Early mobilization in spine decompression surgery: insights from one of the first monocentric studies in Switzerland

Early mobilization in spine decompression surgery: insights from one of the first monocentric studies in Switzerland | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Early mobilization in spine decompression surgery: insights from one of the first monocentric studies in Switzerland Mara Dimitriu, Mario Ropelato, Jacopo Vitale, Armin Mührer-Osmanagic, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6917412/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Introduction: The global rise in the aging population has increased the demand for self-sufficiency in older age and contributed to a higher number of spinal surgeries, driving up healthcare costs. Enhanced Recovery After Surgery (ERAS) protocols aim to improve outcomes by promoting early mobilization, which has shown benefits but lacks standardization in spinal surgery. This study evaluates the impact of early mobilization on outcomes after spinal decompression surgery in Switzerland. Methods: This retrospective study analyzed data from 123 patients who underwent lumbar decompression or microdiscectomy between January and December 2021 at a specialized spine unit. Patients were assigned to an Early Mobilization (EM) group or a control group based on the surgeon’s discretion. The EM group began mobilization on the day of surgery; the control group started the day after. Propensity score matching was used to reduce bias, resulting in 96 matched patients (48 per group, mean age: 56.0 ± 15.7 years). Local infiltration analgesia (LIA) was administered in a subset of patients in both groups. Outcomes included length of hospital stay (LOS), pain (VAS), and disability (COMI-back), assessed preoperatively and three months postoperatively. Results: The EM group had a significantly shorter LOS (3.7 vs. 5.2 days; p < 0.0001). Both groups showed similar improvements in pain and COMI scores (EM: − 4.4; control: − 4.7; p < 0.0001), with no significant differences between groups. LIA had no measurable impact on LOS or opioid use. Complication rates were similar, and patient satisfaction was high in the EM group. Conclusion: Early mobilization after lumbar decompression surgery safely reduces hospital stay without increasing complications or opioid use. These findings support early mobilization as an effective component of ERAS protocols. Further studies with larger cohorts are warranted. Spine surgery rehabilitation COMI fast-track recovery Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Due to a worldwide increase in the ageing population, there is a concomitant rise in the demand for self-sufficiency in older age, improved diagnostic and technical operation procedures, and a better understanding of spinal biomechanics, and their correlation with our patients’ quality of life. Thus, the number of spine surgeries has significantly increased in recent decades [ 1 – 3 ]. This surge has led to higher medico-economic costs and the need for more medical personnel [ 4 , 5 ], necessitating optimization in the pre- and post-surgical management of these patients. With the establishment of the ERAS Society in 2010 and the formation of the Consensus Statement from the ERAS Society in 2021 [ 6 ], spine surgery is aligning with other surgical disciplines to improve treatment quality and outcomes. In the last decade, ERAS has not only changed the treatment path but also increased patient awareness of their own responsibility through education, pre- and post-surgery rehabilitation, and active engagement in therapy decisions. Patients suffering from back pain tend to lack discipline and exhibit a passive attitude towards their health management [ 7 – 11 ]. Addressing these factors helps increasing the number of compliant and active patients, leading to more successful outcomes and reduced healthcare costs [ 12 , 13 ]. Several reviews have synthetized the ERAS pathways in spine surgery [ 14 – 16 ], and Debono et al, 2021[ 14 ] consolidated these publications into a consensus statement using the GRADE System [ 17 ]. Early mobilization after surgery is one of the main pathways of the multimodal ERAS proposals but there is no standardized early mobilization protocol. Traditionally, patients were immobilized for one day after surgery due to concerns about early complications and increased postoperative pain. This standard of care was used as a comparison for the early mobilization protocol in our study. To our knowledge, the effect of early mobilization on patient outcomes after spine surgery has not been extensively studied in Switzerland. The general aim is to mobilize patients out of bed on the day of surgery. This may include transferring from bed to chair, walking in the room or in the hallway, or performing exercises in the room assisted by a physiotherapist or nurse [ 13 , 18 ]. A well-recognized benefit of postoperative mobilization in surgery in general is the reduction of physiological stress in the perioperative phase, which includes insulin resistance, respiratory and cardiac deconditioning, muscle wasting and gastro-intestinal impairment, and the risk of thromboembolism due to immobility [ 19 , 20 ]. Early mobilization in spinal surgery is considered beneficial and safe for the patient. Even in cases of a intraoperative cerebrospinal fluid leak, early mobilization does not appear to lead to higher complication rates [ 21 ]. However, data specifically addressing this aspect of the ERAS concept in spinal surgery is limited and, in particular, as mentioned above, a standardized evidence-based approach is currently lacking [ 22 ]. In Switzerland, from an economic perspective there is limited incentive to develop an early mobilization program for spine surgery due to the healthcare system's reduced reimbursement for patients staying in the hospital less than two nights after lumbar decompression (see regulations on www.swissdrg.org ). As healthcare costs rise, the future of spinal surgery depends on adapting financial refund strategies to the needs of the medical care system and patient necessity. Therefore, the aim of the present study was to evaluate the effect of early mobilization, on the outcomes associated with spinal decompression surgery. The primary outcome of the study was to assess the impact of early mobilization on pain, disability, quality of life as well as length of stay (LOS) and compare it to a control group mobilized after the standard of care, as described above, for the same type of surgery. We hypothesized that early mobilization would reduce LOS and achieve similar outcomes without increasing postsurgical complications. The secondary outcome was to evaluate the impact of early mobilization on pain medication administration and patients' self-sufficiency. We hypothesized that early mobilization would not increase the need for painkillers and that patients would take more responsibility for their self-sufficiency after gaining trust in their recovery post-surgery. MATERIAL AND METHODS Study design This is a retrospective analysis of clinical data collected for clinical routine during the introduction of an ERAS program at our spine center (Schulthess Klinik, Zürich) starting from January 2021 and ending December 2021. So far only two elements, early mobilization and LIA, have been implemented. The study protocol was approved by the Institutional Swiss Ethics Review Committee (Zürich, Switzerland; protocol number:2024-01183) in compliance with the current national and international laws and regulations governing the use of human subjects (Declaration of Helsinki II). The analysis was carried out using our local spine outcomes database, which operates within the framework of the EUROSPINE Spine Tango Surgery Registry. The database, introduced in 2005, documents surgical and patient-related outcome measures of all patients undergoing surgery for spinal disorders in our hospital [23]. Informed consent was obtained from all participants. Study subjects From January to December 2021, a total of n=123 patients underwent lumbar decompression/microdiscectomy for spinal stenosis or disc herniation and were assigned preoperatively to either the Early Mobilization Group (EM) or the conventional (control) group according to the surgeon's assessment, experience, and preference. The Th12/L1 and L5/S1 segments were assigned to the lumbar spine. The same group of spine surgeons performed all the surgeries using an open approach using a microscope for both groups. Elderly and multimorbid patients tended to be assigned to the non-early group, as this was a pilot study and the versatility of the concept needed to be proved. To minimize selection bias, patients were matched by age, BMI and ASA score using propensity score analysis. All operations were performed under general anesthesia and the perioperative anesthesiologic management was similar for both groups. Post-surgery early mobilization protocol The focus of our postoperative management in the EM group was on early mobilization which has a strong recommendation in Debono et al. 2021 consensus statement [21]. An additional intervention was the subcutaneous application of local anesthetic (i.e, local infiltration analgesia: LIA). Specifically, local infiltration consisted of the subcutaneous application of 10-20ml ropivacaine 7.5mg/ml prior to wound closure. Early mobilization was defined as mobilization on the day of surgery taking at least five consecutive steps, if tolerated by the patients (e.g. no nausea and good general health condition). Early mobilization, which also included mobilization in a sitting position, was mainly assisted by physiotherapists, and in a few cases by nursing staff. Furthermore, from the first postoperative day until discharge, all patients performed a 30-minute physiotherapy session per day aimed at educating them on correct transfer techniques, mobilization, stair climbing, basic core muscle activation, and general advice to improve those skills required to manage one's basic physical needs, including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating (i.e. activities of daily living). In the control group, mobilization was performed the day after surgery. Apart from the timing of mobilization, all other aspects of postoperative care, including the general inpatient rehabilitation program, were identical between the two groups. Outcome measures All outcome measures of the present study were collected for clinical routine and analyzed retrospectively. The following outcome measures, before (PRE) and 3 months after surgery (POST), were extracted and considered for the analysis: Length of stay (LOS) : the number of inpatient days from the date of surgery until discharge. Visual Analogue Scale for Pain (VAS-Pain) : subjective ratings of leg and back pain were assessed using a 10-cm visual analog scale anchored by two verbal descriptors, one for each symptom extreme [24]. Subjects indicated their subjective ratings