Enhanced Surgical Recovery ESR: Improving Outcomes

Enhanced Surgical Recovery (ESR) for Spine Surgery: How ERAS, Chiropractic Care, NPs, and Virtual Reality Work Together

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Why Enhanced Surgical Recovery (ESR/ERAS) Matters in Spine Surgery

Spine surgery is a big event for the body. Without a plan, patients can face:

• High opioid use

• Long hospital stays

• Slow mobilization

• Higher risk of complications or readmissions

Enhanced Surgical Recovery (ESR), also known as Enhanced Recovery After Surgery (ERAS), is a structured, evidence-based pathway that guides care before, during, and after surgery. ERAS uses:

• Multimodal, opioid-sparing pain control

• Better nutrition and hydration

• Early mobilization

• Clear patient education

Across many types of surgery, ERAS has been shown to:

• Shorten length of stay (LOS) by about 1–2 days on average IJSSurgery+1

• Lower opioid consumption without increasing pain scores PMC+1

• Cut complications and sometimes readmissions when implemented well The Journal of Neurosurgery+1

In spine surgery specifically, ERAS protocols reduce LOS, lower costs, and decrease in-hospital opioid use compared with traditional care. PMC+1

Clinically, this matches what Dr. Alexander Jimenez, DC, APRN, FNP-BC, sees in his integrated spine and injury practice in El Paso: patients who go into surgery prepared and follow a structured recovery plan with nurse practitioners (NPs), chiropractors, and therapists often move better, need fewer opioids, and return to daily life sooner. El Paso, TX Doctor Of Chiropractic+1

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Core Components of ESR/ERAS for Spine Surgery

Most ESR/ERAS spine pathways share four big pillars: PMC+1

1. Preoperative counseling and education

2. Preoperative nutrition and risk optimization

3. Opioid-sparing multimodal analgesia

4. Early feeding and mobilization

Preoperative Education and Expectation Setting

Education reduces fear, improves adherence, and helps patients engage in their recovery. ERAS and AANA resources highlight: aana.com+1

• Clear explanations of the surgery and recovery timeline

• Specific goals for walking, breathing exercises, and self-care

• Instructions on medications, nutrition, and what to expect after discharge

Helpful pre-op teaching topics:

• What “Enhanced Surgical Recovery” means

• How will pain be managed without relying only on opioids

• Why early walking and sitting up matter

• When a patient can start gentle home exercises or VR-based rehab

Nurse practitioners are often the ones who walk patients through these details, answer questions, and connect surgical, anesthesia, rehab, and chiropractic teams.

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Nutritional Optimization and Prehabilitation

Malnutrition and anemia are strong predictors of poor wound healing, infection, and longer hospital stays in spine surgery. PMC+1

Common pre-op steps include:

• Screening for malnutrition (weight loss, low albumin, poor intake)

• Addressing anemia with iron or other therapies before elective surgery

• Carbohydrate loading up to 2 hours before anesthesia (instead of long fasting) to reduce insulin resistance and muscle breakdown PMC+1

Integrating prehabilitation—light strengthening, posture training, and walking programs—has become a key component of ERAS design for elderly patients undergoing lumbar fusion. ScienceDirect

Here, an integrative team can shine:

• Chiropractors help optimize spinal alignment, posture, and movement patterns before surgery.

• NPs coordinate nutrition referrals, lab work, and medical optimization (blood pressure, diabetes, and smoking cessation).

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Multimodal, Opioid-Sparing Pain Management

A cornerstone of ESR/ERAS is multimodal analgesia—using several non-opioid medications and techniques that target different pain pathways. PubMed+1

Typical tools include:

• Acetaminophen

• NSAIDs or COX-2 inhibitors (when safe)

• Gabapentinoids

• Local anesthetic infiltration or regional blocks

• Low-dose opioids only when needed

In lumbar fusion surgery, ERAS protocols have:

• Significantly reduced in-hospital opioid consumption with no increase in pain scores PMC+1

• Improved early ambulation and overall satisfaction PMC+1

Outside spine surgery, large systems like Penn Medicine, MD Anderson, and HCA Healthcare report ERAS pathways that reduce opioid use by 40–50% while improving pain control. chti.upenn.edu+2MD Anderson Cancer Center+2

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Early Feeding and Early Mobilization

Classical care often kept patients fasting and in bed for long periods. ERAS flips this approach:

• Early return to oral intake

• Sitting up on the day of surgery

• Walking within 24 hours when safe PMC+2Becaris Publishing+2

Benefits include:

• Faster gut function

• Lower risk of blood clots and pneumonia

• Less muscle loss

• Shorter hospital stays

In spine surgery, ERAS pathways are associated with shorter LOS and similar or lower complication and readmission rates compared with traditional care. The Journal of Neurosurgery+2IJSSurgery+2

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How ESR/ERAS Programs Reduce Opioid Use

Reducing opioid exposure is one of ESR’s clearest wins. The strategy is not “no opioids ever,” but “opioids as backup, not the first line.”

