Spine Surgery Recovery ESR: Enhancing Patient Care

Spine Surgery Recovery: ESR, Chiropractic Care, and Nurse Practitioners

 

Enhanced Surgical Recovery (ESR) programs are changing how patients experience spine surgery. When done well, these pathways can cut opioid use, shorten hospital stays, and lower complication and readmission risk—without sacrificing pain control or safety. They work even better when combined with integrative chiropractic care, nurse practitioner (NP) leadership, and new tools such as virtual reality (VR).

Below is an easy-to-read, search-engine-optimized overview of:

• The most effective ESR/ERAS components for spine surgery

• How integrative chiropractic care and NPs fit into these pathways

• How VR can improve strength, participation, and recovery after surgery

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What Is Enhanced Surgical Recovery (ESR) in Spine Surgery?

Different hospitals use different names—Enhanced Recovery After Surgery (ERAS) or Enhanced Surgical Recovery (ESR)—but the idea is the same:
A standardized, evidence-based, team protocol that covers care before, during, and after surgery to reduce stress on the body and speed recovery. ait-journal.com+1

Key goals include:

• Lower opioid use

• Shorter length of stay (LOS)

• Fewer complications

• No increase (and sometimes a decrease) in readmissions

Large meta-analyses of ERAS across many surgical types show shorter hospital stays and fewer complications when protocols are followed. JAMA Network

In spine surgery, ERAS/ESR pathways for procedures like lumbar microdiscectomy, lumbar fusion, cervical surgery, and scoliosis have shown: SpringerLink+1

• Less postoperative opioid use

• Shorter hospital stays

• Similar or lower complication and readmission rates

Core ESR Elements for Spine Surgery

Most ESR spine programs share a common set of components:

• Preoperative counseling and education

• Nutritional and anemia optimization

• Multimodal, opioid-sparing pain management

• Minimally invasive techniques, when possible

• Early oral intake and fluid optimization

• Early mobilization and structured physical therapy ait-journal.com+1

Many spine centers adapt these elements into spine-specific protocols that also include DVT prophylaxis, careful blood-sparing strategies, and specialized rehab. SpringerLink+1

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The Most Effective ESR Components for Spine Surgery

Multimodal, Opioid-Sparing Pain Management

One of the strongest and most consistent findings is that multimodal, opioid-sparing analgesia is central to ESR success.

Instead of relying on opioids alone, ESR protocols combine:

• Acetaminophen (scheduled)

• NSAIDs or COX-2 inhibitors, when safe

• Gabapentinoids (like pregabalin) for nerve-related pain

• Local anesthetic infiltration at the incision

• Regional or neuraxial techniques (when appropriate)

• Non-drug methods like ice, breathing, relaxation, and VR-based distraction SpringerLink+1

In a lumbar microdiscectomy ERAS study, patients on an enhanced recovery pathway had: SpringerLink

• Significantly lower opioid use

• Reduced length of stay

• No increase in pain scores, complications, or 30-day readmissions

At the University of Pennsylvania, an ERAS protocol for elective spine and peripheral nerve surgery showed that: EurekAlert!

• Only 38.6% of ERAS patients needed pain medication one month after surgery vs 70.5% of controls

• At six months, 23.6% of ERAS patients vs 51.9% of controls still needed pain medication

• Patient-controlled analgesia (PCA) use dropped from 61.6% to 1.4%

• Hospital stay decreased (3.4 vs 3.9 days)

These results confirm that smart pain plans can cut opioid exposure without worsening pain, a key goal in the current opioid crisis.

Helpful ESR pain-management practices

• Start non-opioid medications before surgery (“pre-emptive” analgesia)

• Use scheduled, not just “as needed,” non-opioid meds

• Reserve opioids for breakthrough pain only

• Add non-pharmacologic tools: ice, TENS, breathing, mindfulness, and VR-based distraction

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Strong Preoperative Education and Expectation Setting

Education is not “extra”—it is core ESR medicine.