of pain, which ranged from “no pain at all” (score of 0) to “the worst imaginable pain” (score of 10); Core Outcome Measures Index for the back (COMI-back) : an instrument for assessing the key outcomes that are important for patients with back disorders: back and leg/buttock pain (each measured on a 0-10 numeric rating scale), back-related function, symptom-specific well-being, quality of life, social and work disability (each measured on a 0-5 scale). All items refer to “last week”, except disability (“last 4 weeks”). The final COMI score results in a value from 0 (excellent)- 10 (worst) [23,25,26]; Furthermore, the following secondary outcome measures have been collected and analyzed: Patient evaluation in the Perioperative Phase form (PPP33) : is a questionnaire consisting of 33 items that assess the patient's subjective perception of the perioperative process. Each question is rated on a 4-point Likert scale with 1-4 points from "do not/never agree" to "do fully/always agree". Higher PPP33 scores indicate a greater satisfaction of the patient with the perioperative management, from pain situation up to self-sufficiency and comfort due to hospital facilities [27]; Use of opioid medication : since some patients had already prolonged opioid medication pre-operatively (opioid-naive vs non-opiate-naive), the proportion of patients who were discharged with prescribed opioids was examined. All patients initially received a standardized postoperative prescription of oral opioids. Opioid dosage was typically tapered from the first postoperative day onward, depending on the patient's visual analog scale (VAS) score. A VAS score below 5 was generally used as the threshold for initiating a reduction in opioid analgesia. Complications : complications were documented during the inpatient stay or the outpatient check-ups and divided into two groups according to the classification proposed by Rampersaud et al [28]: minor and major complications. Major complications were defined as events requiring significant treatment, including revision surgery, an increased LOS by >7 days, long-term sequelae lasting >6 months, or death. Minor complications were defined as events requiring no or minimal treatment, an increased LOS by 2–7 days, and no sequelae lasting >6 months. Clinical postoperative follow-up controls were performed after 6 weeks and 3 months. If necessary, unscheduled check-ups were also carried out. Lastly, LIA was also considered for the analysis. Statistical analysis Descriptive statistics (mean±SD for normally distributed data and median/range for non-normal data) for all outcome measures were calculated. The normality of the distribution of all study variables was checked using the Shapiro–Wilk test. Data homogeneity for BMI at baseline between the two groups was tested by the unpaired Student’s t tests whereas the equivalent non-parametric Mann-Whitney test was applied for age, as it was not normally distributed. The Chi-square test was performed to evaluate the differences in the frequency distribution of ASA categories in the two study groups. LOS, expressed in days, was not normally distributed so the non-parametric Mann-Whitney test was applied to assess the differences between groups. A two-way analysis of variance (ANOVA) with Bonferroni’s multiple comparisons test was applied to test the differences in COMI, VAS for back pain, and VAS for leg pain at PRE and POST between groups. First, we established whether there was an interaction between the two factors, within-subjects factor (time) and between-subjects factor (group). Then, we evaluated the simple main effects of group and time. Since the results of the nonparametric methods confirmed those obtained with the two-way ANOVA, we focused our attention only on the latter analysis. To assess the possible effect of LIA on LOS, we applied the non-parametric Mann-Whitney test to assess the differences between the two subgroups in EM (i.e. LIA vs non-LIA). A Fischer exact test was used to test the differences in the occurrence of major and minor complications between EM and control groups. Effect sizes (ES) for pairwise comparison were calculated using Cohen’s d and considered to be either trivial (2.00)[29]. The level of significance was set at P < .05. Statistics analysis was done using GraphPad Prism (version 9.00; GraphPad Software, San Diego, CA). RESULTS Tango database searches for lumbar decompression or sequesterectomy identified n=123 patients. Of these, n= 56 were treated according to the EM protocol and n= 67 were in the control group. N=8 patients did not adhere to the EM protocol after surgery and were excluded from this study. After matching the two groups through a propensity score analysis, a total of n=96 patients were included in the analysis (age: 56.0 ± 15.7 years old; BMI: 25.7 ± 3.4); n=48 patients were included in the EM group and n=48 in the control group. No significant baseline differences in age, BMI and ASA score were observed between groups. Figure 1 shows the study flowchart and subjects' screening process, and Table 1 reports the patients' baseline characteristics for both EM and control groups. Table 1. Baseline characteristics. EM (n=48) Control (n=48) Significance BMI (kg/m 2 ) 25.2 ± 3.5 26.0 ± 3.4 p=0.28 Age (years) 54.5 ± 15.5 58.4 ± 16.7 p=0.20 ASA (score) 1 (35%), 2 (52%), 3 (13%) 1 (31%), 2 (54%), 3 (15%) p=0.90 Results are reported as mean + SD. The differences were evaluated with the unpaired Student’s t tests for BMI, with the Mann Whitney test for age, while the Chi-square test was applied for ASA category. Abbreviations: EM: early mobilization group; Control: conventional mobilization group; BMI: Body Mass Index; ASA: American Society of Anesthesiologists Length of stay The mean LOS in the EM group was shorter compared to the control group (3.7 ± 0.9 days vs 5.2 ± 2.1 days; p<0.0001; ES: 0.86, moderate). Figure 2 shows histograms for LOS for both EM and control groups. VAS for pain Raw data and mean ± SD for VAS scores are shown in Figure 3 (panel b and c), while Table 2 shows mean ± SD, the results of the 2-way ANOVA, and ES for significant outcomes. VAS scores for leg and back pain were similar between EM and control: both groups reported a significant reduction in back and leg pain scores from PRE to POST (time effect: p<0.0001), whereas no significant inter-group differences were observed (group effect: ns); in detail, VAS scores for back pain at POST (EM: 2.3 ± 2.1 vs control: 2.1 ± 2.2; p=0.82) and leg pain at POST (EM: 2.7 ± 2.7 vs control: 2.5 ± 2.7; p=0.74) were similar between groups. Table 2. COMI, VAS for back pain, and VAS for leg pain both at baseline and 3 months after surgery for both groups. PRE POST Interaction Group Effect Time Effect Contrasts and Effect Size EM (n=48) Control (n=48) EM (n=48) Control (n=48) COMI 7.7 ± 1.6 7.9 ± 1.5 3.3 ± 2.5 3.2 ± 2.6 ns ns p<0.0001 EM: POST<PRE (p<0.0001); Control: POST<PRE (p<0.0001) VAS for back pain 3.8 ± 2.9 4.5 ± 2.8 2.3 ± 2.1 2.1 ± 2.2 ns ns p<0.0001 EM: POST<PRE (p=0.0026); Control: POST<PRE (p<0.0001) VAS for leg pain 6.8 ± 2.4 6.4 ± 2.5 2.7 ± 2.7 2.5 ± 2.7 ns ns p<0.0001 EM: POST<PRE (p<0.0001); Control: POST<PRE (p<0.0001) Results are reported as mean ± SD. The differences were evaluated with the 2-way ANOVA procedure followed by the Bonferroni’s multiple comparisons (see the “Statistical analyses” section for details). Abbreviations: PRE: baseline evaluation; POST: 3-months evaluation; EM: early mobilization group; Control: conventional mobilization group; COMI: Core Outcome Measure Index; VAS: visual analogue scale; ns, no statistical differences. COMI COMI improved from PRE to POST in both groups (time effect: p<0.0001); in detail, COMI decreased by –4.4 points in EM (p<0.0001 and ES: 2.1, very large) and by – 4.7 points in the control group (p<0.0001 and ES: 2.2., very large). However, no significant inter-group differences were observed (group effect: ns). Table 2 and Figure 3 (panel a) show the mean ± SD of COMI for both study groups. LIA and Opioids Local infiltration, applied as described before, was performed in a subset of EM patients (n=24) as well as in some patients of the control group (n=3). The application of LIA in the EM group did result in any difference in LOS, with 3.3 days for the LIA subgroup and 3.5 days for the non-LIA subgroup (p=0.44). Due to the very small number, the effect of LIA in the control group was not evaluated. In the assessment of opioid medication at discharge, we differentiated between opioid-naïve patients with newly prescribed opioids during hospitalization and those who were already on opioids upon admission. In the early mobilization group, a total of 8 patients were discharged with opioids, of whom 3 were opioid-naive. In the control group, 4 out of a total of 8 patients with opioids at discharge were opioid naïve. Further, LIA had no effect on opioids at discharge. In the EM group 4 out of the 24 patients who received LIA were discharged with opioids, only 1 was opioid-naïve. In the control group, none of the opioid patients had received LIA. PPP33 and complications The PPP33 questionnaire was only administered to the EM subjects. PPP33 subitem scores highlighted high satisfaction among the EM patients with the medical care approach during the hospitalization. In addition, no significant differences were observed in the number of complications between groups. Table 3 shows the mean scores for the 8 subitems of the PPP33, whereas complications for the two study groups are presented in Table 4. Table 3. The Patient evaluation in the Perioperative Phase form (PPP33) scores. PPP33 dimension Mean score Information 3.93 Fear 3.47 Autonomy 3.47 Pain 3.42 Physical complaints 3.49 Rest 3.28 Communication 3.91 Accommodation 3.84 Table 4. Occurrence of major and minor complications in EM and control groups. Major complications EM (n=48) Control (n=48) p-value Recurrent disc herniation (<6 months) 5 (10%) 3 (6%) p=0.71 Re-hospitalization (0.99 Minor complications Temporary neurological deficit 1 (2%) 2 (4%) p=0.62 Urinary retention 1 (2%) 2 (4%) p=0.62 Anaesthesia-related issues 0 (0%) 1 (2%) p>0.99 Prolonged pain 0 (0%) 3 (6%) p=0.24 Data are reported as absolute (numerosity) and relative (percentage) values. Abbreviations: EM: early mobilization group; Control: conventional mobilization group DISCUSSION To the best of our knowledge, this is one of the first retrospective studies focusing on the effect of early mobilization on clinical outcomes associated with spine decompression surgery in Switzerland. The main results of the present study showed that: 1) the mean LOS in the EM group was shorter by 1.8 days compared to the control group; 2) COMI and VAS scores for leg and back pain were similar between groups, with no baseline differences and a significant improvement three months after surgery for both groups; 3) local infiltration did not affect LOS and opioids at discharge; 4) no differences were observed in the occurrence of major and minor complications