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:
Ibrahim Hussain, MD
Assistant Professor
Dept. of Neurological Surgery
Weill Cornell Brain and Spine Center
New York, NY

How did you get interested in ERAS?
Recovery from spine surgery in general has always been pretty tough for patients compared to other potentially equivalent surgeries, such as orthopedic joint replacement, thoracic, or abdominal surgery. They seem to have longer or prolonged hospital stays, pain courses, and other complications, such as postoperative urinary retention and delirium. It made it difficult to watch these patients struggle in the postoperative period and became clear that this was a problem we needed to fix.

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?
It's definitely been an effort for sure. As you know, surgeon preference is often based on little other than anecdotal opinion and bias, so it's taken a long time to get the evidence in front of people to get them to come around. One of the biggest hurdles has been the pharmacologic side of things. Obviously we're trying to reduce opioids as much as possible, but it’s also exactly which and what dose of opioids used, whether or not to use intraoperative Decadron, when to use NSAIDs in cases fusion or not fusion. This has generated a lot of vigorous discussion and strong opinions and so we've had to compromise along the way and arrive at something that seemed to work for everybody. Often times, we leave it up to surgeon discretion.

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?
Unfortunately, we don't have the luxury of being able to hire additional staff specifically for ERAS, so we've used the personnel we have to focus on a few key elements. We asked what are the elements that have been clearly associated with affecting outcomes in spine surgery? Smoking, obesity, nutritional status, bone density and preoperative opioid intake were the ones that emerged as high-yield targets. So we go to go for the low hanging fruit in a way. All our patients are screened for smoking status, BMI, opioid intake, DXA and prealbumin lab studies.

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?
That's a real-world issue and you can talk about optimal selection criteria, but at the end of the day, you have to treat the patients that you see. But I would say that in general, certainly for deformity and multi-level fusion cases, the vast majority of us would put a hard stop on nicotine use and a few of us will test cotinine levels a week or so before surgery. We’ll inform the patient that continuing nicotine up through surgery is a setup for failure, and we don't want poor outcomes. Fortunately most of us have seen reasonably good compliance rates amazingly enough probably because the people that aren't willing to take these additional steps usually won't sign up for surgery. They likely seek care somewhere elsewhere and frankly we are most interested not in the quantity of cases, but the quality of our outcomes, and it bears out in the kind of results we’ve had.

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?
You’re right this is a tough population and it’s not straightforward. If you think about the surgeries that ERAS started with, it was elective colorectal surgery, then moved into hips and knees, and spinal oncology is, in some respects, as far a field as you can get from these. These cases are semi-elective at best so we've used it in select cases and mainly cases where we're doing MIS surgery for spinal tumors, like primary intradural cases. These basically proceed like an MIS TLIF or laminectomy. For the metastatic disease population, it’s limited to cases where we’re performing percutaneous screw stabilization, or MIS separation surgery, or even MIS lateral corpectomies. The biggest problem with so many of these oncology patients is that they’re coming in on significant doses of preoperative opioids, and even though we try to select patients with good ECOG and KPS scores, they still might have challenges postop. I think the people who can help us figure that out are at major cancer centers because it's going to take a large volume of patients to start to stratify them. What does keep with spirit of ERAS with these patients, however, is doing surgery with the right multidisciplinary team to reduce the incidence of complications.

What's the feedback you've gotten from your patients?
I think the only way a patient can really give you some information on what we’re doing right with ERAS is if they’ve had prior surgery elsewhere. Most patients forget their postoperative experience if their surgery was more than a year or two ago and if they do remember, it’s usually due to a subjectively negative experience. Patient satisfaction frequently has little to do with typical validated outcome measures, and that is where managing expectations helps. With ERAS, you deliberately educate patients about what they might or should feel at the various phases of their care. What we don’t want is the patient telling you “I had no idea it was going to feel like this” or “if I had known how this was going to go, I would never have done the surgery”.

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 think regional anesthesia as I mentioned is a big component, and we're working on a number of studies to confirm that right now. The other key element is doing a better job at patient selection. We talk all the time about patient selection based on clinical symptoms and radiology, that's what our training is all about and what we discuss about at conferences. But patient selection with regard to health optimization is something that’s hard and we're not necessarily good at all the time. For instance, setting criteria for properly selecting patients for outpatient surgery that's more than single level decompression or discectomy type cases, such as fusions, is currently being refined. And mitigating the effects of frailty remains a conundrum that is also requiring a multi-disciplinary approach with our colleagues in geriatrics for example.

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.

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Please tell us a bit about your background.
I was born and raised in Reston, Virginia. I did my undergraduate work at The College of William and Mary in Williamsburg, Virginia. I was always drawn towards health care as several members of my family work in the field. After college I pursued a master’s degree in physiology and then went to medical school at the Medical College of Virginia (now known as Virginia Commonwealth University). I ultimately stayed at VCU for residency. In all, I lived in Richmond for 16-17 years. To this day I love that city and have a lot of great memories from there.

