Enhanced Recovery After Surgery

Welcome to the MSSIC ERAS toolkit. In 2019, MSSIC introduced ERAS for spine surgery protocols and began to lay the groundwork for future ERAS performance measures. ERAS protocols propose a multimodal, evidence-based approach to better prepare patients for surgery. The principles of ERAS have been successfully implemented for a variety of surgeries, however, spine surgery has lagged behind other subspecialties.

The evidence to support ERAS in spine surgery has been proposed in recent peer-reviewed literature and has the potential to enhance productivity gains and cost savings. MSSIC began an extensive literature review and used our August 2019 MSSIC Meeting to introduce ERAS for spine surgery. The following contains the MSSIC ERAS Protocol guideline, as well as support resources and tools to assist our sites as they move forward into the 2021 and 2022 Performance Measures.

While the MSSIC ERAS Protocol guideline outlines both essential and suggested elements, sites are encouraged to make their ERAS protocol their own. Each MSSIC site is encouraged to assess the current state at their institution, and take into consideration their unique patient population and unique site culture when developing an ERAS protocol. Our hope is that the following tools and resources will assist you in that process.


MSSIC ERAS Resources & Presentations

The following resources are past presentations from MSSIC meetings with the content focus of ERAS as well as the MSSIC ERAS Pathway guideline.

Building an ERAS Program, Z. Ali, August 2, 2019
Opioid reduction thru ERAS, Z. Ali, August 2, 2019
ERAS Literature Review
Presurgical Education Program Considerations



The following resources are publication articles describing various ERAS pathways at different institutions, common ERAS elements, and the effect ERAS has on patient outcomes.

An ERAS Pathway for Anterior Cervical Spine Surgery
Benefits of Enhanced Recovery After Surgery for Fusion in Degenerative Spine Surgery
Characterizing the Risk and Outcome Profiles of Lumbar Fusion Procedures in Patients with Opioid Use Disorders
Development and Implementation of a Spine Surgery ERAS – The Cleveland Clinic Experience
Does an ERAS Protocol Change Costs and Outcomes of Single-Level Lumbar Microdiscectomy
Enhanced Perioperative Care and Decreased Cost and Length of Stay After Elective Major Spinal Surgery
Enhanced Recovery After Spine Surgery – A Systematic Review
Enhanced Recovery After Spine Surgery – Review of the Literature
ERAS for Major Spine Surgery
ERAS Pain Management
ERAS, An Anesthesiologist Perspective
Implementing ERAS to Improve Outcomes
Poor Nutrition Status and Lumbar Spine Fusion in the Elderly, SPINE Volume 42, Number 13, pp 979-983
Preop Maximization to Reduce Complications
Preoperative Patient Preparation in ERAS
University of Pennsylvania – Development of Neurosurgical ERAS Protocol
University of Pennsylvania – Enhanced Recovery After Elective Spinal Surgery


Screening Tools & ERAS Resources

The following resources are examples of screening tools that can be used to identify risks and recommend interventions to better optimize patients before spine surgery. Included is the American College of Surgeon’s “Strong for Surgery” program as well as the American Society of Enhanced Recovery (ASER) implementation guide.  There are also articles describing the screening tools and interventions implemented by Cleveland Clinic and tools to screen for Frailty.


Strong for Surgery Program

Strong for Surgery empowers hospitals and clinics to integrate checklists into the preoperative phase of clinical practice for elective operations. The checklists are used to screen patients for potential risk factors that can lead to surgical complications, and to provide appropriate interventions to ensure better surgical outcomes. A patient’s risk of negative outcomes from an operation is often both predetermined and modifiable before entering the operating room. Preoperative checklists serve as a communication tool for patients and clinicians to consider common risk areas.

The Strong for Surgery tools are free to surgeons and hospitals.  You may choose to use the entire program or only pieces.  The current tools are attached below.  Under the Provider Resources is a comprehensive implementation guide detailing how to successfully implement the tools.

You may also go to the site below for more information or contact:

Susan Chishimba, Program Manager, Strong for Surgery




American College of Surgeons (ACS) – Individual Screening Checklists

Blood Sugar Checklist – American College of Surgeons
Delirium Checklist – American College of Surgeons
Medication Checklist – American College of Surgeons
Nutrition Screening Checklist – American College of Surgeons
Pain Control Checklist – American College of Surgeons
Patient Directives Checklist – American College of Surgeons
Prehabilitation Checklist – American College of Surgeons
Smoking Checklist – American College of Surgeons


Patient Resources

Nutrition Before Surgery – American College of Surgeons
Preparing for Surgery – American College of Surgeons
Quit Smoking – American College of Surgeons
Safe Pain Control – Adult – American College of Surgeons
Preparing for Surgery – American College of Surgeons


Provider Resources

Drug Induced Delirium in the Elderly
How Long Off Cigarettes – American College of Surgeons
Immunonutrition Studies – American College of Surgeons
Lab Screening Serum Albumin Fact Sheet – American College of Surgeons
Nutrition in Risk Stratification – American College of Surgeons
Strong for Surgery Introduction Presentation
Toolkit – Strong For Surgery Fact Sheets – American College of Surgeons
Toolkit – Strong For Surgery Implementation Guide – American College of Surgeons
Toolkit – Strong For Surgery Info Documents – American College of Surgeons


Other Screening Tools

Article Impact of Frailty
ASER Implementation Guide
Cleveland Clinic ERAS
Impact of Frailty Index


Shared Site Resources

Attached are tools and resources that have been graciously shared by other MSSIC sites. You may use them to assist in the development of your own site tools.

Beaumont Troy – ERAS Spine Protocol for Cervical Fusions and Revisions- Aug 12, 2019
Beaumont Troy – ERAS Spine Protocol for Lumbar Fusions Revisions – Aug 14, 2019
Beaumont Troy – ERAS Spine Protocol for Same Day Lumbar Laminectomy – Nov 5, 2019
Beaumont Troy – Spine ERAS Order Sets