between the EM and control groups; 5) patients' satisfaction and subjective perception of the perioperative process were high for the EM group. All our initial hypotheses were confirmed. Early mobilization is an essential element of the postoperative ERAS protocol, facilitating recovery and reducing healthcare costs by shortening the length of stay. It has been adopted in various surgical specialties, yet remains non-standard in spinal surgery, particularly in Switzerland. Early mobilization after spinal surgery is crucial for several reasons. As part of ERAS, it helps prevent complications such as deep vein thrombosis and pulmonary embolism, which are common risks associated with prolonged bed rest. Additionally, early mobilization aids in restoring muscle strength and flexibility, essential for postoperative rehabilitation and overall functional recovery. Moreover, early ambulation fosters patient independence and psychological well-being by empowering them to actively participate in their recovery process. Therefore, implementing early mobilization protocols following spinal surgery is important for optimizing patient outcomes and enhancing their overall quality of life. The most noticeable effect of early mobilization applied in our institution was a significant reduction in hospitalization. The mean LOS in the EM group was shorter compared to the control group (3.4 ± 0.9 days vs 5.2 ± 2.1 days). Notably, the large standard deviation in the control group was due to the long hospitalization duration of n = 2 patients with 10 and 15 days respectively. The reason for this in some of the patients was a pre-existing comorbidity that required additional pre-operative assessments and anesthesiologic evaluation, in others it was purely for organizational reasons such as longer travel distances to our hospital. Sivaganesan et al. [ 30 ] evaluated the effect of the implementation of a standardized, evidence-based order sets for six high-impact dimensions of perioperative care for elective spine surgery and showed a small but significant difference in LOS compared to the control (2.9+-2.2 days vs 2.5 + .1.7 days; p = 0.021). Similarly, another study by Nazarenko et al.[ 31 ] demonstrated a one-day reduction of LOS in n = 23 ERAS vs n = 25 non-ERAS patients (2.3 days vs 3.8 days; p < 0.05) which is consistent with our findings. Other studies focusing mainly on microdiscectomy or decompression discharged patients within hours or one day [ 32 – 35 ]. The longer LOS observed in our study can be attributed to several factors. Most significantly, the different reimbursement system in Switzerland directly impacts hospitalization duration. However, the Swiss DRG reimbursement system does not allow for cost-effective outpatient surgery; stays shorter than two nights result in a financial penalty. A medical factor for a shorter LOS might be the use of endoscopic technique [ 33 ] whereas we used a microsurgical approach. Another factor might simply be the way LOS was counted. We counted all days patients stayed at the hospital as 1, even when they were discharged in the morning. Most other studies counted hours of hospitalization. Another factor would be that most of those studies used more than 10 specific interventions of the ERAS protocol whereas we implemented 2 standardized items. Non-standardized items such as patient education could not be measured. Our discharge criteria were strictly defined and included: independent ability to walk stairs, instructed basic muscle activation exercises, patient education on daily living activities and rehabilitation procedure, sufficient pain control with oral analgesics, and wound dryness. The latter might be difficult to control in ambulatory surgery. Patient-Reported Outcome Measures (PROMs) serve as crucial indicators of surgical success and patient satisfaction. COMI and VAS scores for leg and back pain were similar between groups, with no baseline differences and a significant improvement three months after surgery for both groups. Therefore, early mobilization yielded similar results on PROMs compared to the standard of care and, in addition, patients' satisfaction and subjective perception of the perioperative process, evaluated through the PPP33 questionnaire, were high in the EM group. In the literature there are only a few reports of PROMs for microdiscectomies or decompressions. Staartjes et al. showed that tubular discectomy and decompression led to good improvement for NRS, ODI and EQ-5D at 6 weeks and 1 year follow up [ 27 ]. In a subgroup analysis for lumbar procedures including decompressions and fusions, Sivaganesan et al. found no differences in the ERAS group compared to a control group for ODI (0.77 vs 0.67), and patient satisfaction at 3 months follow-up [ 30 ]. Similar results are reported by Ali et al. [ 36 ] who examined a mixed group of lumbar procedures, including peripheral nerve surgery, with no difference of outcome in pain scores, EQ-5D, and ODI between ERAS and the control group. Only Nazarenko et al. [ 31 ] compared decompressions vs a control group and showed a significant reduction in VAS, ODI, and the Roland-Morris scale at 1 month follow up; however, the ODI difference was only 10 points, whereas the minimal clinically important change is considered to be 12 [ 37 , 38 ]. We also performed a subgroup analysis comparing LIA (n = 24) vs non-LIA (n = 26) within the EM group and, interestingly, LOS was independent of LIA application. LIA is known to reduce postoperative pain and opioid consumption [ 39 ]; however, we did not evaluate VAS or analgesia use directly after surgery, when the effect of LIA would arguably be at its maximum. Of interest, Kurnutula reported in a retrospective review, analyzing the effect of interfascial plane blocks, a significant reduction of LOS [ 40 ]; however, they also implemented other elements of the ERAS protocol, so this effect might not be attributed solely to LIA. So even though we regard LIA as useful, the single most important factor for our reduction in LOS was early mobilization. Subgroup analysis comparing patients receiving LIA to those who did not, showed no influence on opioid use at discharge. The risk of opioids and their misuse are commonly known. Implementation of ERAS protocols results in reduced opioid use [ 36 , 41 – 43 ]. In our cohort, patients were managed postoperatively with metamizole, paracetamol, and NSAIDs and only on demand opioids. We evaluated opioid use at discharge and did not find a significant difference between the two groups. Therefore, we can safely claim that earlier discharge does not come at the cost of increased analgesia. We did not assess the total opioid dose, and among the patients discharged with opioids 5 out of 8 (EM) vs 4 out of 8 (control) were already receiving opioids upon admission. No significant inter-group differences were observed concerning short- or medium-term minor and major complications. We observed that more patients in the control group had a prolonged course of pain (n = 3; 6%), impacting the longer hospitalization time. Even more importantly, we had no readmissions in the EM group due to unmanageable pain. The patient with postoperative neurological deficit in the EM group had a mild weakness of toe dorsiflexion and foot plantar flexion (M4+/5), which completely resolved by the 6-week follow-up postoperatively. In the control group, one patient had a mild weakness of foot plantar flexion which regressed within 2 months and the other patient had hypaesthesia of dermatoma S1 on the right side which also regressed. In the EM group, there was one readmission due to disc herniation recurrence within the first 30 days. No major complications occurred in any group. Staartjes et al. reported 3–4% adverse events, a reoperation rate of 6%, and a 30-day readmission rate of 6% for n = 1929 discectomy and n = 451 decompression cases [ 33 ]. Sivaganesan et al. [ 30 ] compared lumbar procedures (fusion and decompression mixed) and reported no significant difference in readmission rates but a lower complication rate (12.8% vs 3.8%; p = 0.002) in the intervention group, where a standardized perioperative protocol was applied to improve patient outcomes. Similarly, Wang et al. [ 44 ] reported a reduction of complication rate for MIS TLIF procedures (12% vs 21%). Nevertheless, according to one recent meta-analysis, neither general nor lumbar spine ERAS protocols led to a significant difference in complication rates [ 45 ]. The study has some limitations. First, being a single-center retrospective study with a relatively small sample size may limit the generalizability of the findings to other settings or populations. Second, being retrospective in nature, the study is subject to inherent biases associated with retrospective data analysis. Third, selection bias per se is an issue as surgeons tended to exclude rather multimorbid and older patients from the ERAS program. To minimize this, we matched our groups for age, BMI, and ASA Score. Fourth, adherence to the ERAS protocol using LIA was only 50% and this variability in adherence could impact the study’s outcomes and interpretations. Fifth, although the data was collected prospectively, the lack of blinding is a notable limitation; however, blinding in this setting was not possible. Lastly, the study implemented only two elements of the ERAS protocol, which may not fully capture the potential benefits of a comprehensive ERAS program. The effects of other ERAS elements, such as nutrition and multimodal analgesia, were not evaluated, as these elements have not yet been standardized or systematically implemented in our clinical routine at the institution. CONCLUSIONS In conclusion, our study demonstrates that early mobilization after lumbar decompression/disc herniation surgery is associated with significant reductions in hospital length of stay (LOS) without increasing the risk of complications. The findings suggest that early mobilization protocols can effectively enhance patient recovery and satisfaction, thereby reducing healthcare costs. The lack of significant differences in opioid use at discharge between the groups further supports the safety and feasibility of early mobilization without increasing the need for postoperative analgesia. The results align with existing literature on the benefits of early mobilization in various surgical specialties and underscore its potential to optimize recovery in spinal surgery. Future studies with larger sample sizes, multicenter designs, and comprehensive ERAS protocols are warranted to validate and expand upon these findings. Implementing standardized early mobilization protocols could lead to improved patient outcomes, enhanced efficiency in healthcare delivery, and reduced overall costs, particularly in healthcare systems similar to Switzerland's framework. Declarations Ethics approval and consent to participate The study protocol was approved by the Institutional Swiss Ethics Review Committee (Zürich, Switzerland; protocol number:2024-01183) in compliance with the current national and international laws and regulations governing the use of human subjects (Declaration of Helsinki II). Consent for publication Not applicable Competing interests Daniel Haschtmann (Author 5) - Shareholder of Inno4Spine AG. There are no other conflicts of interest to declare. Availability of data and materials The data used for analysis in this study were obtained from our institutional spine outcomes database. Due to institutional and registry data protection policies, the dataset is not publicly available. However, de-identified data may be made available from the corresponding author upon reasonable request and with permission from the data governance body. Funding The authors received no specific funding for this work. Authors' contributions M.D. and M.R. contributed equally to the drafting of the manuscript. R.R. supervised the overall project. J.V. and F.G. were primarily responsible for data processing, statistical analysis, and the generation of tables and figures. A.M.