How did you get involved in the field of neurocritical care?
I actually did things a bit in reverse – I got interested in neurosurgery because of an interest in the neurocritical care of head injuries. So being in the ICU environment is what eventually drew me towards neurosurgical patients. But I have always loved being in the ICU. I was involved in a sizeable amount of basic science research on TBI during residency and had even completed course work for a PhD. As a PGY-4, one on my principal mentors, Dr. Ross Bullock, left VCU for the University of Miami. As I was finishing residency, I learned that Dr. Bullock had started a fellowship in neurotrauma at Jackson Memorial Hospital/University of Miami. He offered me the first spot in his new fellowship and I could not pass up that opportunity.

How did you find your way to Penn State?
When close to finishing fellowship, I was actively look for positions in neurotrauma and neurocritical care which weren’t really advertised. I received guidance from David Okonkwo, another neurotrauma specialist at the University of Pittsburgh, and someone I had known from graduate school. He worked in the same lab I ultimately joined when he was earning his PhD. His advice was to be more proactive and to reach out to the programs I was interested in explaining my subspecialty interest. At first I thought “cold calling” chairmen was a crazy idea. But he convinced me and he was absolutely right. I reached out to several programs and found that almost all were interested in bringing someone on staff for this type of position. I had to consider my family as well as my wife’s family (who live in Ohio) so we focused on the mid-Atlantic region. I had several offers but knew I wanted to work in Academics. Ultimately ended up picking Penn State. This decision was made easier, in part, due to Dr. Philip Villanueva who was the former neurocritical care director in Miami who had moved to Penn State and knew the people I trained with. Having some friends in common with the staff at PSU was comforting. After considering other places, Penn State was easily the best fit for me.

How is your practice divided up right now?
I do 1-2 weeks a month in the ICU. The rest of the time I have a typical neurosurgery practice focusing on complex and degenerative spine. I typically have two days of clinic per week, one academic day, a full OR day and clean-up day – usually Friday. I try not do any elective surgeries while I’m in the ICU because I want to ensure I give those patients the dedicated attention they need. My general practice is almost all spine. In the beginning of my career I was doing a considerable amount complex spine including deformity corrections. But now I don’t do as much of that because we’ve hired dedicated faculty for those cases. I still do complex trauma cases and I share the tumor work with my other colleagues.

What got you interested in ERAS?
I got interested in ERAS mostly as I was seeking out ways to improve outcomes in the spine surgery aspect of my practice. At first glance, when you’re coming out of training, you know to be cautious with basic risk factors like morbid obesity and tobacco abuse. But what really got me into ERAS was navigating the challenges of the opioid epidemic. When the opioid crisis came along I asked myself “how can I use less opioids for my patients?” I started learning more about multi-modal analgesia and that led quickly to ERAS. As I read more and more I realized that not only is this better in terms of minimizing opioid usage but that surgical outcomes were also superior. As you learn when you implement ERAS strategies, one of the key things for optimizing patient outcomes is setting expectations. I work hard to make sure patients know exactly what to expect with a given surgery. I do work ahead of time to explain the opioid crisis and that studies show that if we can get you to decrease your opioid use by 50% prior to surgery (or better yet, get you off them all together) your outcomes will be better. Patient education and clearly setting expectations well ahead of the surgical date makes a dramatic difference.

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?
I think a good example is nutrition. What was compelling to me was the focus ERAS has on preoperative diet. I thought about it in the ICU - we see a lot of diarrhea and people losing muscle mass. Then you look at the tube feeds that we give patients. One of the first ingredients is high fructose corn syrup. I think most people conscious of their diet know that high fructose corn syrup is problematic. And we are giving our most critically ill patients this stuff. If I eat foods now (with no illness to overcome) with ingredients like high fructose corn syrup I feel awful. So if someone injured and needs to heal, why are we giving them this? So imagine you could improve the tube feed formula so that its closer to actual food.

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?
ERAS is intriguing to me because it is proactive. It’s looking at all stages of care from preoperative to intraoperative to postoperative to recovery. It looks at all the little things that you should be doing for somebody. You’re taking the patients through every phase of their treatment, not just surgery. Now one interesting idea is the development of an app which is being pursued already by other members in the community. Basically, the patient has a portal they can access on the app and go through an extensive list of questions and baseline characteristics. It would take your information and then delineate, in order, the steps to take to optimize outcome for a given surgery. It would prompt them to see a dietitian (and display the recommendations), maybe use some cognitive behavioral therapy, get prehabilitation etc. Then on the day before surgery have your high protein meal. Then there would be an area that tells the user what to expect on the day of surgery etc. The app walks them through their journey. Not only does it display results and guidance for the patient – but the surgeon can see the progress as well. You take advantage of technology to track what the patient is doing it once out of the hospital. This would serve as a great guide and it also addresses their expectations. Some places may have dedicated ERAS centers/concierge who follow these patients also. To me that’s the future. I think that could improve results in spine surgery in a heartbeat.

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?
Do your best to come out of the gates using ERAS as much you can. Otherwise I’m afraid you’ll fall into the same trap that many experienced surgeons fall into: it becomes very challenging to alter practice habits later in their career. They may feel that their outcomes are good enough, but they may not be actually looking at their own hard data and even minor ways to improve them. If you get out and start your practice doing it the way you’re comfortable with, in a particular way, three years into practice it’ll be more difficult to change.

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”.

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