Enhanced recovery after neurosurgery: a narrative review comparing clinical outcomes, protocols, and challenges with standard postoperative care.
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BACKGROUND: By integrating evidence-based pre-, intra-, and postoperative therapies, enhanced recovery after surgery (ERAS) protocols have transformed perioperative care in numerous surgical specialties. Although their use in neurosurgery aims to maximize patient recovery, minimize complications, and reduce hospital stays, the evidence remains heterogeneous, and large randomized controlled trials are scarce. OBJECTIVES: This narrative review contrasts the clinical outcomes, advantages, and challenges of ERAS protocols with those of conventional postoperative care in neurosurgery, with a focus on cranial, spinal, pediatric, cancer, and functional procedures. METHODS: A thematic synthesis of peer-reviewed clinical evidence was conducted using PubMed, Scopus, and Google Scholar (2000-2025). Studies comparing ERAS and standard care were reviewed for outcomes including length of stay (LOS), complications, pain control, opioid use, and patient satisfaction. Meta-analyses and systematic reviews were considered for context only, while emphasis was placed on primary clinical data. RESULTS: ERAS protocols were associated with reduced LOS (3.9 → 3.4 days in spine; 13 → 10 days in cranial surgery), lower postoperative complications [fever -7.9%, unplanned intensive care unit admissions -34.1%], and decreased opioid and patient-controlled analgesia use (-12.1% and -60.2%, respectively). Patient recovery and functional independence improved, although 30-day readmissions slightly increased (+1.0%) before declining by 90 days (-0.3%). Implementation remains inconsistent due to resource limitations, challenges with multidisciplinary coordination, and protocol variability across institutions. CONCLUSION: This narrative review demonstrates that ERAS protocols improve recovery, reduce complications, and lower opioid dependence in neurosurgical patients compared with standard care. Despite these advantages, variation in protocol adherence and the limited number of high-quality RCTs restrict universal adoption. Future multicenter trials and standardized frameworks are essential to validate and optimize ERAS integration across neurosurgical practice.