-O. contributed to data curation. R.W., I.C.-M., and M.N. were involved in data acquisition and implementation of study methods. D.H., T.F., and F.P. contributed to the study concept and data acquisition. All authors reviewed the manuscript. Clinical trial number: Not applicable. References Deyo, R.A., D.T. Gray, W. Kreuter, S. Mirza, B.I. Martin, United States trends in lumbar fusion surgery for degenerative conditions, Spine (Phila. Pa. 1976). 30 (2005) 1441–5; discussion 1446-7. https://doi.org/10.1097/01.brs.0000166503.37969.8a. Weinstein, J.N., J.D. Lurie, P.R. Olson, K.K. Bronner, E.S. Fisher, United States’ trends and regional variations in lumbar spine surgery: 1992-2003, Spine (Phila. Pa. 1976). 31 (2006) 2707–2714. https://doi.org/10.1097/01.brs.0000248132.15231.fe. Rajaee, S.S., H.W. Bae, L.E.A. Kanim, R.B. Delamarter, Spinal fusion in the United States: analysis of trends from 1998 to 2008. Rajaee SS, Bae HW, Kanim LE, Delamarter RB. 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Nazarenko, A.G., N.A. Konovalov, A.V. Krut’ko, T.N. Zamiro, I.B. Geroeva, R.R. Gubaydullin, N.E. Khoreva, A.N. Komarov, M.A. Stepanyan, M.V. Konstantinova, A.M. Kazachonok, R.A. Onoprienko, V.A. Korolishin, T.N. Kubynina, M.A. Martynova, Postoperative applications of the fast track technology in patients with herniated intervertebral discs of the lumbosacral spine, Zh. Vopr. Neirokhir. Im. N N Burdenko. 80 (2016) 5–12. https://doi.org/10.17116/neiro20168045-12. Debono, B., P. Sabatier, V. Garnault, O. Hamel, P. Bousquet, J.-P. Lescure, J.-Y. Plas, Outpatient Lumbar Microdiscectomy in France: From an Economic Imperative to a Clinical Standard-An Observational Study of 201 Cases, World Neurosurg. 106 (2017) 891–897. https://doi.org/10.1016/j.wneu.2017.07.065. Staartjes, V.E., M.P. de Wispelaere, M.L. Schröder, Improving recovery after elective degenerative spine surgery: 5-year experience with an enhanced recovery after surgery (ERAS) protocol, Neurosurg. 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Casey, Intramuscular Local Anesthetic Infiltration at Closure for Postoperative Analgesia in Lumbar Spine Surgery: A Systematic Review and Meta-Analysis, Spine . 42 (2017) 1088–1095. https://doi.org/10.1097/BRS.0000000000001443. Kurnutala, L.N., J.E. Dibble, S. Kinthala, M.A. Tucci, Enhanced Recovery After Surgery Protocol for Lumbar Spinal Surgery With Regional Anesthesia: A Retrospective Review, Cureus. 13 (2021) e18016. https://doi.org/10.7759/cureus.18016. Brusko, G.D., J.P.G. Kolcun, J.A. Heger, A.D. Levi, G.R. Manzano, K. Madhavan, T. Urakov, R.H. Epstein, M.Y. Wang, Reductions in length of stay, narcotics use, and pain following implementation of an enhanced recovery after surgery program for 1- to 3-level lumbar fusion surgery, Neurosurg. Focus. 46 (2019) E4. https://doi.org/10.3171/2019.1.FOCUS18692. Soffin, E.M., D.S. Wetmore, J.D. Beckman, E.D. Sheha, A.S. Vaishnav, T.J. Albert, C.H. Gang, S.A. Qureshi, Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study, Neurosurg. Focus. 46 (2019) E8. https://doi.org/10.3171/2019.1.FOCUS18645. Smith, J., S. Probst, C. Calandra, R. Davis, K. Sugimoto, L. Nie, T.J. Gan, E. Bennett-Guerrero, Enhanced recovery after surgery (ERAS) program for lumbar spine fusion, Perioper Med (Lond). 8 (2019) 4. https://doi.org/10.1186/s13741-019-0114-2. Y. Wang, M.Y., C.M. Peng-Yuan, J. Grossman, Development of an Enhanced Recovery After Surgery (ERAS) approach for lumbar spinal fusion, J. Neurosurg. Spine. 26 (2017) 411–418. https://doi.org/10.3171/2016.9.SPINE16375. Pennington, Z., E. Cottrill, D. Lubelski, J. Ehresman, N. Theodore, D.M. Sciubba, Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery, J. Neurosurg. Spine. 34 (2020) 325–347. https://doi.org/10.3171/2020.6.SPINE20795. Additional Declarations Competing interest reported. Daniel Haschtmann (Author 5) - Shareholder of Inno4Spine AG. There are no other conflicts of interest to declare. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 22 Aug, 2025 Reviews received at journal 10 Aug, 2025 Reviewers agreed at journal 20 Jul, 2025 Reviewers invited by journal 26 Jun, 2025 Editor invited by journal 24 Jun, 2025 Editor assigned by journal 24 Jun, 2025 Submission checks completed at journal 24 Jun, 2025 First submitted to journal 17 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Daniel Haschtmann (Author 5) - Shareholder of Inno4Spine AG. There are no other conflicts of interest to declare.","formattedTitle":"Early mobilization in spine decompression surgery: insights from one of the first monocentric studies in Switzerland","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDue to a worldwide increase in the ageing population, there is a concomitant rise in the demand for self-sufficiency in older age, improved diagnostic and technical operation procedures, and a better understanding of spinal biomechanics, and their correlation with our patients\u0026rsquo; quality of life. Thus, the number of spine surgeries has significantly increased in recent decades [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]. This surge has led to higher medico-economic costs and the need for more medical personnel [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e], necessitating optimization in the pre- and post-surgical management of these patients. With the establishment of the ERAS Society in 2010 and the formation of the Consensus Statement from the ERAS Society in 2021 [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e], spine surgery is aligning with other surgical disciplines to improve treatment quality and outcomes. In the last decade, ERAS has not only changed the treatment path but also increased patient awareness of their own responsibility through education, pre- and post-surgery rehabilitation, and active engagement in therapy decisions. Patients suffering from back pain tend to lack discipline and exhibit a passive attitude towards their health management [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]. Addressing these factors helps increasing the number of compliant and active patients, leading to more successful outcomes and reduced healthcare costs [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. Several reviews have synthetized the ERAS pathways in spine surgery [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e], and Debono et al, 2021[\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e] consolidated these publications into a consensus statement using the GRADE System [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eEarly mobilization after surgery is one of the main pathways of the multimodal ERAS proposals but there is no standardized early mobilization protocol. Traditionally, patients were immobilized for one day after surgery due to concerns about early complications and increased postoperative pain. This standard of care was used as a comparison for the early mobilization protocol in our study. To our knowledge, the effect of early mobilization on patient outcomes after spine surgery has not been extensively studied in Switzerland. The general aim is to mobilize patients out of bed on the day of surgery. This may include transferring from bed to chair, walking in the room or in the hallway, or performing exercises in the room assisted by a physiotherapist or nurse [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. A well-recognized benefit of postoperative mobilization in surgery in general is the reduction of physiological stress in the perioperative phase, which includes insulin resistance, respiratory and cardiac deconditioning, muscle wasting and gastro-intestinal impairment, and the risk of thromboembolism due to immobility [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Early mobilization in spinal surgery is considered beneficial and safe for the patient. Even in cases of a intraoperative cerebrospinal fluid leak, early mobilization does not appear to lead to higher complication rates [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, data specifically addressing this aspect of the ERAS concept in spinal surgery is limited and, in particular, as mentioned above, a standardized evidence-based approach is currently lacking [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eIn Switzerland, from an economic perspective there is limited incentive to develop an early mobilization program for spine surgery due to the healthcare system\u0026apos;s reduced reimbursement for patients staying in the hospital less than two nights after lumbar decompression (see regulations on \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.swissdrg.org\u003c/span\u003e\u003c/span\u003e). As healthcare costs rise, the future of spinal surgery depends on adapting financial refund strategies to the needs of the medical care system and patient necessity. Therefore, the aim of the present study was to evaluate the effect of early mobilization, on the outcomes associated with spinal decompression surgery. The primary outcome of the study was to assess the impact of early mobilization on pain, disability, quality of life as well as length of stay (LOS) and compare it to a control group mobilized after the standard of care, as described above, for the same type of surgery. We hypothesized that early mobilization would reduce LOS and achieve similar outcomes without increasing postsurgical complications. The secondary outcome was to evaluate the impact of early mobilization on pain medication administration and patients\u0026apos; self-sufficiency. We hypothesized that early mobilization would not increase the need for painkillers and that patients would take more responsibility for their self-sufficiency after gaining trust in their recovery post-surgery.