Key elements:

• Pre-op planning: Begin non-opioid pain meds before surgery to “prime” pain pathways. Norton Healthcare

• Intra-op strategies: Regional blocks, local infiltration, and non-opioid infusions when appropriate. PubMed+1

• Post-op routines: Scheduled non-opioid medications with opioids reserved for breakthrough pain.

In spine surgery, studies report:

• Decreased in-hospital opioid use and lower MME (morphine milligram equivalents) with ERAS pathways, especially in lumbar fusion patients. PMC+1

• Improved postoperative pain scores when multimodal analgesia is used consistently. ScienceDirect+1

VR-based pain management (described below) is now emerging as another non-pharmacologic tool that can reduce the need for opioids after surgery. JAMA Network+1

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Shorter Hospital Stays and Lower Readmission Rates

Multiple reviews of ERAS in adult spine surgery show:

• Shorter hospital stays by about 1–2 days

• Lower overall costs

• No increase in complications or readmissions when protocols are followed well PMC+2The Journal of Neurosurgery+2

Some systems highlight concrete numbers:

• HCA Healthcare’s Enhanced Surgical Recovery (ESR) program reports about a 2-day reduction in average LOS and meaningful drops in readmissions across several surgical lines. hcahealthcaretoday.com+2South Florida Hospital News+2

• Pathways for spinal deformity and pediatric scoliosis report shorter LOS and fewer complications with ERAS-style care. MDPI+2LWW Journals+2

A few early ERAS spine reports found slightly higher readmission rates, especially when protocols were new or patient selection was complex, highlighting the need for careful implementation and follow-up. ait-journal.com+1

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The Role of Nurse Practitioners in ESR Spine Pathways

Nurse practitioners are central to the success of ESR programs. AANA and ERAS resources stress interdisciplinary teams, with advanced practice clinicians helping drive consistency and patient-centered care. aana.com+1

Before surgery, NPs commonly:

• Perform detailed histories and physicals

• Screen for malnutrition, anemia, diabetes, and other modifiable risks

• Coordinate lab work, imaging, and specialist consultations

• Provide pre-op education about ERAS steps and recovery goals

During hospitalization, NPs help:

• Adjust multimodal pain regimens and taper opioids appropriately

• Monitor early mobilization, bowel function, and wound status

• Communicate between surgeons, anesthesiologists, physical therapists, and chiropractors

After discharge, NPs often:

• Run telemedicine follow-ups to monitor pain, function, and red-flag symptoms

• Refine non-opioid medications, sleep support, and mood management

• Coordinate referrals to chiropractic care, physical therapy, and VR-guided rehab

Dr. Jimenez’s dual-scope practice—combining Nurse Practitioner and Chiropractic credentials—illustrates how NPs can bridge biomedical, functional, and musculoskeletal care in a single integrated recovery plan. El Paso, TX Doctor Of Chiropractic+1

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Integrative Chiropractic Care in ESR for Spine Surgery

Chiropractic care, when coordinated with the surgeon and NP, can fit naturally into ESR pathways—especially in the prehabilitation and later post-op phases.

Important: Chiropractic providers must follow the surgeon’s specific restrictions, especially after fusion or instrumentation procedures.

Prehabilitation: Preparing the Body for Surgery

Before surgery, chiropractors can:

• Improve spinal alignment and posture (within safe limits)

• Coach patients on neutral spine mechanics for sitting, standing, and log-rolling

• Address muscle imbalance and stiffness through soft tissue work

• Design gentle prehab exercises to build basic strength and endurance

Such prehab can improve function and resilience before the surgical “stress,” similar to other ERAS prehabilitation strategies in the spine. ScienceDirect+1

Postoperative Recovery and Long-Term Function

After adequate healing and surgeon clearance, integrative chiropractic care can:

• Address compensatory joint restrictions above and below the surgical site

• Use gentle mobilization and soft tissue techniques to reduce muscle tension and scar-related stiffness

• Support safe return to functional movements (lifting, bending, twisting within guidelines)

Recent clinical articles highlight that chiropractic care, when added to rehabilitation, can help:

• Improve posture and movement control

• Reduce muscle tension and pain

• Support faster return to daily activities Active Health and Wellness Center+2Chiropractor Pearland, TX+2

For spinal fusion specifically, expert guidance suggests waiting several months before direct chiropractic work in the fused segment. Still, it supports careful, individualized care in the area once the surgeon confirms solid fusion. New York City Spine+1

In Dr. Jimenez’s integrative clinic, chiropractic care is combined with NP-led medical management, functional medicine, and neuromuscular rehab to support long-term spine stability, especially after trauma, motor vehicle accidents, or complex fusions. El Paso, TX Doctor Of Chiropractic+1

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Virtual Reality (VR) as a New ESR Tool for Spine Recovery

Virtual reality is quickly moving from gaming into serious pain management and rehabilitation.

