What are the current ESPEN and ASPEN peri‑operative nutrition recommendations for adult patients undergoing elective spinal instrumentation, fusion, or decompression?

ESPEN/ASPEN Perioperative Nutrition Guidelines for Spinal Surgery

All adult patients undergoing elective spinal instrumentation, fusion, or decompression should undergo preoperative nutritional screening using serum albumin or prealbumin, and those identified as malnourished (albumin <3.5 g/dL or prealbumin <20 mg/dL) require immediate nutritional optimization with early postoperative feeding initiated within hours of surgery. 1

Preoperative Nutritional Assessment

Mandatory Screening Parameters

• Measure serum albumin and prealbumin preoperatively in all spine surgery patients, as these are the only validated serological markers with Grade B evidence for predicting adverse outcomes 1
• Albumin <3.5 g/dL is associated with increased surgical site infections, wound complications, nonunions, and hospital readmissions 1
• Prealbumin <20 mg/dL independently predicts deep surgical site infections (OR 3.28) and should trigger immediate intervention 1
• Screen all patients on hospital admission using NRS-2002 (Nutritional Risk Score) which includes BMI <20.5 kg/m², weight loss >5% within 3 months, diminished food intake, and disease severity 1

Risk Stratification

• High-risk patients (NRS ≥5, weight loss >10%, BMI <18.5, albumin <30 g/L) should have surgery postponed 7-14 days for nutritional optimization 1
• Patients with severe nutritional risk require preoperative intervention even if surgery must be delayed 1
• No specific evidence exists for non-serological nutritional assessments in spine surgery (Grade I - insufficient evidence) 1

Preoperative Nutritional Optimization

Timing and Intervention Strategy

• Clear fluids are permitted until 2 hours before anesthesia; solid foods until 6 hours before anesthesia 1
• Administer preoperative carbohydrate loading the night before and 2 hours before surgery in most patients undergoing major surgery 1
• For malnourished patients, initiate nutritional support 5-7 days preoperatively when feasible 1
• Comprehensive nutritional optimization (screening, supplementation, adequate protein/calories) reduces postoperative complications, shortens hospital stay, and lowers mortality more effectively than targeting isolated electrolyte thresholds 2

Supplementation Protocol

• Provide oral nutritional supplements (ONS) or enteral nutrition to patients with documented malnutrition 1
• Consider immunonutrition formulas containing arginine, omega-3 fatty acids, and nucleotides for major spine surgery, though this is primarily validated for cancer surgery and severe trauma 1
• Protein and caloric intake optimization yields stronger outcome benefits than pursuing specific electrolyte targets 2

Postoperative Nutritional Management

Early Feeding Protocol (Critical)

• Initiate oral intake including clear liquids within hours after spine surgery - this is a Grade A recommendation with strong consensus 1
• Early feeding (within 24 hours) does not impair anastomotic healing and significantly shortens hospital length of stay 1
• Normal food or enteral nutrition should begin on postoperative day 1-2 in most patients 1

Indications for Nutritional Support Therapy

Initiate nutritional support therapy immediately without delay if: 1

• Patient anticipated to be unable to eat for >5 days perioperatively
• Patient cannot maintain >50% of recommended intake for >7 days
• Patient develops postoperative complications impairing oral intake

Route Selection Algorithm

1. First-line: Oral nutritional supplements for inadequate oral intake 1
2. Second-line: Enteral nutrition via feeding tube if oral route fails or contraindicated 1
3. Third-line: Parenteral nutrition only if enteral route contraindicated or patient cannot meet <50% caloric requirements for >7 days via oral/enteral routes 1

Contraindications to enteral nutrition: 1

• Intestinal obstruction or ileus
• Severe shock
• Intestinal ischemia
• High output fistula
• Severe intestinal hemorrhage

Tube Feeding Specifications

• Start tube feeding at low flow rate (10-20 mL/h) due to limited intestinal tolerance 1
• Expect 5-7 days to reach target intake - this is not harmful 1
• Use standard whole protein formula in most patients 1
• Place feeding tube within 24 hours after surgery for patients requiring tube feeding 1

Metabolic Considerations Specific to Spine Surgery

• The postoperative phase involves heightened metabolic demand, oxidative stress, systemic inflammation, and accelerated protein catabolism requiring focused nutritional support 2
• Target energy requirements: 25-30 kcal/kg ideal body weight 1
• Target protein requirements: 1.5 g/kg ideal body weight 1, 3
• Maintain blood glucose control with sliding scale insulin or continuous infusions as needed 3

Monitoring and Follow-up

• Reassess nutritional status regularly during hospital stay and continue support after discharge if needed 1
• Document food intake systematically and provide nutritional counseling as needed 1
• Long-term nutritional monitoring is recommended for all patients who received perioperative nutritional support 1

Critical Pitfalls to Avoid

• Do not wait for severe malnutrition to develop - start therapy early when nutritional risk becomes apparent 1
• Do not rely on isolated electrolyte values for clinical decision-making; integrate overall nutritional status, volume status, and clinical condition 2
• Do not delay feeding postoperatively - traditional prolonged fasting increases complications and length of stay 1
• Insufficient evidence exists to support multimodal nutrition management protocols specifically for preventing surgical site infections in spine surgery (Grade I) 1

Evidence Quality Note

The Congress of Neurological Surgeons provides the only spine surgery-specific nutritional guidelines (2021), offering Grade B evidence for albumin/prealbumin screening but Grade I (insufficient) evidence for preoperative nutritional interventions 1. Therefore, general ESPEN surgical guidelines (2021) should be applied to fill these gaps, as they provide comprehensive Grade A recommendations for perioperative feeding protocols applicable to all major surgery including spine procedures 1.