\u003c/p\u003e"},{"header":"MATERIAL AND METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a retrospective analysis of clinical data collected for clinical routine during the introduction of an ERAS program at our spine center (Schulthess Klinik, Z\u0026uuml;rich) starting from January 2021 and ending December 2021. So far only two elements, early mobilization and LIA, have been implemented. The study protocol was approved by the Institutional Swiss Ethics Review Committee (Z\u0026uuml;rich, Switzerland; protocol number:2024-01183) in compliance with the current national and international laws and regulations governing the use of human subjects (Declaration of Helsinki II). The analysis was carried out using our local spine outcomes database, which operates within the framework of the EUROSPINE Spine Tango Surgery Registry. The database, introduced in 2005, documents surgical and patient-related outcome measures of all patients undergoing surgery for spinal disorders in our hospital [23]. \u0026nbsp;Informed consent was obtained from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy subjects\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom January to December 2021, a total of n=123 patients underwent lumbar decompression/microdiscectomy for spinal stenosis or disc herniation and were assigned preoperatively to either the Early Mobilization Group (EM) or the conventional (control) group according to the surgeon\u0026apos;s assessment, experience, and preference. The Th12/L1 and L5/S1 segments were assigned to the lumbar spine. The same group of spine surgeons performed all the surgeries using an open approach using a microscope for both groups. Elderly and multimorbid patients tended to be assigned to the non-early group, as this was a pilot study and the versatility of the concept needed to be proved. To minimize selection bias, patients were matched by age, BMI and ASA score using propensity score analysis. All operations were performed under general anesthesia and the perioperative anesthesiologic management was similar for both groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePost-surgery early mobilization protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe focus of our postoperative management in the EM group was on early mobilization which has a strong recommendation in Debono et al. 2021 consensus statement [21]. An additional intervention was the subcutaneous application of local anesthetic (i.e, local infiltration analgesia: LIA). Specifically, local infiltration consisted of the subcutaneous application of 10-20ml ropivacaine 7.5mg/ml prior to wound closure. Early mobilization was defined as mobilization on the day of surgery taking at least five consecutive steps, if tolerated by the patients (e.g. no nausea and good general health condition). Early mobilization, which also included mobilization in a sitting position, was mainly assisted by physiotherapists, and in a few cases by nursing staff. Furthermore, from the first postoperative day until discharge, all patients performed a 30-minute physiotherapy session per day aimed at educating them on correct transfer techniques, mobilization, stair climbing, basic core muscle activation, and general advice to improve those skills required to manage one\u0026apos;s basic physical needs, including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating (i.e. activities of daily living). In the control group, mobilization was performed the day after surgery.\u0026nbsp;Apart from the timing of mobilization, all other aspects of postoperative care, including the general inpatient rehabilitation program, were identical between the two groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll outcome measures of the present study were collected for clinical routine and analyzed retrospectively. The following outcome measures, before (PRE) and 3 months after surgery (POST), were extracted and considered for the analysis:\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cu\u003eLength of stay (LOS)\u003c/u\u003e: the number of inpatient days from the date of surgery until discharge.\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eVisual Analogue Scale for Pain (VAS-Pain)\u003c/u\u003e: subjective ratings of leg and back pain were assessed using a 10-cm visual analog scale anchored by two verbal descriptors, one for each symptom extreme [24]. Subjects indicated their subjective ratings of pain, which ranged from \u0026ldquo;no pain at all\u0026rdquo; (score of 0) to \u0026ldquo;the worst imaginable pain\u0026rdquo; (score of 10);\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eCore Outcome Measures Index for the back (COMI-back)\u003c/u\u003e: an instrument for assessing the key outcomes that are important for patients with back disorders: back and leg/buttock pain (each measured on a 0-10 numeric rating scale), back-related function, symptom-specific well-being, quality of life, social and work disability (each measured on a 0-5 scale). All items refer to \u0026ldquo;last week\u0026rdquo;, except disability (\u0026ldquo;last 4 weeks\u0026rdquo;). The final COMI score results in a value from 0 (excellent)- 10 (worst) [23,25,26];\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eFurthermore, the following secondary outcome measures have been collected and analyzed:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cu\u003ePatient evaluation in the Perioperative Phase form\u003c/u\u003e\u003cu\u003e\u0026nbsp;(PPP33)\u003c/u\u003e: is a questionnaire consisting of 33 items that assess the patient\u0026apos;s subjective perception of the perioperative process. Each question is rated on a 4-point Likert scale with 1-4 points from \u0026quot;do not/never agree\u0026quot; to \u0026quot;do fully/always agree\u0026quot;. Higher PPP33 scores indicate a greater satisfaction of the patient with the perioperative management, from pain situation up to self-sufficiency and comfort due to hospital facilities [27];\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eUse of opioid medication\u003c/u\u003e: since some patients had already prolonged opioid medication pre-operatively (opioid-naive vs non-opiate-naive), the proportion of patients who were discharged with prescribed opioids was examined. All patients initially received a standardized postoperative prescription of oral opioids. Opioid dosage was typically tapered from the first postoperative day onward, depending on the patient\u0026apos;s visual analog scale (VAS) score. A VAS score below 5 was generally used as the threshold for initiating a reduction in opioid analgesia.\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eComplications\u003c/u\u003e: complications were documented during the inpatient stay or the outpatient check-ups and divided into two groups according to the classification proposed by Rampersaud et al [28]: minor and major complications. Major complications were defined as events requiring significant treatment, including revision surgery, an increased LOS by \u0026gt;7 days, long-term sequelae lasting \u0026gt;6 months, or death. Minor complications were defined as events requiring no or minimal treatment, an increased LOS by 2\u0026ndash;7 days, and no sequelae lasting \u0026gt;6 months. Clinical postoperative follow-up controls were performed after 6 weeks and 3 months. If necessary, unscheduled check-ups were also carried out.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eLastly, LIA was also considered for the analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics (mean\u0026plusmn;SD for normally distributed data and median/range for non-normal data) for all outcome measures were calculated. The normality of the distribution of all study variables was checked using the Shapiro\u0026ndash;Wilk test. Data homogeneity for BMI at baseline between the two groups was tested by the unpaired Student\u0026rsquo;s t tests whereas the equivalent non-parametric Mann-Whitney test was applied for age, as it was not normally distributed. The Chi-square test was performed to evaluate the differences in the frequency distribution of ASA categories in the two study groups. LOS, expressed in days, was not normally distributed so the non-parametric Mann-Whitney test was applied to assess the differences between groups. A two-way analysis of variance (ANOVA) with Bonferroni\u0026rsquo;s multiple comparisons test was applied to test the differences in COMI, VAS for back pain, and VAS for leg pain at PRE and POST between groups. First, we established whether there was an interaction between the two factors, within-subjects factor (time) and between-subjects factor (group). Then, we evaluated the simple main effects of group and time. Since the results of the nonparametric methods confirmed those obtained with the two-way ANOVA, we focused our attention only on the latter analysis. To assess the possible effect of LIA on LOS, we applied the non-parametric Mann-Whitney test to assess the differences between the two subgroups in EM (i.e. LIA vs non-LIA). A Fischer exact test was used to test the differences in the occurrence of major and minor complications between EM and control groups. Effect sizes (ES) for pairwise comparison were calculated using Cohen\u0026rsquo;s d and considered to be either trivial (\u0026lt;0.20), small (0.21\u0026ndash;0.60), moderate (0.61\u0026ndash;1.20), large (1.21\u0026ndash;2.00), or very large (\u0026gt;2.00)[29]. The level of significance was set at P \u0026lt; .05. Statistics analysis was done using GraphPad Prism (version 9.00; GraphPad Software, San Diego, CA).\u0026nbsp;\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eTango database searches for lumbar decompression or sequesterectomy identified n=123 patients. Of these, n= 56 were treated according to the EM protocol and n= 67 were in the control group. N=8 patients did not adhere to the EM protocol after surgery and were excluded from this study. After matching the two groups through a propensity score analysis, a total of n=96 patients were included in the analysis (age: 56.0 \u0026plusmn; 15.7 years old; BMI: 25.7 \u0026plusmn; 3.4); n=48 patients were included in the EM group and n=48 in the control group. No significant baseline differences in age, BMI and ASA score were observed between groups. Figure 1 shows the study flowchart and subjects\u0026apos; screening process, and Table 1 reports the patients\u0026apos; baseline characteristics for both EM and control groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eBaseline characteristics.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEM\u003c/strong\u003e \u003cem\u003e(n=48)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e \u003cem\u003e(n=48)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignificance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e \u003cem\u003e(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e25.2 \u0026plusmn; 3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e26.0 \u0026plusmn; 3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ep=0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e \u003cem\u003e(years)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e54.5 \u0026plusmn; 15.