Oral Is as Effective as Intravenous Tranexamic Acid at Reducing Blood Loss in Thoracolumbar Spinal Fusions

Abstract

Study Design. A prospective randomized trial at a university affiliated tertiary medical center between February 2017 and March 2020.Objective. The aim of this study was to compare perioperative blood loss in patients undergoing elective posterior thoracolumbar fusion who were treated with IV versus PO TXA. Summary of Background Data. The use of antifibrinolytic agents such as tranexamic acid (TXA) to decrease operative blood loss and allogenic blood transfusions is well documented in the literature. Although evidence supports the use of intravenous (IV) and topical formulations of TXA in spine surgery, the use of oral (PO) TXA has not been studied. Methods. A total of 261 patients undergoing thoracolumbar fusion were randomized to receive 1.95 g of PO TXA 2 hours preoperatively or 2 g IV TXA (1 g before incision and 1 g before wound closure) intraoperatively. The sample was further stratified into three categories based on number of levels fused (oneto two-level fusions, three to five, and more than five). The primary outcome was the reduction of hemoglobin. Secondary outcomes included calculated blood loss, drain output, postoperative transfusion, complications, and length of hospital stay. Equivalence analysis was performed with a two one-sided test.Results. One hundred thirty-seven patients received IV and 124 received PO TXA. The average age was 62 AE 13 years (mean AE SD), including 141 females and 120 males. Revision cases comprised of 67% of the total sample. Patient demographic factors were similar between groups except for weight, BMI, and preoperative platelet count. The mean reduction of hemoglobin was similar between IV and PO groups (3.56 vs. 3.28 g/dL, respectively; P ¼ 0.002, equivalence). IV TXA group had a higher transfusion rate compared to PO TXA group (22 patients [19%] vs. 12 patients [10%]; P ¼ 0.03). In addition, IV group had longer length of stay (LOS) than PO group (4.4 vs. 3.7 days; P ¼ 0.02). Conclusion. Patients treated with IV and PO TXA experienced the same perioperative blood loss after small and large spinal fusions. In subgroup analysis, the intermediate (three to five level) spinal fusions had less blood loss with PO TXA than IV TXA. Given its lower cost, PO TXA represents a superior alternative to IV TXA in patients undergoing elective posterior thoracolumbar fusion and may improve health care cost-efficiency in the studied population.

Comparative efficacy and safety of different hemostatic medications during spinal surgery: A network meta-analysis

“…After duplicate removal (n = 129), a total of 503 records were screened on title and abstract, and 451 were excluded. Out of 52 studies, 34 RCTs [3,10,19–50] were selected, and 34 of them met the inclusion criteria to be included in this network meta-analysis. The research selection and flow chart of literature retrieval are reflected in Figure 1.…”

The efficacy and safety of tranexamic acid in transforaminal lumbar interbody fusion: a systematic review and meta-analysis

“…The full text of 13 articles were read and 8 articles were eliminated. These included one meeting ( 15 ), two registered studies without results ( 16 , 17 ), one study performed on posterior lumbar interbody fusion ( 18 ), two studies that were unable to extract data from patients with TLIF ( 19 , 20 ), one study that did not use tranexamic acid ( 21 ), and one study that compared oral tranexamic acid with intravenous use ( 22 ). Finally, five trials with three RCT studies and two retrospective studies, totaling 984 patients, were included in our study ( 10 , 11 , 12 , 23 , 24 ).…”

Update on Applications and Limitations of Perioperative Tranexamic Acid

“…126 TXA for Spine Surgery The use of TXA in spine surgery has shown a larger benefit. [127][128][129][130] A recent summary of outcomes found that TXA reduced intraoperative, postoperative, and total blood loss, with variable reduction in RBC transfusion and no clear signal for prothrombotic complications. 15 Another meta-analysis of topical TXA in spine surgery also found reduced blood loss with favorable effects on postoperative hemoglobin and no increase in deep vein thrombosis and pulmonary embolism.…”