Programs that prioritize pre-op counseling see better adherence, fewer surprises, and greater patient satisfaction. EurekAlert!+1

Effective pre-op education usually covers:

• What will happen before, during, and after surgery

• Expected pain levels and realistic recovery timelines

• How and why early movement is important

• How multimodal pain control works (and why opioids are limited)

• Bowel care, sleep, and nutrition guidance

• Warning signs that require urgent contact (to avoid late or unsafe readmissions)

Bullet-point handouts, nurse or NP-led pre-op classes, and digital modules make this easier. ERAS studies show that such structured education is part of why these pathways lower opioid use and shorten LOS. EurekAlert!+1

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Nutrition and Anemia Optimization

Spine surgery places a high metabolic and healing demand on the body. Malnutrition and untreated anemia increase: PMC+2DukeSpace+2

• Wound complications

• Infection risk

• Need for transfusions

• Longer hospital stays

Research in spine surgery shows:

• Low albumin (< 3.5 g/dL) is an independent risk factor for major complications and longer LOS. DukeSpace+1

• Poor nutritional status is associated with higher infection and readmission rates following complex spinal procedures. PMC

• Anemia and low hemoglobin increase transfusion risk and may worsen outcomes. The Journal of Neurosurgery+1

ESR nutrition and anemia steps often include:

• Screening albumin, prealbumin, total protein, and hemoglobin

• Correcting iron deficiency and B12/folate when needed

• Using oral or enteral supplements (protein, amino acids, micronutrients)

• Encouraging carbohydrate loading and minimizing fasting before surgery

• Avoiding unnecessary bowel prep that worsens dehydration or nutrition ait-journal.com+1

Integrated clinics like Dr. Alex Jimenez’s in El Paso often tie this into functional medicine—balancing inflammation, blood sugar, and gut health before surgery to support better post-op healing. El Paso, TX Doctor Of Chiropractic

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Early Mobilization and Function-Focused Rehab

“Bedrest” after spine surgery is largely an outdated concept.

ERAS/ESR protocols promote safe, early mobilization, often starting on the day of surgery or on post-op day 1, unless there are specific restrictions. SpringerLink+1

Benefits of early mobilization:

• Lower risk of blood clots and pneumonia

• Better bowel function

• Less muscle wasting and stiffness

• Shorter hospital stays

• No increase in complications or readmissions when safely supervised SpringerLink+1

Typical early-mobility milestones:

• Sitting up at the edge of the bed

• Standing and walking short distances with help

• Gradually increasing steps and standing time each day

• Beginning gentle exercises (ankle pumps, core activation, breathing drills)

Enhanced recovery microdiscectomy protocols show that with early mobilization plus multimodal analgesia, patients can go home sooner, with lower opioid use and no rise in 30-day readmissions. SpringerLink

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Standardized Pathways and Readmission Rates

One concern is always: “If we push discharge earlier, will readmissions go up?”

Data from spine ERAS pathways suggest that readmission rates stay the same or even decrease when ESR is implemented correctly: SpringerLink+1

• In the microdiscectomy ERAS study, 30-day readmissions and reoperations were not higher in the ERAS group. SpringerLink

• Other ERAS spine series show no increase in 30–90-day readmissions, even with shorter LOS and lower opioid use. IJSSurgery+1

Why? Because the protocol:

• Identifies risks before surgery

• Standardizes responses to pain, nausea, and hypotension

• Provides clear post-discharge instructions and follow-up

• Encourages early contact with the team (NPs, therapists) to handle issues before they become readmission-level problems

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How Integrative Chiropractic Care Fits Into ESR Spine Pathways

Chiropractors are not replacing surgeons in ESR—they’re complements, especially in clinics where they work hand-in-hand with NPs, physical therapists, and surgeons.

Articles on post-surgical rehab emphasize that chiropractic care can complement exercise rehab by improving alignment, joint mobility, and nervous system regulation, and by encouraging proper posture and releasing muscle tension that builds up after surgery. Active Health and Wellness Center+1

Prehabilitation (“Pre-hab”) Before Surgery

Before surgery, integrative chiropractors can help patients enter the OR in better physical condition, which supports ESR goals.