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e58.4 \u0026plusmn; 16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ep=0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASA\u003c/strong\u003e \u003cem\u003e(score)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e1 (35%), 2 (52%), 3 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e1 (31%), 2 (54%), 3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ep=0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eResults are reported as mean + SD. The differences were evaluated with the unpaired Student\u0026rsquo;s t tests for BMI, with the Mann Whitney test for age, while the Chi-square test was applied for ASA category. Abbreviations: EM: early mobilization group; Control: conventional mobilization group; BMI: Body Mass Index; ASA: American Society of Anesthesiologists\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLength of stay\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean LOS in the EM group was shorter compared to the control group (3.7 \u0026plusmn; 0.9 days vs 5.2 \u0026plusmn; 2.1 days; p\u0026lt;0.0001; ES: 0.86, moderate). Figure 2 shows histograms for LOS for both EM and control groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVAS for pain\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRaw data and mean \u0026plusmn; SD for VAS scores are shown in Figure 3 (panel b and c), while Table 2 shows mean \u0026plusmn; SD, the results of the 2-way ANOVA, and ES for significant outcomes. VAS scores for leg and back pain were similar between EM and control: both groups reported a significant reduction in back and leg pain scores from PRE to POST (time effect: p\u0026lt;0.0001), whereas no significant inter-group differences were observed (group effect: ns); in detail, VAS scores for back pain at POST (EM: 2.3 \u0026plusmn; 2.1 vs control: 2.1 \u0026plusmn; 2.2; p=0.82) and leg pain at POST (EM: 2.7 \u0026plusmn; 2.7 vs control: 2.5 \u0026plusmn; 2.7; p=0.74) were similar between groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e COMI, VAS for back pain, and VAS for leg pain both at baseline and 3 months after surgery for both groups.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePRE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePOST\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInteraction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup Effect\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime Effect\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContrasts and Effect Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEM\u003c/strong\u003e \u003cem\u003e(n=48)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(n=48)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEM\u003c/strong\u003e \u003cem\u003e(n=48)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e \u003cem\u003e(n=48)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOMI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e7.7 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e7.9 \u0026plusmn; 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e3.3 \u0026plusmn; 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e3.2 \u0026plusmn; 2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eEM: POST\u0026lt;PRE (p\u0026lt;0.0001);\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eControl: POST\u0026lt;PRE (p\u0026lt;0.0001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS for back pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e3.8 \u0026plusmn; 2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;4.5 \u0026plusmn; 2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e2.3 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eEM: POST\u0026lt;PRE (p=0.0026);\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eControl: POST\u0026lt;PRE (p\u0026lt;0.0001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS for leg pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e6.8 \u0026plusmn; 2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e6.4 \u0026plusmn; 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e2.7 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e2.5 \u0026plusmn; 2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eEM: POST\u0026lt;PRE (p\u0026lt;0.0001);\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eControl: POST\u0026lt;PRE (p\u0026lt;0.0001)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eResults are reported as mean \u0026plusmn; SD. The differences were evaluated with the 2-way ANOVA procedure followed by the Bonferroni\u0026rsquo;s multiple comparisons (see the \u0026ldquo;Statistical analyses\u0026rdquo; section for details). Abbreviations: PRE: baseline evaluation; POST: 3-months evaluation; EM: early mobilization group; Control: conventional mobilization group; COMI: Core Outcome Measure Index; VAS: visual analogue scale; ns, no statistical differences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOMI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCOMI improved from PRE to POST in both groups (time effect: p\u0026lt;0.0001); in detail, COMI decreased by \u0026ndash;4.4 points in EM (p\u0026lt;0.0001 and ES: 2.1, very large) and by \u0026ndash; 4.7 points in the control group (p\u0026lt;0.0001 and ES: 2.2., very large). However, no significant inter-group differences were observed (group effect: ns). Table 2 and Figure 3 (panel a) show the mean \u0026plusmn; SD of COMI for both study groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLIA and Opioids\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLocal infiltration, applied as described before, was performed in a subset of EM patients (n=24) as well as in some patients of the control group (n=3). The application of LIA in the EM group did result in any difference in LOS, with 3.3 days for the LIA subgroup and 3.5 days for the non-LIA subgroup (p=0.44). Due to the very small number, the effect of LIA in the control group was not evaluated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the assessment of opioid medication at discharge, we differentiated between opioid-na\u0026iuml;ve patients with newly prescribed opioids during hospitalization and those who were already on opioids upon admission. In the early mobilization group, a total of 8 patients were discharged with opioids, of whom 3 were opioid-naive. In the control group, 4 out of a total of 8 patients with opioids at discharge were opioid na\u0026iuml;ve. Further, LIA had no effect on opioids at discharge. In the EM group 4 out of the 24 patients who received LIA were discharged with opioids, only 1 was opioid-na\u0026iuml;ve. In the control group, none of the opioid patients had received LIA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePPP33 and complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe PPP33 questionnaire was only administered to the EM subjects. PPP33 subitem scores highlighted high satisfaction among the EM patients with the medical care approach during the hospitalization. In addition, no significant differences were observed in the number of complications between groups. Table 3 shows the mean scores for the 8 subitems of the PPP33, whereas complications for the two study groups are presented in Table 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e The Patient evaluation in the Perioperative Phase form (PPP33) scores.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePPP33 dimension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003col\u003e\n \u003cli\u003eInformation\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003col start=\"2\"\u003e\n \u003cli\u003eFear\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003col start=\"3\"\u003e\n \u003cli\u003eAutonomy\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003col start=\"4\"\u003e\n \u003cli\u003ePain\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003col start=\"5\"\u003e\n \u003cli\u003ePhysical complaints\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003col start=\"6\"\u003e\n \u003cli\u003eRest\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003col start=\"7\"\u003e\n \u003cli\u003eCommunication\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003col start=\"8\"\u003e\n \u003cli\u003eAccommodation\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Occurrence of major and minor complications in EM and control groups.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"476\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMajor complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEM\u0026nbsp;\u003c/strong\u003e\u003cem\u003e(n=48)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e \u003cem\u003e(n=48)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eRecurrent disc herniation (\u0026lt;6 months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e5 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e3 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003ep=0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eRe-hospitalization (\u0026lt;30 days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003ep\u0026gt;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinor complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eTemporary neurological deficit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003ep=0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eUrinary retention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003ep=0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eAnaesthesia-related issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003ep\u0026gt;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eProlonged pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e3 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003ep=0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are reported as absolute (numerosity) and relative (percentage) values. Abbreviations: EM: early mobilization group; Control: conventional mobilization group\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTo the best of our knowledge, this is one of the first retrospective studies focusing on the effect of early mobilization on clinical outcomes associated with spine decompression surgery in Switzerland. The main results of the present study showed that: 1) the mean LOS in the EM group was shorter by 1.8 days compared to the control group; 2) COMI and VAS scores for leg and back pain were similar between groups, with no baseline differences and a significant improvement three months after surgery for both groups; 3) local infiltration did not affect LOS and opioids at discharge; 4) no differences were observed in the occurrence of major and minor complications between the EM and control groups; 5) patients' satisfaction and subjective perception of the perioperative process were high for the EM group. All our initial hypotheses were confirmed.