John O'Toole, MD, MS, is Professor of Neurosurgery at Rush University Medical Center in Chicago, IL. He received his medical degree from Harvard Medical School and completed a residency in Neurological Surgery at the Neurological Institute of New York at Columbia-Presbyterian Medical Center in New York City followed by a fellowship in Spine Surgery at the University of Chicago. He received his Master of Science degree in Clinical Research from Rush University Graduate Medical College and serves as a lecturer for both the medical and graduate student programs. He serves as Co-Director of the Comprehensive Spine Tumor Clinic at Rush University Medical Center in conjunction with Radiation, Medical, and Neuro-Oncology staff and also serves as Surgical Director of the Neurosciences Service Line at Rush University Medical Center.
Dr O'Toole's clinical specialties include minimally invasive spine surgery, spinal oncology (including spinal column and spinal cord tumors), spinal radiosurgery, complex spinal reconstruction, and spinal arthroplasty. His research interests are clinical outcomes for spinal surgery, evidence-based clinical practice guideline development, image-guided spinal surgery, and development of new spinal surgical techniques and devices. He is an investigator on a number of investigator-initiated as well as multicenter and industry-sponsored research protocols.
Dr O'Toole has presented and published on a wide variety of topics in spinal surgery and has served as an advisor and peer reviewer for several interdisciplinary education and research organizations and journals. He is an active member of multiple neurosurgical and spinal surgical societies and has served on numerous national committees and workgroups including the AANS/CNS Guidelines Committee; the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves Guidelines, Outcomes and Executive Committees; the North American Spine Society Evidence-Based Medicine Committee and Clinical Practice Guideline Development Committee; the Orthopaedic Research and Education Foundation Spine Prospective Clinical Research Grant Committee; and the Neurosurgical Research and Education Foundation Development Committee.
An Interview by:
How did you get interested in ERAS?
Minimally invasive spine surgery started to take over and my practice, since the beginning with regards to degenerative spine pathology, has been largely MIS in nature. The promise of MIS was always been improved perioperative outcomes, namely, less blood loss, lower infection rates, shorter length of stay, and faster recovery. But I was finding that it wasn't quite fast enough, and length of stay was longer than I thought it should be for some of these patients. ERAS seemed like an opportunity for us to do better and really fulfill the full promise of MIS by working collaboratively with other services in the hospital to improve patient’s postoperative experience.
In talking with our anesthesia and pain medicine colleagues here, it became clear that we needed to institute a more programmatic ERAS protocol and we used MIS as the poster child for this program. As we got into it, we started to realize this really made a huge difference, from preop to the intraop to the postop setting, and we've continued to modify it along the way. We keep adding new pieces to the puzzle and it continues to evolve to a point now where the hospital is implementing hospital-wide ERAS protocols for every patient undergoing any kind of spine surgery because this has been such a game changer.
You work with a large group of neurosurgeons, orthopedic surgeons, anesthesiologists – what challenges did you face in getting this large group on board with ERAS-related changes?
Some of the pushback also initially came from anesthesia - some anesthesiologists didn't want to be told what to do with their intraoperative anesthetic regimen. This is perhaps the cornerstone of a real spinal ERAS program, other than preoperative education for the patients. The “wide open fentanyl drip” in the OR was sort of the historical standard, so it was important to get our anesthesia colleagues on board with a different approach. Part of that may be a generational stance and the anesthesia teams we work with now are fully committed to ERAS protocols. But interdepartmental education, not just in anesthesia, but within neurosurgery and orthopedic surgery has been key.
In the end, this is the ultimate example of collaborative work in a clinical setting. We now have orthopedics, anesthesia, pain medicine, physical therapy, occupational therapy, nursing, radiology and nursing from pre-op, PACU, floor, outpatient etc. - we have all these stake holders involved because we know that every step along the way requires buy in from these services, otherwise the chain falls apart and patients get stuck. We have ‘champions’ in each arena, which if you don’t, you're going to be quixotic in your attempts at getting ERAS done efficiently. Patients are excited to hear that they are part of this kind of program to make their post-operative experience better.
What specific changes within your outpatient practice or department have been made to implement ERAS protocols? Do you have dedicated staff focusing on this?
Our surgeons and nurses know we have to counsel patients even in the first consultation – we’ll say these are the things you need to do or we need to do with you if we're going to have optimal outcomes from surgery. This means sending them to smoking cessation clinics, bariatric surgery clinic, getting them in with nutrition services, and referral to our pain service here who works closely with us to work on opioid reduction prior to surgery.
The patient education piece is the most important and the hardest to do, particularly in a big urban center like Chicago. You're talking about trying to educate a wide array of people from different backgrounds, education, and social situations about what they should do before and after surgery. We're still working on ways to navigate this educational piece, since it’s vital for success.
Many ERAS protocols have “hard stops” which limit certain populations eligible for surgery. This, among other aspects of ERAS, clearly have economic impact on the greater hospital organization. Have you run into issues in this regard?