Pre-hab chiropractic care may include:

• Spinal and postural assessment to identify dysfunctional movement patterns

• Gentle spinal and extremity adjustments (when appropriate) to improve mobility and reduce pain

• Soft tissue work for tight hip flexors, glutes, hamstrings, and paraspinal muscles

• Corrective exercises for core stability, hip strength, and balance

• Education on:

  • Safe bending, lifting, and twisting (“BLT”) rules

  • How to get in/out of bed or a car after surgery

  • What to expect during early walking and rehab

This aligns with ESR’s focus on early mobilization and function; the stronger and more coordinated a patient is before surgery, the faster they usually regain function afterward. Active Health and Wellness Center+1

Postoperative Chiropractic Care (Within Surgical Restrictions)

After spine surgery—especially fusion—chiropractic care must be carefully coordinated with the surgeon and ESR team. High-velocity adjustments are usually avoided over fused segments until healing is solid and cleared.

But there is still a lot chiropractors can safely do:

• Gentle joint mobilization above and below the fused area (when appropriate)

• Soft tissue techniques for muscles around, but not on, the incision

• Posture retraining and gait work to avoid compensatory strain

• Ergonomic coaching (sitting, standing, sleeping positions, workstation setup)

• Progressive, spine-safe strengthening of core and hip muscles

Post-fusion guidance from spine centers notes that chiropractic care can help reduce scar-related stiffness, improve mobility, and support a safe return to activity when integrated with the surgeon’s plan. New York City Spine+1

Non-Opioid Pain Management and Nervous System Regulation

Chiropractic care can support ESR’s opioid-sparing goals by offering:

• Manual therapies that decrease muscle spasm and pain

• Joint mobilization that reduces mechanical stress on healing tissue

• Techniques aimed at calming sympathetic overactivation, which can amplify pain perception

These approaches fit well with multimodal strategies that rely on non-opioid medications plus non-drug techniques to keep pain tolerable and function high. SpringerLink+1

Dr. Alexander Jimenez’s Clinical Perspective

In his El Paso practice, Dr. Alex Jimenez, DC, APRN, FNP-BC, integrates: El Paso, TX Doctor Of Chiropractic

• Chiropractic care

• Nurse practitioner–led medical management

• Functional medicine, nutrition, and sports-specific rehab

Clinical patterns he commonly sees in post-spine surgery patients:

• Those who engaged in pre-hab and understood ESR principles often need lower opioid doses and regain mobility faster.

• Patients benefit when chiropractic, PT, and NP follow-ups are coordinated with telemedicine check-ins, aligning with ESR pathway timing.

• Focus on posture, soft-tissue balance, and core strength reduces secondary pain generators (hips, sacroiliac joints, mid-back), which can otherwise trigger more opioid use or unnecessary imaging.

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The Role of Nurse Practitioners (NPs) in ESR Spine Programs

Nurse practitioners are the connective tissue of an ESR program. They ensure protocols are followed and individualized.

Before Surgery

NPs can:

• Conduct comprehensive pre-op assessments

• Screen for:

  • Malnutrition (albumin, weight loss, appetite)

  • Anemia and other lab abnormalities

  • Uncontrolled diabetes, hypertension, or sleep apnea

• Coordinate referrals for:

  • Nutrition support

  • Smoking cessation

  • Cardiology or pulmonary clearance

• Lead ERAS education visits or classes, walking patients and families through:

  • The ESR timeline

  • What to expect with pain and mobility

  • How opioid-sparing plans will work

This directly supports the nutrition, anemia, education, and risk-reduction components of ESR. PMC+2SAGE Journals+2

During Hospitalization

In the perioperative and early post-op period, NPs often:

• Adjust multimodal analgesia (non-opioids first, opioids as rescue)

• Monitor for side effects (sedation, constipation, delirium)

• Reinforce early mobilization goals with PT/OT and nursing

• Troubleshoot barriers to discharge (uncontrolled pain, nausea, psychosocial issues)

By doing this, they help maintain pathway fidelity, which is closely tied to shorter LOS and stable readmission rates. JAMA Network+1

After Discharge: Keeping Readmissions Low

Post-discharge, NPs are key to preventing avoidable readmissions:

• Telemedicine or in-clinic check-ins within the first week or two

• Reviewing:

  • Pain medication use and side effects

  • Wound status

  • Mobility and home safety

• Coordinating with chiropractors, PT, and primary care

• Escalating care when there are red flags (fever, new weakness, severe new pain, wound changes)

In an integrative setting like Dr. Jimenez’s, NPs also bridge functional medicine, telehealth, and rehabilitation, ensuring that ESR pathways extend beyond hospital walls. El Paso, TX Doctor Of Chiropractic+1

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Virtual Reality (VR) and New Technologies in ESR Spine Recovery

Virtual reality is rapidly moving from “cool gadget” to evidence-based tool in perioperative care.