What VR can do after spine surgery:

• Distract the brain from pain signals reduces pain intensity

• Lower anxiety and kinesiophobia (fear of movement)

• Guide graded physical therapy or exercise in an engaging way

• Improve mood, focus, and overall rehab motivation

Umbrella reviews and clinical trials show that VR:

• Reduces perioperative and chronic pain across many conditions Frontiers+1

• Can lower postoperative pain scores and opioid requirements compared with controls in surgical patients JAMA Network+1

• Supports motor control and function in chronic low back pain through VR-based training JMIR Publications+1

Examples of how VR fits ESR for spine surgery:

• Early post-op: Short VR sessions in the hospital for pain distraction, breathing practice, and gentle guided movements (when cleared).

• Home phase: Structured VR “exergames” that coach safe core activation, posture drills, and balance challenges, paired with telemedicine visits. arXiv+1

In a dual-scope, tech-forward practice like Dr. Jimenez’s, VR can be integrated with:

• NP-led medication and sleep management

• Chiropractic guidance on safe movement patterns

• Telehealth follow-ups to adjust intensity and track progress El Paso, TX Doctor Of Chiropractic+2El Paso, TX Doctor Of Chiropractic+2

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Sample ESR Pathway for Lumbar Fusion with NP, Chiropractic, and VR

Below is a simplified example of how a patient’s journey might look under an ESR-style spine program.

Preoperative Phase (4–6 weeks before surgery)

• NP visit:

  • Full medical review, labs, nutrition screening

  • Adjusts medications, manages anemia or diabetes

  • Educates on the ERAS plan and sets recovery goals

• Chiropractic prehab (as tolerated):

  • Neutral spine mechanics training

  • Gentle soft tissue care and mobility work

  • Customized home exercise program

• Nutrition & lifestyle:

  • Protein and calorie optimization

  • Smoking cessation and reduced alcohol use

  • Carbohydrate-loading instructions for the day before surgery PMC+1

Day of Surgery and Inpatient Stay

• Anesthesia & surgical team:

  • Apply multimodal analgesia and minimal-opioid anesthesia

  • Encourage early oral intake and sitting up the same day if possible jmedsciences.com+1

• NP and nursing team:

  • Monitor pain with a non-opioid-first strategy

  • Start DVT prophylaxis and bowel regimen

  • Educate the patient on walking goals and log-rolling

• Early VR introduction (if system available):

  • 10–15-minute VR sessions for distraction and relaxation

  • Short guided movement or breathing modules ScienceDirect+1

Post-Discharge (First 6–12 Weeks)

• Telehealth NP follow-ups:

  • Check pain scores, function, and wound healing

  • Taper opioids and reinforce multimodal pain plan

  • Screen for sleep, mood, or red-flag symptoms

• Progressive VR rehab:

  • Virtual walk-throughs, balance tasks, and core activation

  • Gradual progression based on surgeon/NP clearance

• Chiropractic follow-up (after surgeon clears):

  • Gentle mobilization above/below fusion

  • Soft tissue work for muscle guarding

  • Functional training in daily activities and work tasks Active Health and Wellness Center+2New York City Spine+2

Long-Term Phase (3–12+ Months)

• Focus on:

  • Building strength and stamina

  • Maintaining spinal alignment and posture

  • Reducing the recurrence of back pain

  • Supporting weight management, anti-inflammatory nutrition, and healthy sleep

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Practical Tips for Patients Considering ESR for Spine Surgery

Questions to ask your surgeon or NP:

• “Do you use an Enhanced Recovery (ERAS/ESR) pathway for spine surgery?”

• “How is pain managed without relying only on opioids?”

• “When will I be expected to sit up and walk after surgery?”

• “Will I have access to a nutrition plan, physical therapy, chiropractic care, or VR-based rehab?”

How to prepare your body and mind:

• Stay as active as you safely can before surgery.

• Eat enough protein and whole foods; discuss supplements with your team.

• Ask about stopping smoking or vaping and limiting alcohol.

• Practice breathing exercises and relaxation techniques (these blend well with VR later). MDPI+1

Red flags to report right away after discharge:

• Fever, worsening leg weakness, loss of bowel or bladder control

• Uncontrolled pain despite your plan

• New numbness, swelling, or redness around the incision

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Takeaway: ESR + Integrative Care + VR = Stronger, Safer Recovery

Enhanced Surgical Recovery (ESR/ERAS) for spine surgery is not a single drug or device. It is a coordinated pathway guided by evidence and teamwork.