Another example is obesity - most of us have a BMI of 40 cut off for elective cases with some exceptions such as severe cervical myelopathy or acute foot drop, but otherwise these patients are referred to the bariatric clinic. We emphasize the need for weight management preop because the data is fairly compelling on lower quality long-term and short-term outcomes with obesity.
To some extent there are hard stops and it is surgeon dependent, but you have to design these protocols and procedures in the context of your environment, nobody is operating in a vacuum. If the local environment is that 60% of the population are smokers, the economic analysis isn’t about outcomes in spine surgery with smokers, but more of the institution stepping in and implementing smoking cessation clinics. But if only 5% of the population are smokers, you know where the value is so I think understanding your patient population and getting your administration to understand that is important. Institutions aren’t just looking at your total RVUs for the year alone anymore, they are also looking at quality, reoperations and readmissions. These have become some of the most important metrics for hospital administrators, which ERAS works to address.
A significant portion of your practice is dedicated to spine oncology. Have you had success applying ERAS protocols to this, often times difficult to manage, population?
What's the feedback you've gotten from your patients?
The part we've added in the last year or two where we've seen patients have a different subjective experience is the addition of regional anesthesia. We perform erector spinae plane blocks for all minimally invasive surgeries and patients clearly note the difference, particularly in the first 24 to 48 hours. They are shocked because they very often are pain free for the first day or so, which if they've had prior surgery, was usually not the case.
What do you see as the future of ERAS in spine surgery?
I also think a lot of the advancements in ERAS are going to have to come from pharma. We’re going to need better drug options, longer acting regional anesthetics, and medications that treat pain that aren't opioid based. The pharmaceutical industry is a big part of this; the advent of gabapentinoids changed so much of what we do, so we need to find the next class of drugs that will come along to help us more optimally manage patients’ postoperative pain. Our surgeries can keep getting smaller, like endoscopic TLIF for example, that's a procedural change that can really help influence the patient’s experience. But at some point we're going to reach a limit in being able to do effective fusions and instrumentation through smaller and smaller approaches, and then we’ll have to rely on these other modalities to help us get there.
J. Christopher Zacko, MD
Please tell us a bit about your background.
How did you get involved in the field of neurocritical care?
How did you find your way to Penn State?
How is your practice divided up right now?
What got you interested in ERAS?
I started using ERAS strategies and it worked very well in my practice. I’m fortunate enough that at my hospital we already had options like IV Tylenol and Exparel,. I started using the tools of multimodal analgesia and it seemed to work like magic. In fact, my first patient utilizing these strategies underwent an ALIF. He left the left the hospital the morning after surgery feeling great. Unfortunately, he did bounce back to the ER a week later ---- with opioid withdrawal. He felt so good he stopped his chronic opioid regiment abruptly and went into withdrawal. Now it doesn’t work that well in every case I know. But the beauty of ERAS is that it doesn’t leave any stone unturned. You have to consider smoking cessation programs, nutritionists to help them with their diet, and eventually that is something that we will all insist on.
What are some ERAS applications in neurocritical care?
From another perspective, let’s take head injury as we don’t have a ton of data on how to help people with TBI. With neurocritical care you have to look at the whole patient. What we are feeding them, optimal blood pressure, oxygenation, heart rate, type of IV fluid use etc. We need to keep them as healthy as possible until they can have an opportunity to heal. We have to work all these levers to keep these patients healing and that is similar to what ERAS does. Is any one of these small details going to have a huge difference in their overall recovery? We may never know. But if you can find the best possible option for every one of these small things for each of our patients, it will surely lead to better outcomes.
What are the some of the future aspects of ERAS in spine surgery that you foresee?
Another very interesting and promising idea is being pursued by a clinical pathologist colleague of mine. We are working on a test that may get FDA approved soon. It’s a pharmacogenetic-based test that tells a patient whether if they are genetically predisposed to the development of opioid addiction. It’s powerful for the surgeon - it can be a red flag or help you know how to manage that patient ultimately. But Imagine the power of that for the patient? Here is a test that tells you that if you use these certain medications, there’s a good chance you’re going to become dependent on them. There will even be a way, in time, that these tests will look at your pharmacokinetics and know which exact opioid will work best for you. For example, a patient may be a better responder and thus need less medications if they are an oxycodone vs. Ultram. Unfortunately, this test’s approval process has gotten derailed by COVID, but is certainly the future of better understanding the role of opioid minimization in ERAS.
What advice do you have for novice or new surgeons interested in getting involved with ERAS?
In addition, think about this question: what would make you, as a knowledgeable surgeon who’s trained at various hospital, take notice of a practice should you ever need surgery? What would sound attractive and exceptional to you if you were a patient? You would know immediately when someone is going above and beyond. These are the things to focus on – and these are the things ERAS brings to your practice.
The comprehensive approach provided by ERAS are often outside the spine surgeon’s normal strike zone. But once you think about it, make a checklist, build a team around it, you’ll find you that all these little things will greatly improve the experience for your patient. Don’t be afraid to challenge the model at your institution. I heard a phrase as a med student that has stuck with me all these years, “for most surgeons you have a choice between now and later – the answer is almost always now”.