Management of Anticoagulation/Antiplatelet Medication and Venous Thromboembolism Prophylaxis in Elective Spine Surgery: Concise Clinical Recommendations Based on a Modified Delphi Process

Abstract

Study Design. Delphi method. Objective. To gain consensus on the following questions:(1) When should anticoagulation/antiplatelet (AC/AP) medication be stopped before elective spine surgery?; (2) When should AC/AP medication be restarted after elective spine surgery?;(3) When, how, and in whom should venous thromboembolism (VTE) chemoprophylaxis be started after elective spinal surgery?Summary of Background Data. VTE can lead to significant morbidity after adult spine surgery, yet postoperative VTE prophylaxis practices vary considerably. The management of preoperative AC/AP medication is similarly heterogeneous. Materials and Methods. Delphi method of consensus development consisting of three rounds (January 26, 2021, to June 21, 2021.Results. Twenty-one spine surgeons were invited, and 20 surgeons completed all rounds of questioning. Consensus ( > 70%

Anticoagulation in Elective Spine Surgery: A Narrative Review of Reported Guidelines and Current Literature

“…It should be worth noting that as of 2021, NASS has issued a call to update their clinical practice guidelines; however, recent literature surveying a series of German spine surgeons, and those within the United States, has come to the agreement that even low-dose aspirin should be held 7 days before surgery. 6,7 It is worth noting not only did this German survey report a large percentage of surgeons who deemed aspirin to be a perioperative risk factor, but several additional studies note a large practice variation in aspirin cessation supporting the need for further guidelines. 3,7 In 2014, the American College of Cardiology and American Heart Association (ACC/AHA) issued its Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.…”

Anticoagulation in Elective Spine Surgery: A Narrative Review of Reported Guidelines and Current Literature

“…3,28 The interpractice variation regarding warfarin management in spine surgery has been largely unexplored; however, it is worth noting the previously mentioned survey study of 20 US spine surgeons did come to an agreement regarding a 5-day period of cessation for warfarin; however, they failed to mention any INR goals. 6 Of the extremely limited current research on warfarin management in spine surgery patients, one of the most cited studies was conducted by Young et al 29 In this study, 263 patients undergoing lumbar fusion and/or decompression for degenerative spine pathology were retrospectively investigated to determine the role of warfarin on operative blood loss, transfusions, and postoperative epidural hematomas. This study excluded patients on any additional anticoagulants and objectively measured operative blood loss via cell saver.…”

“…35 Although the previously addressed Delphi study of 20 US spine surgeons came to a consensus of holding DOACs 2 days before spine surgery, both of these studies fail to make any evidence-based claims using evidence within the literature. 6 The closest set of regulatory strategies comes from ASRA, which generalized their recommendations to start and stop DOACs surrounding spine interventional procedures based solely on pharmacokinetics. 4 General recommendations were made to halt the use of DOACs approximately 4 to 5 drug half-lives before intervention (ie, pausing dabigatran 4 days prior, rivaroxaban 3 days prior, and apixaban 3 days before spine pain interventional procedures), while restarting agents approximately 24 hours after the procedure.…”