Enhanced Recovery After Spine Surgery: The Role of NPs, Chiropractors, and VR Technology

Enhanced Surgical Recovery (ESR) for spine surgery is changing how patients heal. When it is done well—with strong pre-op education, nutrition support, multimodal pain control, and early movement—it can cut opioid use, shorten hospital stays, and reduce readmissions. Integrative chiropractic care and nurse practitioners (NPs) fit naturally into this model, and newer tools such as virtual reality (VR) can further accelerate recovery.

Below is a clear overview of how ESR/ERAS works for spine surgery, how chiropractic and NPs strengthen the pathway, and how VR can be used to improve strength, function, and long-term outcomes.

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

Enhanced Surgical Recovery (ESR), also known as Enhanced Recovery After Surgery (ERAS), is a structured, evidence-based care pathway that follows the patient from pre-op clinic to home recovery. It is designed to:

Reduce the body’s stress response to surgery
Protect organ function
Get patients walking, eating, and healing faster
Lower complications, opioid use, and readmission rates

Classic ERAS principles include:

Preoperative counseling and education
Nutrition optimization and minimal fasting
Carbohydrate drinks up to 2 hours before anesthesia
Standardized multimodal analgesia (non-opioid + opioid only as needed)
Early mobilization after surgery PMC+1

Large reviews show that ERAS programs across surgical specialties reduce complications, length of stay (LOS), and readmissions by combining these elements into a single, well-coordinated pathway.PMC+1

Why ESR Matters Specifically for Spine Surgery

Spine surgery—especially lumbar fusion and deformity correction—carries high risks of:

Severe post-operative pain
Prolonged bed rest and deconditioning
High opioid requirements
Longer hospital stays and readmissions

Studies of ERAS-style protocols for lumbar fusion report:

>50% reduction in in-hospital opioid use
Earlier ambulation and catheter removal
Better 3-month pain scores compared with pre-ERAS care.Norton Healthcare Provider

At specialized spine centers using ESR protocols, patients show:

Less than 2% requiring IV narcotics
Average LOS shortened by about one day
Readmission rates under 5%, compared with a ~7% national average hcadam.com

This is where integrative chiropractic care, nurse practitioners, and VR technology can layer on additional benefits.

Core ESR Components That Cut Opioids, Shorten Stays, and Reduce Readmissions

Strong Preoperative Education and Expectation Setting

Patients do better when they know what is coming. ERAS pathways emphasize pre-op counseling so patients understand:

What their pain is likely to feel like
How multimodal pain control will work
When they are expected to get out of bed and walk
What to do at home to stay on track

The AANA (American Association of Nurse Anesthesiology) highlights patient/family education as a core ERAS element and notes that patient-centered, multidisciplinary pathways improve satisfaction and shorten hospital stay.AANA

Helpful pre-op education topics for spine surgery ESR:

How multimodal pain management reduces opioids
Why early walking is critical for preventing clots and stiffness
How nutrition and hydration affect pain, energy, and wound healing
What “red flag” symptoms require an urgent call or ER visit

When patients are treated like partners, they are more likely to follow the pathway, which lowers complications and readmissions.

Nutrition Optimization and Carbohydrate Loading

Poor nutrition is a known risk factor for post-surgical complications, longer stays, and delayed healing. ERAS protocols call for:

Screening for malnutrition and anemia
Treating deficits before surgery whenever possible
Avoiding long fasting periods
Providing carbohydrate drinks up to 2 hours before anesthesia to maintain energy and reduce insulin resistance PMC

In spine ESR programs:

Patients often receive a pre-surgery carb drink to avoid prolonged fasting and support early mobilization and healing.hcadam.com

Pre-op nutrition steps that help spine ESR succeed:

Nutrition assessment (weight loss, albumin levels, appetite)
Iron and B-vitamin support for anemia, when present
Guidance on protein intake and hydration
Clear instructions on when to stop solid food vs clear fluids

Optimizing nutrition reduces wound problems, infections, and readmissions, and supports faster rehabilitation.