When done well, ESR for spine surgery:

• Cuts opioid use through multimodal analgesia and non-drug tools

• Shortens hospital stays and may reduce readmissions

• Uses nutrition, early mobilization, and prehabilitation to strengthen the body

• Integrates chiropractic care to improve posture, mobility, and long-term spinal health

• Adds modern technologies like VR to manage pain, boost motivation, and guide safe movement

Dr. Alexander Jimenez’s integrated clinic in El Paso combines ERAS principles, nurse practitioner oversight, chiropractic expertise, and emerging VR tools to offer a practical blueprint for safer, faster, and more complete recovery after spine surgery. PMC+3El Paso, TX Doctor Of Chiropractic+3El Paso, TX Doctor Of Chiropractic+3

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References

1. Bansal, T., et al. (2022). Enhanced recovery after surgery (ERAS) protocol in spine surgery (systematic review). Global Spine literature via PMC. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC9293758/

2. Tong, Y., Fernandez, L., Bendo, J. A., & Spivak, J. M. (2020). Enhanced recovery after surgery trends in adult spine surgery: A systematic review. International Journal of Spine Surgery, 14(4), 623–638. Retrieved from https://www.ijssurgery.com/content/14/4/623

3. Chang, H. K., et al. (2020). Less opioid consumption with enhanced recovery after lumbar fusion. Spine (PMCID: PMC7136122). Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC7136122/

4. Elsarrag, M., et al. (2019). Enhanced recovery after spine surgery: A systematic review. Neurosurgical Focus, 46(4), E3. Retrieved from https://thejns.org/focus/view/journals/neurosurg-focus/46/4/article-pE3.xml

5. Melnyk, M., et al. (2011). Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Canadian Journal of Anesthesia, 58(2), 169–177. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC3202008/

6. AANA. (2024). Enhanced Recovery After Surgery: Clinical practice resources. Retrieved from https://www.aana.com/practice/clinical-practice/clinical-practice-resources/enhanced-recovery-after-surgery/

7. Jain, S. N., et al. (2023). Enhanced recovery after surgery: Exploring the advances in perioperative care. Journal of Clinical Medicine, 12(x), 1–20. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC10654132/

8. Martínez-Ortega, A. J., et al. (2022). Perioperative nutritional support: A review of current evidence. Nutrients, 14(8), 1601. Retrieved from https://www.mdpi.com/2072-6643/14/8/1601

9. Licina, A., et al. (2020). Pathway for enhanced recovery after spinal surgery: A systematic review and narrative synthesis. medRxiv preprint. Retrieved from https://www.medrxiv.org/content/10.1101/2020.08.16.20175943v1.full-text

10. Norton Healthcare. (2021). Study finds Enhanced Recovery After Surgery (ERAS) protocols help recovery after lumbar fusion. Retrieved from https://nortonhealthcareprovider.com/news/eras-protocol-spine-surgery/

11. HCA Healthcare. (2022). HCA Healthcare’s innovative approach to surgical recovery promotes better outcomes, decreased opioid usage, and faster recovery. Retrieved from https://hcahealthcaretoday.com/2022/12/13/hca-healthcares-innovative-approach-to-surgical-recovery-promotes-better-outcomes-decreased-opioid-usage-and-faster-recovery-times-for-patients/

12. Sauro, K. M., et al. (2024). Enhanced Recovery After Surgery guidelines and hospital length of stay. JAMA Network Open. Retrieved from https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2820097

13. Viderman, D., et al. (2023). Virtual reality for pain management: An umbrella review. Frontiers in Medicine, 10, 1203670. Retrieved from https://www.frontiersin.org/articles/10.3389/fmed.2023.1203670/full

14. Pandrangi, V. C., et al. (2022). Effect of virtual reality on pain management and opioid use among hospitalized patients after head and neck surgery. JAMA Otolaryngology–Head & Neck Surgery, 148(7), 1–8. Retrieved from https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2792875

15. Li, R., et al. (2024). Virtual reality–based training in chronic low back pain. Journal of Medical Internet Research, 26, e45406. Retrieved from https://www.jmir.org/2024/1/e45406/

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18. New York City Spine. (2025). How a chiropractor can aid spinal fusion recovery. Retrieved from https://newyorkcityspine.com/how-a-chiropractor-can-aid-spinal-fusion-recovery/

19. Dallas Accident & Injury Rehab. (2024). Integrating chiropractic care with other treatments. Retrieved from https://dallasaccidentandinjuryrehab.com/integrating-chiropractic-care-with-other-treatments/

20. Dr. Alexander Jimenez, DC, APRN, FNP-BC. (n.d.). El Paso, TX Chiropractor – Injury Medical & Chiropractic Clinic PA. Retrieved from https://dralexjimenez.com/

21. Dr. Alexander Jimenez, DC, APRN, FNP-BC. (2025). Personalized training & rehabilitation (and related integrative posts). Retrieved from https://www.linkedin.com/in/dralexjimenez