\u003c/p\u003e \u003cp\u003eEarly mobilization is an essential element of the postoperative ERAS protocol, facilitating recovery and reducing healthcare costs by shortening the length of stay. It has been adopted in various surgical specialties, yet remains non-standard in spinal surgery, particularly in Switzerland. Early mobilization after spinal surgery is crucial for several reasons. As part of ERAS, it helps prevent complications such as deep vein thrombosis and pulmonary embolism, which are common risks associated with prolonged bed rest. Additionally, early mobilization aids in restoring muscle strength and flexibility, essential for postoperative rehabilitation and overall functional recovery. Moreover, early ambulation fosters patient independence and psychological well-being by empowering them to actively participate in their recovery process. Therefore, implementing early mobilization protocols following spinal surgery is important for optimizing patient outcomes and enhancing their overall quality of life.\u003c/p\u003e \u003cp\u003eThe most noticeable effect of early mobilization applied in our institution was a significant reduction in hospitalization. The mean LOS in the EM group was shorter compared to the control group (3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9 days vs 5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 days). Notably, the large standard deviation in the control group was due to the long hospitalization duration of n\u0026thinsp;=\u0026thinsp;2 patients with 10 and 15 days respectively. The reason for this in some of the patients was a pre-existing comorbidity that required additional pre-operative assessments and anesthesiologic evaluation, in others it was purely for organizational reasons such as longer travel distances to our hospital. Sivaganesan et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] evaluated the effect of the implementation of a standardized, evidence-based order sets for six high-impact dimensions of perioperative care for elective spine surgery and showed a small but significant difference in LOS compared to the control (2.9+-2.2 days vs 2.5\u0026thinsp;+\u0026thinsp;.1.7 days; p\u0026thinsp;=\u0026thinsp;0.021). Similarly, another study by Nazarenko et al.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] demonstrated a one-day reduction of LOS in n\u0026thinsp;=\u0026thinsp;23 ERAS vs n\u0026thinsp;=\u0026thinsp;25 non-ERAS patients (2.3 days vs 3.8 days; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) which is consistent with our findings. Other studies focusing mainly on microdiscectomy or decompression discharged patients within hours or one day [\u003cspan additionalcitationids=\"CR33 CR34\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The longer LOS observed in our study can be attributed to several factors. Most significantly, the different reimbursement system in Switzerland directly impacts hospitalization duration. However, the Swiss DRG reimbursement system does not allow for cost-effective outpatient surgery; stays shorter than two nights result in a financial penalty. A medical factor for a shorter LOS might be the use of endoscopic technique [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] whereas we used a microsurgical approach. Another factor might simply be the way LOS was counted. We counted all days patients stayed at the hospital as 1, even when they were discharged in the morning. Most other studies counted hours of hospitalization. Another factor would be that most of those studies used more than 10 specific interventions of the ERAS protocol whereas we implemented 2 standardized items. Non-standardized items such as patient education could not be measured. Our discharge criteria were strictly defined and included: independent ability to walk stairs, instructed basic muscle activation exercises, patient education on daily living activities and rehabilitation procedure, sufficient pain control with oral analgesics, and wound dryness. The latter might be difficult to control in ambulatory surgery.\u003c/p\u003e \u003cp\u003ePatient-Reported Outcome Measures (PROMs) serve as crucial indicators of surgical success and patient satisfaction. COMI and VAS scores for leg and back pain were similar between groups, with no baseline differences and a significant improvement three months after surgery for both groups. Therefore, early mobilization yielded similar results on PROMs compared to the standard of care and, in addition, patients' satisfaction and subjective perception of the perioperative process, evaluated through the PPP33 questionnaire, were high in the EM group. In the literature there are only a few reports of PROMs for microdiscectomies or decompressions. Staartjes et al. showed that tubular discectomy and decompression led to good improvement for NRS, ODI and EQ-5D at 6 weeks and 1 year follow up [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In a subgroup analysis for lumbar procedures including decompressions and fusions, Sivaganesan et al. found no differences in the ERAS group compared to a control group for ODI (0.77 vs 0.67), and patient satisfaction at 3 months follow-up [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Similar results are reported by Ali et al. [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] who examined a mixed group of lumbar procedures, including peripheral nerve surgery, with no difference of outcome in pain scores, EQ-5D, and ODI between ERAS and the control group. Only Nazarenko et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] compared decompressions vs a control group and showed a significant reduction in VAS, ODI, and the Roland-Morris scale at 1 month follow up; however, the ODI difference was only 10 points, whereas the minimal clinically important change is considered to be 12 [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe also performed a subgroup analysis comparing LIA (n\u0026thinsp;=\u0026thinsp;24) vs non-LIA (n\u0026thinsp;=\u0026thinsp;26) within the EM group and, interestingly, LOS was independent of LIA application. LIA is known to reduce postoperative pain and opioid consumption [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]; however, we did not evaluate VAS or analgesia use directly after surgery, when the effect of LIA would arguably be at its maximum. Of interest, Kurnutula reported in a retrospective review, analyzing the effect of interfascial plane blocks, a significant reduction of LOS [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]; however, they also implemented other elements of the ERAS protocol, so this effect might not be attributed solely to LIA. So even though we regard LIA as useful, the single most important factor for our reduction in LOS was early mobilization. Subgroup analysis comparing patients receiving LIA to those who did not, showed no influence on opioid use at discharge. The risk of opioids and their misuse are commonly known. Implementation of ERAS protocols results in reduced opioid use [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In our cohort, patients were managed postoperatively with metamizole, paracetamol, and NSAIDs and only on demand opioids. We evaluated opioid use at discharge and did not find a significant difference between the two groups. Therefore, we can safely claim that earlier discharge does not come at the cost of increased analgesia. We did not assess the total opioid dose, and among the patients discharged with opioids 5 out of 8 (EM) vs 4 out of 8 (control) were already receiving opioids upon admission.\u003c/p\u003e \u003cp\u003eNo significant inter-group differences were observed concerning short- or medium-term minor and major complications. We observed that more patients in the control group had a prolonged course of pain (n\u0026thinsp;=\u0026thinsp;3; 6%), impacting the longer hospitalization time. Even more importantly, we had no readmissions in the EM group due to unmanageable pain. The patient with postoperative neurological deficit in the EM group had a mild weakness of toe dorsiflexion and foot plantar flexion (M4+/5), which completely resolved by the 6-week follow-up postoperatively. In the control group, one patient had a mild weakness of foot plantar flexion which regressed within 2 months and the other patient had hypaesthesia of dermatoma S1 on the right side which also regressed. In the EM group, there was one readmission due to disc herniation recurrence within the first 30 days. No major complications occurred in any group. Staartjes et al. reported 3\u0026ndash;4% adverse events, a reoperation rate of 6%, and a 30-day readmission rate of 6% for n\u0026thinsp;=\u0026thinsp;1929 discectomy and n\u0026thinsp;=\u0026thinsp;451 decompression cases [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Sivaganesan et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] compared lumbar procedures (fusion and decompression mixed) and reported no significant difference in readmission rates but a lower complication rate (12.8% vs 3.8%; p\u0026thinsp;=\u0026thinsp;0.002) in the intervention group, where a standardized perioperative protocol was applied to improve patient outcomes. Similarly, Wang et al. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] reported a reduction of complication rate for MIS TLIF procedures (12% vs 21%). Nevertheless, according to one recent meta-analysis, neither general nor lumbar spine ERAS protocols led to a significant difference in complication rates [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study has some limitations. First, being a single-center retrospective study with a relatively small sample size may limit the generalizability of the findings to other settings or populations. Second, being retrospective in nature, the study is subject to inherent biases associated with retrospective data analysis. Third, selection bias \u003cem\u003eper se\u003c/em\u003e is an issue as surgeons tended to exclude rather multimorbid and older patients from the ERAS program. To minimize this, we matched our groups for age, BMI, and ASA Score. Fourth, adherence to the ERAS protocol using LIA was only 50% and this variability in adherence could impact the study\u0026rsquo;s outcomes and interpretations. Fifth, although the data was collected prospectively, the lack of blinding is a notable limitation; however, blinding in this setting was not possible. Lastly, the study implemented only two elements of the ERAS protocol, which may not fully capture the potential benefits of a comprehensive ERAS program. The effects of other ERAS elements, such as nutrition and multimodal analgesia, were not evaluated, as these elements have not yet been standardized or systematically implemented in our clinical routine at the institution.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eIn conclusion, our study demonstrates that early mobilization after lumbar decompression/disc herniation surgery is associated with significant reductions in hospital length of stay (LOS) without increasing the risk of complications. The findings suggest that early mobilization protocols can effectively enhance patient recovery and satisfaction, thereby reducing healthcare costs.