Multimodal, Opioid-Sparing Analgesia

One of the most powerful ESR tools is multimodal analgesia—using several non-opioid and regional techniques to control pain, so fewer opioids are needed. Key elements include:

Scheduled acetaminophen and NSAIDs (if safe)
Gabapentinoids for neuropathic pain in select patients
Regional/local anesthetic blocks at incision sites
Short-acting opioids only as “rescue,” not as the mainstay of therapy PMC+1

A major review of ERAS pathways shows that multimodal regimens:

Reduce opioid requirements
Lower opioid-related side effects
Contribute to shorter hospital stays and fewer complicationsPMC+1

In the Reston Hospital ESR spine program, patients receive a pre-op oral multimodal regimen (muscle relaxer, anti-inflammatory, long-acting pain medication, Tylenol, and a nerve pain medication as appropriate). After ESR implementation:

<2% of patients required IV narcotics
Pain was better controlled by pre-emptive and scheduled non-opioid medications hcadam.com

Multimodal pain strategy staples for spine ESR:

Pre-emptive oral non-opioid medications
Local anesthetic at the surgical site (e.g., TAP block or wound infusion)
Strict protocols for when opioids are started, tapered, and stopped
Patient education about non-drug pain tools (positioning, ice, breathing, VR, etc.)

Minimally Invasive Techniques and Early Tube Removal

ESR protocols encourage:

Shorter incisions when possible
Minimally invasive approaches
Limiting drains and catheters
Removing tubes early to support mobilization and reduce infection risk PMC+1

These steps:

Decrease surgical stress
Reduce pain
Support earlier walking and oral intake
Shorten LOS and lower infection-related readmissions

Early Mobilization and Structured Physical Therapy

Getting spine patients moving quickly—usually the day of surgery—is a pillar of ESR.AANA+1

For example:

The Norton Healthcare ERAS lumbar fusion study found that ERAS patients ambulated earlier, had catheters removed sooner, and used fewer opioids. Norton Healthcare Provider
Reston’s ESR program reports that over 96% of spine patients walk within hours of surgery, contributing to shorter stays and better overall outcomes.hcadam.com

Early mobilization elements often include:

Sitting at the edge of the bed on surgery day
Walking with assistance in the hall
Early use of walkers and braces as ordered
Basic leg pumps and ankle circles in bed

This is the perfect place for integrative chiropractic care and later-phase VR-based rehab to build on the foundation once the surgeon clears more active movement.

How Integrative Chiropractic Care Strengthens ESR for Spine Surgery

Chiropractic care is not applied directly to fresh surgical levels, but it plays a powerful supportive role before and after spine surgery when integrated correctly.

Post-surgical rehabilitation articles highlight that combining musculoskeletal treatments (exercise rehab + manual therapy) can improve posture, joint mobility, and nervous system regulation, speeding recovery. Active Health and Wellness Center+1

Pre-Hab: Preparing the Spine and Body Before Surgery

Before surgery, an integrative chiropractor can:

Assess posture and movement patterns
Improve core stability and hip mobility
Address compensatory areas above and below the planned surgical site
Teach safe movement patterns (log-rolling, proper bending, basic neutral spine positioning)

Pre-hab goals:

Go into surgery with better muscle strength and flexibility
Reduce chronic joint restrictions that could slow rehab
Teach “spine sparing” techniques, and patients will need post-op

As a dual-credentialed chiropractor and nurse practitioner, Dr. Alexander Jimenez, DC, APRN, FNP-BC, uses pre-hab strategies in personal injury and spine cases to prepare patients for procedures and create a smoother post-operative recovery, blending functional movement work with medical risk assessment. El Paso, TX Doctor Of Chiropractic

Post-Op: Gentle, Targeted Chiropractic Support After Surgeon Clearance

Once the fusion or decompression is stable and the surgeon gives clearance (often 3–6 months after fusion), chiropractic care can help by focusing on:

Regions above and below the fusion to reduce overload
Gentle, low-force adjustments away from the surgical segment
Soft tissue techniques to reduce muscle guarding and scar-related stiffness
Posture retraining and core strengthening in coordination with physical therapy Active Health and Wellness Center+1

Benefits may include:

Less pain in non-surgical segments
Better range of motion
Reduced risk of compensatory problems like sacroiliac dysfunction or upper-back strain
Improved walking, sitting, and lifting tolerance

