaction, and enabling early patient discharge from hospital (Choi et al., 2022; Dietz et al., 2019, Ljungqvist et al., 2017). One of the key benefits from ERAS protocols is reduction in hospital length of stay (Bansal, Sharan & Garg; 2022). These outcomes are achieved by addressing pre-operative, perioperative and post-operative factors in the patient’s journey, that encompass not just pain management but also providing a holistic, and interdisciplinary approach to patient care (Ali et al, 2019). There is a nursing consideration that if patients are well prepared for surgery pre-operatively, their recovery post operatively may be accelerated.

Other key nursing considerations in the ERAS program may include pain management, nutrition, elimination, mobility, psychological needs, sleep, wound care and support as well as patient and family education with the patient at the centre of their care. Preoperative education and counselling, smoking and ethyl alcohol cessation, nutritional evaluation and optimisation of medications are all fundamental nursing considerations. All these nurse-led interventions are important as they contribute to reduced length of stay. ERAS programs ensure patients are educated pre-operatively to reconcile personal expectations with anticipated post-operative outcomes. However, according to Yoo et al. (2019) positive postoperative outcomes are linked to postoperative patient satisfaction but have no association with pre-operative patient expectations.

Rampersaud et al. (2022) demonstrated a link between patient expectations and outcomes suggesting that if patients had higher expectations pre-operatively, they were more likely to be less satisfied with their post-surgical outcomes. The nursing role is vital in addressing the patient’s expectations in such instances. Perhaps it would be better to manage preoperative expectations and provide education on the realistic recovery time, the importance of early mobilization, pain management, wound healing and overall outcomes. These models of patient care are in line with the New Zealand (NZ) Māori health model ‘Te Whare Tapu Whā’ which ensures four pillars of health, which are Taha tinana (physical health), Taha wairua (spiritual health), Taha whanau (family health) and Taha hinengaro (mental health) giving the picture that if one of these walls is missing or unbalanced, the person may become unwell and in order for us to be successful in our patient outcomes, all four must be supported (Ministry of Health NZ, 2023). There are currently no ERAS programs in New Zealand, but Australia has these programs in operation, for instance, the Westmead ERAS Protocol (Pahwa et al., 2024). The limitations to ERAS programs are that they require commitment of ample time and healthcare resources to operate effectively and support the provision of holistic patient care throughout the surgical journey. Also, pre -operative and post-operative experiences are reliant on effective communication, sharing quality information and support. All these aspects are vital for success of any ERAS program, but require time and commitment from multiple members of the multidisciplinary team. If implemented successfully these interventions can reduce hospital stay and complications with a smoother journey through recovery for the patient but similarly, longer waiting times would complicate this process.

The main goal of ERAS protocols is to utilise a combination of multimodal, multidisciplinary interventions to control pain and achieve positive patient outcomes post-surgery (Pahwa et al., 2024). As such, there are different ERAS protocols specific for surgical interventions (Naftalovich et al., 2022; Pahwa et al., 2024). A summary of six protocols from different institutions are outlined in Table 1 which largely focused on medication management (Naftalovich et al, 2022). Two key themes in the ERAS protocols reviewed are early mobilisation and multimodal pain relief tailored to individual patients for spinal surgery. It was noted that although dosage of multimodal medication was difficult to determine, the interventions can affect recovery time, complication and readmission rates (Bhatia & Buvanendran, 2019). However other pain management strategies can be considered such as yoga, cognitive behavioural therapy and music therapy (Grasu et al., 2018). These would be difficult to implement, standardise and would require allocation of ample time and resources from hospitals and a willingness to participate from patients.

These six protocols addressed various aspects of pre, intra and post-operative pain management and differed in their clinical approach. For ERAS protocols to be effective, they have to be adaptable to each individual, as patients experience pain differently and express varying pain thresholds. A unique note from the Perelman ERAS protocol which incorporated the practice of patients chewing gum as an intervention for post-operative pain management (Ali et al.,2018; Ali et al., 2019). Liao et al. (2022) also determined that chewing gum not only significantly reduced postoperative pain for patients following spinal surgery but also shortened the time between surgery and first bowel motion. Some ERAS protocols utilised minimum or regular pain relief with supplemental options as an intervention to contain break through pain (Pahwa et al., 2024). Nursing interventions such as early mobilisation, early nutrition, prevention of Venous Thromboembolism and early discharge are key features that support timely patient recovery post operatively (Ali et al.; 2019; Grazu et al.; 2018; Pahwa et al., 2024; Soffin et al.,2019)

This paper has illuminated factors that impact patients’ recovery from spinal surgery. The use of ERAS programs has been explored as a strategic evidence-based approach that can facilitate early patient recovery and discharge. Support for the patient and their family through the recovery journey is fundamental. Preoperatively, it is important to discuss and manage surgical expectations, risk screening, managing anxiety, mobility and pain assessment and planning. Managing patients’ expectations of pain and recovery following spinal surgery is vital and requires specialist neurosurgical nursing expertise. Considerations for effective nursing interventions in postoperative recovery include, thorough nursing assessment, effective communication, early patient mobilisation, prevention of constipation or other complications and effective multimodal pain relief. Further multi-centred research could be conducted in these areas to determine what comprises spinal surgical patient satisfaction in relation with post-operative care and to ascertain the aspects of nurse-clinician interventions that can be improved upon to enhance the patient experience and optimise recovery. All aspects of care are dependent on each other and therefore prevention of complications and early discharge from hospital is important. Important domains for careful nursing consideration are pain relief, elimination, early mobility, nutrition, wound care, culture and psychological support.