Table 3. Summary of the findings for clinical care

1.Preadmission information, education and counseling

Preadmission information, education and counseling may have a positive impact on subjective perioperative patient experience. Studies do not show any evidence of harm;

2.Risk assessment, preoperative optimization, including lifestyle factor modification

2.1 Preoperative risk stratification

Preoperative risk assessment tools tests can be used to identify patients at risk of complications; Prognostic accuracy and predictive ability of a risk measurement tool should be considered;

2.2 Preoperative assessment and optimization

Preoperative assessment and optimization of modifiable comorbidities should be performed on all patients. Although the degree to which preoperative optimization affects healthcare outcomes is unclear, it is intuitive that any modifiable co-morbidities should be optimized using the preoperative process

2.3 Alcohol use

Increased alcohol consumption has been shown to be associated with increased perioperative morbidity. For alcohol abusers, 1 month of abstinence before surgery is beneficial;

2.4 Tobacco use

For tobacco users, 1 month of abstinence before surgery decreases the risk of infection and wound healing;

3.Prehabilitation

Multimodal prehabilitation may improve patient reported outcome

measures and allow for earlier hospital discharge in spinal surgery;

 4.1. Nutritional Assessment and Screening

Risk assessment and screening of nutritional status should be performed in patients undergoing spinal surgery;

 4.2 Immuno-nutrition

There have been no benefits of immuno-nutrition in spinal surgery;

 5. Management of anaemia

Clinically guided use of intravenous or oral iron, vitamin B12, folic acid or erythropoietin for patients suffering from anaemia and/or low iron stores should be implemented in patients undergoing moderate and major spinal surgery;

 6. Perioperative blood conservation strategies

Tranexamic acid used at the higher dosage is effective in decreasing intraoperative blood loss. Cell saver techniques should be used in adolescents undergoing major corrective surgery. Cell-saver techniques may be beneficial when major blood loss is anticipated in adults.

 7.Preoperative fasting and carbohydrate loading

In patients without delayed gastric emptying standard societal fasting implementations can be made;

 8. Pre-emptive analgesia

Multimodal pre-emptive analgesia utilizing individual gabapentinoids and non-steroidal anti-inflammatory agents improves pain scores and functional measures in the immediate post-operative period;

 9. Prevention of postoperative nausea and vomiting

Risk assessment of patients according to the anaesthetic and procedural factors is recommended. Step- wise non-pharmacological and pharmacological PONV prophylaxis according to the guidelines is recommended. Use of anaesthetic techniques which minimize risk of PONV in high-risk patients should be considered;

 10.1 Surgical site preparation

Chlorhexidine gluconate (CHG) is more effective at reducing the pre-operative viable bacterial load than povidone. Alcohol based agents are superior to aqueous solutions;

 10.2 Antimicrobial prophylaxis

Routine prophylaxis with cefazolin within 1 h prior to skin incision is recommended. Patients with MRSA should be treated prophylactically with vancomycin initiated 1 h prior to skin incision;

 11.Local anaesthetic infiltration

Local anaesthetic wound infiltration in major spinal surgery has some immediate benefit on postoperative pain scores;

 12. Standard Anaesthetic protocol

Total intravenous anaesthesia utilizing propofol demonstrates improved post-operative recovery markers after surgery. Higher total doses of intra-operative remifentanil are likely to result in the phenomena of acute opioid tolerance and hyperalgesia;

 13. Surgical access- open and minimally invasive spinal surgery

Minimally invasive surgical approaches improve pain scores, decrease opioid consumption and decrease length of stay, when used within the appropriate clinical context;

 14. Maintain normothermia

Measures to maintain normothermia and avoid hyperthermia should be implemented in spinal surgical patients;

 15. Intraoperative fluid and electrolyte therapy

Goal-directed intraoperative fluid management should be implemented using contextually appropriate indicators and measurements of cardiac output in patients undergoing moderate/major surgery of the spine;

 16. Peri-operative analgesia

Simple analgesics such as acetaminophen and NSAIDs are safe and efficacious, particularly in combination. Ketamine in both intraoperative and post-operative form reduces pain scores. Consideration should be given to pre-emptive gabapentinoid administration; Intravenous lignocaine has been shown to have immediate and long-term benefits for analgesia and function;

 17. Thromboprophylaxis

Patients undergoing spinal surgery should have mechanical thromboprophylaxis by well-fitting compression stockings and/or intermittent pneumatic compression until discharge. There is a role for careful use of chemoprophylaxis;

 18. Urinary drainage

Urinary catheters should be removed as soon as feasible;

 19. Post-operative nutrition and fluid management

Patients should be encouraged to transition as early as tolerated to oral intake. Postoperative fluid replacement should be carefully guided by patient intake and ongoing fluid losses;

 20. Post-operative glycemic control

Maintain conventional blood glucose target in the postoperative period in patients undergoing spinal surgery;

 21. Early mobilization

Patients should be mobilized actively on the day of surgery as permitted by the clinical condition; Patients should be encouraged to mobilize actively from the morning of the first postoperative day;

 22.Audit

Audit of compliance and care outcomes should be performed regularly in ERSS programs;