How VR Helps ESR Goals

VR systems use a headset to place patients in immersive, interactive environments. In spine surgery recovery, VR can:

• Distract the brain from pain signals

• Reduce anxiety and catastrophizing

• Provide guided physical therapy and movement games

• Track movement quality and effort

Several studies and reviews show that VR:

• Reduces postoperative pain scores compared to usual care in a variety of surgeries (including craniotomy and spine). Nature+1

• Can lower opioid use after surgery—for example, VR gaming reduced pain and opioid consumption after head and neck surgery compared with smartphone-based gaming. JAMA Network

• Decreases pain and anxiety in patients who had surgery under spinal anesthesia. PubMed+1

• Is generally feasible and acceptable as a self-administered postsurgical pain tool. ScienceDirect+1

In low back pain and lumbar rehabilitation:

• VR-based rehab systems use sensors and game-like environments to encourage core activation, controlled bending, and endurance, with better engagement than standard home exercises. Frontiers+1

Spine-focused AR/VR reviews highlight that combining wearable sensors, game mechanics, and virtual rehab environments can allow clinicians to monitor and coach patients remotely—exactly what ERAS/ESR aims to achieve. Advances+1

Practical Ways VR Can Be Built into ESR for Spine

Before surgery

• VR educational modules: patients “walk through” the hospital stay virtually

• Relaxation and breathing programs to lower anxiety

In the hospital

• Short VR sessions used as part of multimodal analgesia

• Guided, gamified movements (reaching, gentle trunk activation, balance challenges) that match surgeon restrictions

After discharge

• Home-based VR rehab that:

  • Prompts daily graded exercises

  • Tracks adherence and performance

  • Provides instant feedback and encouragement

• Telemedicine visits where NPs or chiropractors review VR data and tweak the program

In a clinic like Dr. Jimenez’s, VR can be combined with:

• Chiropractic-guided movement patterns

• NP oversight of safety and pain medication

• Functional medicine strategies (sleep, nutrition, and stress management) to create a truly integrated digital ESR pathway. El Paso, TX Doctor Of Chiropractic+1

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Putting It All Together: What Patients and Teams Can Do

For Patients Planning Spine Surgery

Consider asking your team:

• “Do you use an Enhanced Surgical Recovery or ERAS pathway for spine surgery?”

• “How will my pain be controlled without relying solely on opioids?”

• “Will I get pre-op education and written instructions?”

• “Is my nutrition and anemia being checked and optimized before surgery?”

• “Who will coordinate my recovery—is there an NP or care coordinator I can contact?”

• “Can I work with a chiropractor or physical therapist for pre-hab and post-op rehab?”

• “Are there any VR or app-based rehab options I can use at home?”

For Clinics and Hospitals

To strengthen ESR spine programs:

• Build a multidisciplinary team (surgeon, anesthesiologist, NP, PT, chiropractor, nutritionist, and IT/digital team).

• Standardize:

  • Pre-op education and checklists

  • Nutrition/anemia screening and interventions

  • Multimodal analgesia order sets

  • Early mobilization protocols

  • Discharge and follow-up templates

• Add integrative chiropractic involvement for pre-hab and post-op rehab when appropriate.

• Pilot VR-based pain and rehab modules, track opioid use, LOS, and readmissions.

• Use NP-led follow-up (including telemedicine) to catch problems early and reinforce pathway steps.

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Conclusion

Enhanced Surgical Recovery (ESR) and ERAS protocols for spine surgery are not just buzzwords—they are proven frameworks that:

• Reduce opioid use

• Shorten hospital stays

• Maintain or lower complications and readmission rates EurekAlert!+2SpringerLink+2

When you add:

• Integrative chiropractic care for pre-hab, posture, mobility, and non-opioid pain relief

• Nurse practitioners to coordinate care, education, and medication management

• Virtual reality and digital rehab tools to boost participation and reduce pain

…you create a powerful, patient-centered pathway that supports faster, safer, and more sustainable recovery after spine surgery.