Chiropractic as a Non-Opioid Pain and Function Tool

Within ESR, chiropractic care becomes one more non-opioid pain strategy, alongside:

Physical therapy and exercise
Mind–body tools (breathing, relaxation, VR)
Nutrition and sleep optimization

This integrative approach aligns with ERAS principles of multimodal, opioid-sparing pain control and early mobilization.PMC+1

The Central Role of Nurse Practitioners in Spine ESR

Nurse practitioners are natural “connectors” in ESR pathways. ERAS guidance specifically highlights the value of nurse-led coordination and ERAS coordinators for education, data tracking, and pathway adherence.AANA

Pre-Op Optimization and Education

NPs can:

Perform detailed pre-surgical assessments
Screen for malnutrition, anemia, diabetes, smoking, and other modifiable risks
Arrange lab work, nutrition referrals, and pre-hab consults
Explain ESR expectations and answer patient questions

In many hospitals, NPs act as ERAS coordinators, rounding on patients, checking compliance (ambulation, diet, pain scores, narcotic use), and closing gaps in the pathway.AANA

In-Hospital and Early Post-Op Management

During hospitalization and early follow-up, spine ESR NPs typically:

Titrate multimodal analgesia and monitor for side effects
Guard against unnecessary opioid escalation
Encourage early mobilization and oral intake
Reinforce spine precautions and home instructions

They also identify early red flags (fever, new weakness, uncontrolled pain, wound problems) and coordinate fast responses, helping prevent readmissions.

Long-Term Rehab, Telemedicine, and Integration with Chiropractic

On the outpatient side, NPs can:

Provide telemedicine check-ins to monitor pain, function, and medication use
Gradually taper opioids, while adding non-drug strategies (heat, stretching, VR sessions, meditation, topical medicines)
Coordinate referrals to integrative chiropractic care and physical therapy
Communicate with the surgeon, physical therapist, chiropractor, and primary care provider to keep everyone aligned

Clinicians like Dr. Jimenez, who practice as both DC and APRN, are uniquely positioned to blend ESR principles with chiropractic post-op rehab and telehealth follow-ups to support safe, sustained recovery after spine surgery. El Paso, TX Doctor Of Chiropractic

How Virtual Reality (VR) Can Be Used to Boost Strength, Reduce Pain, and Improve Recovery

Virtual reality is emerging as a powerful, non-drug adjunct for surgical recovery. VR programs use immersive visual and audio environments to:

Distract from pain
Reduce anxiety
Guide graded movement in a fun, game-like way

Systematic reviews of VR in orthopedic and back-pain rehab show that immersive VR can:

Lower pain and anxiety scores
Reduce opioid use in some post-operative settings
Improve adherence to rehabilitation exercises
Enhance balance, mobility, and muscle strength in orthopedic patients PMC+2Semantic Scholar+2

VR-assisted rehab for postsurgical patients has been shown to improve function, mobility, balance, and range of motion while reducing pain compared with conventional therapy alone.Lippincott Williams & Wilkins Journals+2MDPI+2

Where VR Fits in a Spine ESR Pathway

Pre-Op Phase: Education and Anxiety Control

VR can:

Walk patients through a virtual “tour” of what to expect on surgery day
Offer guided relaxation or breathing programs to lower pre-op anxiety
Practice basic movements (using avatars) that will be required after surgery, like getting out of bed safely

This supports the ERAS emphasis on patient education and psychological readiness.AANA+1

Immediate Post-Op: Pain and Anxiety Reduction

In the early post-op period (while still in the hospital), short VR sessions can:

Provide immersive distraction (e.g., calming ocean scenes or interactive games)
Decrease perceived pain intensity
Lower anxiety and help patients tolerate early movement and breathing exercises

Reviews of VR in postoperative orthopedic populations report meaningful reductions in acute pain and anxiety, with some studies showing reduced opioid use compared with standard care alone. Semantic Scholar+2MDPI+2

Early Rehab: Guided Strengthening and Balance Training

Once the surgeon and ESR team allow more active rehab, VR-based physical therapy can:

Deliver graded core and leg exercises in a game-like setting
Use motion sensors to track posture and movement quality
Train balance and gait with real-time feedback
Adjust difficulty based on patient performance

Systematic reviews of VR in orthopedic rehab and chronic low back pain show improvements in pain, balance, and strength, often equal or superior to conventional rehab, with excellent patient engagement and adherence.PMC+2advrehab.org+2

Long-Term Recovery: Treating Fear of Movement and Building Confidence

For some spine patients, fear of movement and chronic pain linger long after surgery. VR programs that combine:

Graded exposure
Relaxation
Cognitive-behavioral strategies

have been shown to reduce fear of movement and improve function in patients with low back pain.PMC+1

This is especially powerful when coordinated with:

NP-led medication tapering
Chiropractic and physical therapy
Sleep, nutrition, and stress-management support

Best Practices for Using VR Safely and Effectively After Spine Surgery

To fit VR into an ESR spine pathway:

Screening and Safety

Screen for motion sickness, seizures, or severe vertigo
Start with short sessions (5–10 minutes) and progress gradually
Respect the surgeon’s movement restrictions (e.g., no trunk rotation early on)

Program Design

Use calm, low-intensity visual scenes early, then progress to active games
Focus early on breathwork, relaxation, and gentle reaching or seated movements
Gradually introduce core and leg work as bracing and healing allow
Tailor programs for each patient’s surgery type (fusion vs decompression)

Team Integration

NPs can prescribe and monitor VR use, tracking pain scores and opioid needs
Physical therapists and chiropractors can suggest specific movements and limits
Data from VR sessions (time active, range of motion, balance scores) can feed into the record to show progress

Putting It All Together: Example ESR-Style Spine Surgery Pathway with Chiropractic, NPs, and VR

Below is a simplified example of how an integrated spine ESR pathway might look:

4–6 Weeks Before Surgery

NP Visit
- Full risk assessment (nutrition, anemia, diabetes, smoking)
- Labs and medical optimization
- ESR education (multimodal pain, early walking, VR options)
Chiropractic Pre-Hab (If appropriate)
- Posture, gait, and movement screening
- Core and hip strengthening within pain tolerance
- Instruction in safe transfers and spine-neutral positions
VR (Optional)
- Anxiety-reduction and expectations education
- Gentle avatar-based movement practice

Day of Surgery and Hospital Stay

In OR / PACU
- Pre-emptive multimodal analgesia + local/regional blocks
- Defined opioid-sparing protocol
Post-Op Day 0–1
- Early sitting and walking, guided by PT and nursing
- Oral multimodal medications (acetaminophen, NSAID, nerve pain medicines as appropriate)
- Short VR sessions for distraction and relaxation (if stable)
NP and ESR Team
- Daily rounding to review:
  - Pain scores and opioid use
  - Ambulation status
  - Diet progression
  - Foley and drain removal
- Adjust medications and address barriers to movement

Weeks 1–6 After Discharge

Telemedicine NP Visits
- Monitor pain, function, and wound status
- Taper opioids strategically
- Reinforce walking and home exercises
Home or Outpatient PT
- Progressive strengthening, posture, and gait training
VR at Home or Clinic
- Guided low-impact virtual exercises within surgeon-approved limits
- Pain distraction sessions when needed
- Balance training and simple game-based tasks to keep patients active

3–6 Months and Beyond

Surgeon Clears Active Manual Care
- An integrative chiropractor focuses on:
  - Adjacent-level mechanics
  - Scar tissue mobility (soft tissue work)
  - Pelvis and hip alignment to protect the fusion
- Continued strengthening and movement retraining
NP, Chiropractor, PT, and Patient
- Collaborate on long-term goals: return to work, sports, or higher-level activity
- VR may shift to more advanced motor control and fitness-oriented programs

This type of integrated ESR pathway—supported by chiropractors, NPs, and VR—can lock in the benefits observed in spine ERAS research: lower opioid use, shorter stays, fewer readmissions, and stronger, more confident patients.Norton Healthcare Provider+2hcadam.com+2

References

American Association of Nurse Anesthesiology. (n.d.). Enhanced recovery after surgery. Retrieved from https://www.aana.com/practice/clinical-practice/clinical-practice-resources/enhanced-recovery-after-surgery/ AANA

