Enhanced Recovery Pathways Associated With Shorter Hospital Stays After Pediatric Scoliosis Surgery, Review Finds

A sweeping synthesis of clinical evidence has found that multidisciplinary enhanced recovery pathways used in pediatric scoliosis correction surgery are associated with shorter hospital stays, though the strength of that signal is tempered by serious methodological concerns. The systematic review and meta-analysis, published in Frontiers in Pediatrics, also found that evidence supporting reduced operative duration is statistically fragile, and that no significant associations were detected for postoperative complications or 30-day readmissions.

The research team, led by investigators at the Affiliated Provincial Hospital of Shandong First Medical University in Jinan, China, systematically searched six major medical databases from inception through March 31, 2026. They identified twenty studies that compared structured multidisciplinary perioperative pathways against usual care in pediatric scoliosis populations. These pathways typically combine preoperative patient education, standardized anesthesia protocols, multimodal analgesia, early mobilization, and accelerated discharge planning into coordinated bundles of care delivered by surgeons, anesthesiologists, nurses, and physiotherapists working together.

The most robust finding concerned length of hospital stay. Fifteen studies comprising 1,909 patients contributed to the pooled estimate, revealing a weighted mean difference of negative 1.75 days, with a 95 percent confidence interval of negative 2.18 to negative 1.32 days. This reduction remained statistically significant even under a conservative sensitivity analysis using restricted maximum likelihood estimation with Knapp-Hartung adjustment, which yielded a weighted mean difference of negative 1.80 days. However, the heterogeneity across studies was exceptionally high, with an I-squared value of 97.3 percent, and Egger’s regression test detected significant funnel-plot asymmetry consistent with possible small-study effects or publication bias.

By contrast, the evidence for reduced operative duration proved far less reliable. The primary DerSimonian-Laird random-effects analysis of nine studies with 1,113 patients initially suggested a significant reduction of 26.05 minutes in operative time. Yet when the researchers applied their prespecified conservative sensitivity analysis designed for outcomes with extreme heterogeneity, the association became statistically non-significant, with a confidence interval spanning from negative 59.23 to positive 14.32 minutes. The I-squared value for this outcome reached 96.6 percent, reflecting profound between-study variance that undermines confidence in any single pooled estimate.

For postoperative complications, twelve studies encompassing 1,874 patients revealed no statistically significant association between pathway implementation and complication rates, with an odds ratio of 0.75 and a confidence interval crossing unity. Heterogeneity for this outcome was moderate at 34.5 percent. Similarly, seven studies comprising 1,386 patients demonstrated no significant association with 30-day unplanned readmissions, yielding an odds ratio of 1.21 with negligible heterogeneity.

The methodological profile of the included studies presents substantial limitations. Seventeen of the twenty studies utilized retrospective cohort designs, while only three were prospective. No randomized controlled trials were identified. The researchers applied the Risk of Bias in Non-Randomized Studies of Interventions tool and found that confounding, selection of participants, and measurement of outcomes were the domains most frequently contributing to moderate or high risk judgments. Six studies were classified as low risk, seven as moderate, and seven as high risk.

Using the GRADE framework, the certainty of evidence was rated as very low for all four outcomes. Downgrading was driven principally by the predominance of retrospective observational designs, which introduce selection bias and residual confounding by indication. Extreme unexplained inconsistency for the continuous outcomes and documented publication bias for length of hospital stay further eroded confidence. The review was also not prospectively registered in PROSPERO, though the authors state that the methodological framework was established a priori before study selection.

The researchers emphasize that the observed reduction in hospital stay should be interpreted as an average association across heterogeneous settings rather than a uniform effect applicable to every clinical program. Many of the included pathways deliberately accelerated discharge criteria and incorporated structured discharge planning as active intervention components. The reduction in length of stay therefore reflects a combination of clinical recovery and administrative discharge protocols rather than necessarily indicating accelerated physiological healing. This distinction is critical for clinicians interpreting the results.

The included populations were predominantly adolescents with idiopathic scoliosis undergoing posterior spinal fusion, though one study enrolled patients with early-onset scoliosis. Most studies were conducted in the United States, with additional contributions from China, Canada, France, Australia, and Denmark. The interventions varied in composition and intensity, spanning enhanced recovery after surgery protocols, rapid recovery programs, accelerated discharge pathways, and perioperative surgical home models. Because these were implemented as bundled multidisciplinary packages, the available comparative studies do not permit attribution of observed associations to any single discipline or pathway element.

The authors conclude that future research should prioritize prospective, multicenter designs capable of disambiguating specific intervention components, alongside consistent reporting of standardized care elements, long-term functional outcomes, and health-economic evaluations. Given the very low certainty of evidence, pooled estimates should be viewed as indicators of perioperative efficiency rather than precise benchmarks, with implementation tailored to local resources and monitored for unforeseen consequences.

Subject of Research: Systematic review of enhanced recovery pathways in pediatric scoliosis correction surgery

Article Title: Association of multidisciplinary perioperative enhanced recovery pathways with perioperative outcomes in pediatric scoliosis correction surgery: a systematic review and meta-analysis

Article References: Ma, P., & Lai, J. (2026). Association of multidisciplinary perioperative enhanced recovery pathways with perioperative outcomes in pediatric scoliosis correction surgery: a systematic review and meta-analysis. Frontiers in Pediatrics, 14, Article 1968212. https://doi.org/10.3389/fped.2026.1968212

Image Credits: AI Generated

DOI: 10.3389/fped.2026.1968212

Keywords: pediatric scoliosis, enhanced recovery pathways, meta-analysis, hospital length of stay, posterior spinal fusion, perioperative outcomes, GRADE certainty, publication bias, retrospective cohort studies, multimodal analgesia, early mobilization, discharge planning