\u003c/p\u003e \u003cp\u003eThe lack of significant differences in opioid use at discharge between the groups further supports the safety and feasibility of early mobilization without increasing the need for postoperative analgesia. The results align with existing literature on the benefits of early mobilization in various surgical specialties and underscore its potential to optimize recovery in spinal surgery. Future studies with larger sample sizes, multicenter designs, and comprehensive ERAS protocols are warranted to validate and expand upon these findings. Implementing standardized early mobilization protocols could lead to improved patient outcomes, enhanced efficiency in healthcare delivery, and reduced overall costs, particularly in healthcare systems similar to Switzerland's framework.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institutional Swiss Ethics Review Committee (Z\u0026uuml;rich, Switzerland; protocol number:2024-01183) in compliance with the current national and international laws and regulations governing the use of human subjects (Declaration of Helsinki II).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDaniel Haschtmann (Author 5) - Shareholder of Inno4Spine AG. There are no other conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used for analysis in this study were obtained from our institutional spine outcomes database. Due to institutional and registry data protection policies, the dataset is not publicly available. However, de-identified data may be made available from the corresponding author upon reasonable request and with permission from the data governance body.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.D. and M.R. contributed equally to the drafting of the manuscript. R.R. supervised the overall project. J.V. and F.G. were primarily responsible for data processing, statistical analysis, and the generation of tables and figures. A.M.-O. contributed to data curation. R.W., I.C.-M., and M.N. were involved in data acquisition and implementation of study methods. D.H., T.F., and F.P. contributed to the study concept and data acquisition. All authors reviewed the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDeyo, R.A., D.T. Gray, W. Kreuter, S. Mirza, B.I. Martin, United States trends in lumbar fusion surgery for degenerative conditions, Spine (Phila. Pa. 1976). 30 (2005) 1441\u0026ndash;5; discussion 1446-7. https://doi.org/10.1097/01.brs.0000166503.37969.8a.\u003c/li\u003e\n\u003cli\u003eWeinstein, J.N., J.D. Lurie, P.R. Olson, K.K. Bronner, E.S. 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Sch\u0026uuml;nemann, GRADE Working Group, GRADE: an emerging consensus on rating quality of evidence and strength of recommendations, BMJ. 336 (2008) 924\u0026ndash;926. https://doi.org/10.1136/bmj.39489.470347.AD.\u003c/li\u003e\n\u003cli\u003eTazreean, R., G. Nelson, R. Twomey, Early mobilization in enhanced recovery after surgery pathways: current evidence and recent advancements, J. Comp. Eff. Res. 11 (2022) 121\u0026ndash;129. https://doi.org/10.2217/cer-2021-0258.\u003c/li\u003e\n\u003cli\u003eHarper, C.M., Y.M. Lyles, Physiology and complications of bed rest, J. Am. Geriatr. Soc. 36 (1988) 1047\u0026ndash;1054. https://doi.org/10.1111/j.1532-5415.1988.tb04375.x.\u003c/li\u003e\n\u003cli\u003eBrower, R.G., Consequences of bed rest, Crit. Care Med. 37 (2009) S422-8. https://doi.org/10.1097/CCM.0b013e3181b6e30a.\u003c/li\u003e\n\u003cli\u003eAljoghaiman, M., Y. Ellenbogen, R. Takroni, K. Yang, F. Farrokhyar, K. 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Spine J. 21 (2012) 130\u0026ndash;137. https://doi.org/10.1007/s00586-011-1992-2.\u003c/li\u003e\n\u003cli\u003eEberhart, L., Lebensqualit\u0026auml;tsforschung: Messung der Patientenzufriedenheit am Beispiel des PPP33-Fragebogens, in: Thieme, 2006: pp. 772\u0026ndash;776.\u003c/li\u003e\n\u003cli\u003eRampersaud, Y.R., E.R.P. Moro, M.A. Neary, K. White, S.J. Lewis, E.M. Massicotte, M.G. Fehlings, Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols, Spine (Phila. Pa. 1976). 31 (2006) 1503\u0026ndash;1510. https://doi.org/10.1097/01.brs.0000220652.39970.c2.\u003c/li\u003e\n\u003cli\u003eHopkins, W.G., S.W. Marshall, A.M. Batterham, J. Hanin, Progressive statistics for studies in sports medicine and exercise science, Med. Sci. Sports Exerc. 41 (2009) 3\u0026ndash;13. https://doi.org/10.1249/MSS.0b013e31818cb278.\u003c/li\u003e\n\u003cli\u003eSivaganesan, A., J.B. Wick, S. Chotai, C. Cherkesky, B.F. Stephens, C.J. Devin, Perioperative Protocol for Elective Spine Surgery Is Associated With Reduced Length of Stay and Complications, J. Am. Acad. Orthop. Surg. 27 (2019) 183\u0026ndash;189. https://doi.org/10.5435/JAAOS-D-17-00274.\u003c/li\u003e\n\u003cli\u003eNazarenko, A.G., N.A. Konovalov, A.V. Krut\u0026rsquo;ko, T.N. Zamiro, I.B. Geroeva, R.R. Gubaydullin, N.E. Khoreva, A.N. Komarov, M.A. Stepanyan, M.V. Konstantinova, A.M. Kazachonok, R.A. Onoprienko, V.A. Korolishin, T.N. Kubynina, M.A. Martynova, Postoperative applications of the fast track technology in patients with herniated intervertebral discs of the lumbosacral spine, Zh. Vopr. Neirokhir. Im. N N Burdenko. 80 (2016) 5\u0026ndash;12. https://doi.org/10.17116/neiro20168045-12.\u003c/li\u003e\n\u003cli\u003eDebono, B., P. Sabatier, V. Garnault, O. Hamel, P. Bousquet, J.-P. Lescure, J.-Y. 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Qureshi, Design and Implementation of an Enhanced Recovery After Surgery (ERAS) Program for Minimally Invasive Lumbar Decompression Spine Surgery: Initial Experience, Spine . 44 (2019) E561\u0026ndash;E570. https://doi.org/10.1097/BRS.0000000000002905.\u003c/li\u003e\n\u003cli\u003eAli, Z.S., T.M. Flanders, A.K. Ozturk, N.R. Malhotra, L. Leszinsky, B.J. McShane, D. Gardiner, K. Rupich, H.I. Chen, J. Schuster, P.J. Marcotte, M.J. Kallan, M.S. Grady, L.A. Fleisher, W.C. Welch, Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution, J. Neurosurg. Spine. (2019) 1\u0026ndash;9. https://doi.org/10.3171/2018.9.SPINE18681.\u003c/li\u003e\n\u003cli\u003eJohnsen, L.G., C. Hellum, O.P. Nygaard, K. Storheim, J.I. Brox, I. Rossvoll, G. Leivseth, M. Grotle, Comparison of the SF6D, the EQ5D, and the oswestry disability index in patients with chronic low back pain and degenerative disc disease, BMC Musculoskelet. 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Focus. 46 (2019) E8. https://doi.org/10.3171/2019.1.FOCUS18645.\u003c/li\u003e\n\u003cli\u003eSmith, J., S. Probst, C. Calandra, R. Davis, K. Sugimoto, L. Nie, T.J. Gan, E. Bennett-Guerrero, Enhanced recovery after surgery (ERAS) program for lumbar spine fusion, Perioper Med (Lond). 8 (2019) 4. https://doi.org/10.1186/s13741-019-0114-2.\u003c/li\u003e\n\u003cli\u003eY. Wang, M.Y., C.M. Peng-Yuan, J. Grossman, Development of an Enhanced Recovery After Surgery (ERAS) approach for lumbar spinal fusion, J. Neurosurg. Spine. 26 (2017) 411\u0026ndash;418. https://doi.org/10.3171/2016.9.SPINE16375.\u003c/li\u003e\n\u003cli\u003ePennington, Z., E. Cottrill, D. Lubelski, J. Ehresman, N. Theodore, D.M. Sciubba, Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery, J. Neurosurg. Spine. 34 (2020) 325\u0026ndash;347. https://doi.org/10.3171/2020.6.SPINE20795.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Spine, surgery, rehabilitation, COMI, fast-track recovery","lastPublishedDoi":"10.21203/rs.3.rs-6917412/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6917412/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe global rise in the aging population has increased the demand for self-sufficiency in older age and contributed to a higher number of spinal surgeries, driving up healthcare costs. Enhanced Recovery After Surgery (ERAS) protocols aim to improve outcomes by promoting early mobilization, which has shown benefits but lacks standardization in spinal surgery. This study evaluates the impact of early mobilization on outcomes after spinal decompression surgery in Switzerland.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis retrospective study analyzed data from 123 patients who underwent lumbar decompression or microdiscectomy between January and December 2021 at a specialized spine unit. Patients were assigned to an Early Mobilization (EM) group or a control group based on the surgeon\u0026rsquo;s discretion. The EM group began mobilization on the day of surgery; the control group started the day after. Propensity score matching was used to reduce bias, resulting in 96 matched patients (48 per group, mean age: 56.0\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7 years). Local infiltration analgesia (LIA) was administered in a subset of patients in both groups. Outcomes included length of hospital stay (LOS), pain (VAS), and disability (COMI-back), assessed preoperatively and three months postoperatively.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe EM group had a significantly shorter LOS (3.7 vs. 5.2 days; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Both groups showed similar improvements in pain and COMI scores (EM: \u0026minus;\u0026thinsp;4.4; control: \u0026minus;\u0026thinsp;4.7; p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), with no significant differences between groups. LIA had no measurable impact on LOS or opioid use. Complication rates were similar, and patient satisfaction was high in the EM group.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eEarly mobilization after lumbar decompression surgery safely reduces hospital stay without increasing complications or opioid use. These findings support early mobilization as an effective component of ERAS protocols. Further studies with larger cohorts are warranted.\u003c/p\u003e","manuscriptTitle":"Early mobilization in spine decompression surgery: insights from one of the first monocentric studies in Switzerland","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 07:30:22","doi":"10.21203/rs.3.rs-6917412/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"311877969155014400793000014226775541068","date":"2025-08-22T23:52:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-10T15:34:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325442037926675692780814340875938349537","date":"2025-07-20T05:03:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-26T12:18:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-24T10:35:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-24T09:24:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-24T09:21:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-06-17T21:04:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5a210f4d-2656-42bb-9296-6d2f8773c2e7","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-02T07:30:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-02 07:30:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6917412","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6917412","identity":"rs-6917412","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}