Active Health Center. (2025, July 31). Rehabilitation after surgery: Integrating chiropractic care into recovery. Retrieved from https://activehealthcenter.com/rehabilitation-after-surgery-integrating-chiropractic-care-into-recovery/ Active Health and Wellness Center

Dr. Alex Jimenez, DC, El Paso, TX chiropractor – Personal injury specialist. (n.d.). Retrieved from https://dralexjimenez.com/ El Paso, TX Doctor of Chiropractic

Liu, H. W., et al. (2025). Virtual reality–assisted rehabilitation for patients… American Journal of Physical Medicine & Rehabilitation. Retrieved from https://journals.lww.com/ajpmr/fulltext/2025/11000/virtual_reality_assisted_rehabilitation_for.2.aspx Lippincott Williams & Wilkins Journals

Melnyk, M., Casey, R. G., Black, P., & Koupparis, A. J. (2011). Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Canadian Urological Association Journal, 5(5), 342–348. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC3202008/ PMC

Norton Healthcare. (2021, July 22). Study finds Enhanced Recovery After Surgery (ERAS) protocols help recovery after lumbar fusion. Retrieved from https://nortonhealthcareprovider.com/news/eras-protocol-spine-surgery/ Norton Healthcare Provider

Reston Hospital Center. (n.d.). Enhanced surgical recovery – Center for Scoliosis and Spinal Deformity. Retrieved from https://www.hcadam.com/api/public/content/f42a4095a6f9451baa991b5a56cad568?v=4786eda4&download=true hcadam.com

Shen, M. R., & Waljee, J. F. (2019). Enhanced recovery after surgery protocols: Can they reduce postoperative opioid use? Annals of Surgery, 270(6), e72. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC7042977/ PMC

Vuong, T., et al. (2024). Virtual reality as a pain control adjunct in orthopedics. Cureus. Retrieved from https://pdfs.semanticscholar.org/b230/d5d86e943e28fd9d5b1921d07ed92b2a9a52.pdf Semantic Scholar

Esteban-Sopeña, J., et al. (2024). Effectiveness of virtual reality on postoperative pain: A systematic review. Life, 14(3), 289. Retrieved from https://www.mdpi.com/2075-1729/14/3/289 MDPI

Jeyaraman, M., et al. (2024). Enhancing orthopedic rehabilitation: The emergence and role of virtual reality. Journal of Clinical Orthopaedics and Trauma. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC11043980/ PMC

Nagpal, A. S., et al. (2022). Virtual reality in the management of chronic low back pain: A scoping review. Pain Practice. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC8915689/ PMC

Garofano, M., et al. (2025). Remote rehabilitation and virtual reality interventions in chronic low back pain. Technologies, 13(5), 186. Retrieved from https://www.mdpi.com/2227-7080/13/5/186 MDPI

New York City Spine. (2025, January 2). How a chiropractor can aid spinal fusion recovery. Retrieved from https://newyorkcityspine.com/how-a-chiropractor-can-aid-spinal-fusion-recovery/ New York City Spine

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, and physical medicine, as well as wellness, sensitive health issues, and functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from various disciplines. Each specialist is governed by their professional scope of practice and the jurisdiction in which they are licensed to practice. We utilize functional health and wellness protocols to treat and support care for musculoskeletal injuries or disorders. Our videos, posts, topics, subjects, and insights cover clinical matters and issues that directly or indirectly support our clinical scope of practice. Our office has made a reasonable effort to provide supportive citations and to identify relevant research studies that support our posts. We provide copies of supporting research studies upon request to regulatory boards and the public.
We understand that we cover matters that require an additional explanation of how they may assist in a particular care plan or treatment protocol. To discuss the subject matter above further, please contact Dr. Alex Jimenez or us at 915-50-0900.
Dr. Alex Jimenez, DC, MSACP, CCST, IFMCP, CIFM, ATN*
Email: coach@elpasofunctionalmedicine.com
Licensed in: Texas & New Mexico*

🔴 Rated Top El Paso Doctor & Specialist by ✔️ RateMD* | Years 2014,2015,2016,2017,2018,2019

Chiropractic Podcast