Brief intraoperative heparinization and blood loss in anterior lumbar spine surgery

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>The anterior approach to the lumbar spine may be associated with iliac artery thrombosis. Intraoperative heparin can be administered to prevent thrombosis; however, there is a concern that this will increase the procedural blood loss. The aim of this study was to examine whether intraoperative heparin can be administered without increasing blood loss in anterior lumbar spine surgery.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>A prospective study of consecutive anterior approaches for lumbar spine surgery was performed between January 2009 and June 2014 by a single vascular surgeon and a single spine surgeon. Patients underwent an anterior lumbar interbody fusion (ALIF) at L4–5 and/or L5–S1, a total disc replacement (TDR) at L4–5 and/or L5–S1, or a hybrid procedure with a TDR at L4–5 and an ALIF at L5–S1. Heparin was administered intravenously when arterial flow to the lower limbs was interrupted during the procedure. Heparin was usually reversed on removal of the causative retraction.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>The cohort consisted of 188 patients with a mean age of 41.7 years; 96 (51.1%) were male. Eighty-four patients (44.7%) had an ALIF, 57 (30.3%) had a TDR, and 47 (25.0%) had a hybrid operation with a TDR at L4–5 and an ALIF at L5–S1. One hundred thirty-four patients (71.3%) underwent a single-level procedure (26.9% L4–5 and 73.1% L5–S1) and 54 (28.7%) underwent a 2-level procedure (L4–5 and L5–S1). Seventy-two patients (38.3%) received heparinization intraoperatively. Heparin was predominantly administered during hybrid operations (68.1%), 2-level procedures (70.4%), and procedures involving the L4–5 level (80.6%).</jats:p> <jats:p>There were no intraoperative ischemic vascular complications reported in this series. There was 1 postoperative deep venous thrombosis.</jats:p> <jats:p>The overall mean estimated blood loss (EBL) for the heparin group (389.7 ml) was significantly higher than for the nonheparin group (160.5 ml) (p &lt; 0.0001). However, when all variables were analyzed with multiple linear regression, only the prosthesis used and level treated were found to be significant in blood loss (p &lt; 0.05). The highest blood loss occurred in hybrid procedures (448.1 ml), followed by TDR (302.5 ml) and ALIF (99.7 ml). There were statistically significant differences between the EBL during ALIF compared with TDR and hybrid (p &lt; 0.0001), but not between TDR and hybrid. The L4–5 level was associated with significantly higher blood loss (384.9 ml) compared with L5–S1 (111.4 ml) (p &lt; 0.0001).</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>During an anterior exposure for lumbar spine surgery, the administration of heparin does not significantly increase blood loss. The prosthesis used and level treated were found to significantly increase blood loss, with TDR and the L4–5 level having greater blood loss compared with ALIF and L5–S1, respectively. Heparin can be administered safely to help prevent thrombotic intraoperative vascular complications without increasing blood loss.</jats:p></jats:sec>

The Incidence of Venous Thromboembolism in Patients Undergoing Anterior Lumbar Interbody Fusion: A Proposed Thromboprophylactic Regime

“…In their study of 188 patients, they used heparin in 38.3% of patients and had 1 patient with a DVT (0.5%). 19 Overall, they found a small statistically significant increase in the amount of blood loss with those receiving heparin. Our study did not look at the estimated blood loss for each patient; however, increased blood loss does not seem to be a major issue with this regime.…”

Who bleeds during elective anterior lumbar surgery?

“…We have opted to use intra-operative heparinization to prevent thrombo-embolic arterial complications when the iliac vessels were temporarily occluded by the necessary retraction. Preliminary findings regarding the use of intra-operative heparin suggested it had no significant effect, but rather the increase in the observed BL was due to the use of the TDR [8] . We wished to further investigate whether TDR was associated with higher BL compared with ALIF.…”

“…In addition to the level, prosthesis and number of target discs, factors suggested to effect blood loss include age [6] , increasing body mass index (BMI) [7] , intraoperative heparinization [8] and continuation of low-dose aspirin (LD-ASA) [9] . There is concern that elderly patients with an increased BMI have a higher propensity to bleed during anterior exposure.…”

Sagittal plane rotation center of lower lumbar spine during a dynamic weight-lifting activity

“…In contemporary surgical treatment of severe degenerative disc diseases, such as spondylolisthesis and disc herniation, fusion and total disc replacement are similarly used to treat different segments (Freeman and Davenport, 2006; Herkowitz, 2006; McAfee et al, 2005; Rohan et al, 2009; Sim et al, 2015). However, patient follow-up studies reported different clinical outcomes when fusion or total disc replacement was used to treat disc diseases at L4-L5 or L5-S1 segments (Dewing et al, 2008; Okoro and Sell, 2010; Siepe et al, 2007; Sinigaglia et al, 2009).…”