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References

1. Adogwa, O., et al. (2014). Preoperative serum albumin level as a predictor of postoperative complications after spine surgery. [PDF]. DukeSpace. DukeSpace

2. Active Health Center. (2025). Rehabilitation after surgery: Integrating chiropractic care into recovery. https://activehealthcenter.com/rehabilitation-after-surgery-integrating-chiropractic-care-into-recovery/ Active Health and Wellness Center

3. Buztepe, M. H., et al. (2025). Effectiveness of gamified virtual reality in patients with lumbar disc herniation. Healthcare. https://pmc.ncbi.nlm.nih.gov/articles/PMC12486732/ Frontiers

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6. Keny, C., et al. (2025). Immersive virtual reality for postoperative pain among older surgical adults: A scoping review. AOSopen. https://journals.lww.com/aosopen/fulltext/2025/06000/immersive_virtual_reality_for_postoperative_pain.21.aspx Lippincott Williams & Wilkins Journals

7. Lier, E. J., et al. (2024). Virtual reality for postsurgical pain management: A feasibility and effectiveness study. Journal of PeriAnesthesia Nursing. https://www.sciencedirect.com/science/article/pii/S003960602400391X ScienceDirect

8. Lu, Y., et al. (2023). Enhanced recovery after microdiscectomy: Reductions in opioid use, length of stay and cost. BMC Surgery, 23, 230. https://bmcsurg.biomedcentral.com/articles/10.1186/s12893-023-02130-3 SpringerLink

9. Luca, A., et al. (2023). Augmented and virtual reality in spine surgery: Applications, benefits, and challenges. EFORT Open Reviews. https://pmc.ncbi.nlm.nih.gov/articles/PMC10405158/ PMC

10. Naftalovich, R., et al. (2022). Enhanced Recovery After Surgery (eRAS) protocols for spine surgery: Review of the literature. Advances in Therapy. https://www.ait-journal.com/Enhanced-Recovery-After-Surgery-ERAS-protocols-for-spine-surgery-review-of-literature%2C141307%2C0%2C2.html ait-journal.com

11. National Spine Health Foundation. (n.d.). Enhanced Recovery After Surgery (ERAS). https://spinehealth.org/article/enhanced-recovery-after-surgery/ National Spine Health Foundation

12. Payne, O., et al. (2022). Virtual reality and its use in postoperative pain following surgery: A meta-analysis. Scientific Reports. https://www.nature.com/articles/s41598-022-17183-2 Nature

13. Penn Medicine. (2020, August 6). Penn’s “Enhanced Recovery” program significantly reduces post-op opioid use. EurekAlert. https://www.eurekalert.org/news-releases/856638 EurekAlert!

14. Sauro, K. M., et al. (2024). Enhanced Recovery After Surgery guidelines and hospital outcomes: A meta-analysis of randomized clinical trials. JAMA Network Open. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2820097 JAMA Network

15. Sharif, S., et al. (2025). Perioperative nutritional supplementation in spine surgery patients: A scoping review. Global Spine Journal. https://pmc.ncbi.nlm.nih.gov/articles/PMC12022738/ ScienceDirect

16. Slomski, A. (2022). Virtual reality lessens postoperative pain. JAMA. https://jamanetwork.com/journals/jama/fullarticle/2795282 JAMA Network

17. Tong, Y., et al. (2020). Enhanced Recovery After Surgery trends in adult spine surgery: A systematic review. International Journal of Spine Surgery, 14(4), 623–640. https://www.ijssurgery.com/content/14/4/623 IJSSurgery

18. Ukogu, C. O., et al. (2018). Preoperative nutritional status as a risk factor for major complications following posterior cervical fusion. Global Spine Journal. https://journals.sagepub.com/doi/10.1177/2192568218760540 SAGE Journals

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20. Dr. Alex Jimenez, DC, APRN, FNP-BC. (n.d.). El Paso, TX chiropractor & family practice nurse practitioner. https://dralexjimenez.com/ El Paso, TX Doctor Of Chiropractic