Recommendations from the ICM-VTE: Spine

Abstract

The ICM-VTE Spine Delegates* 1 -Is routine screening for DVT required in the preoperative and/or post-operative period for patients undergoing spine procedures?Response/Recommendation: There is no role for routine screening for deep venous thrombosis (DVT) in patients undergoing spine procedures. Doppler ultrasonography surveillance may be considered in high-risk surgical patients including those who are older, with spine injury, personal history of VTE, malignancy, cervical spondylotic myelopathy (CSM), and/or non-ambulatory.Strength of Recommendation: Limited.Delegates vote: Agree 96.43% Disagree 3.57% Abstain 0.00% (Strong Consensus).Rationale: Venous thromboembolism (VTE) is a wellknown complication of major orthopaedic and spine surgeries. The reported incidence of VTE in patients undergoing spine surgery range from 0.29% -31% 1-3 . Moreover, the overall rates of pulmonary (PE) and associated fatality after spinal surgery are 1.38% and 0.34%, respectively [2][3][4][5] .Although contrast venography has been used for diagnosis of DVT, it is not suitable for the routine screening of asymptomatic patients due to potential complications, technical issues, expense, and invasiveness 6 . Similarly, the use of D-dimer, a byproduct of fibrinolysis 7 , as a screening tool lacked sensitivity and specificity in detecting VTE after hip arthroplasty [8][9][10][11][12] . Ultrasonography, on the other hand, has become the primary non-invasive method for investigating suspected DVT of the femoral and popliteal veins 9 . Standard ultrasound showed relatively high sensitivity (> 90%) for proximal or (around 60%) for below-the-knee DVT in a systematic review of diagnostic cohort studies 13 . Duplex ultrasonography (DUS) has also improved precision and efficiency in diagnosing DVT compared to most non-invasive techniques 14 . Furthermore, combined D-dimer and ultrasound screening in patients with acute spinal cord injury have improved the detection of VTE compared to D-dimer screening alone 15 .However, controversy remains regarding the use of routine screening for DVT in the perioperative period for patients undergoing spine procedures. We performed an extensive systematic review of all publications. A total of 26 articles that satisfied all inclusion criteria were selected for data extraction after full review. Information about these studies with respect to year of publication, level of evidence, number of patients, methods of screening, timing of screening, methods of prophylaxis, and incidence of VTE are summarized in Table I. Studies suggest against screening for patients undergoing spine surgery while others recognize that only patients at high risk may benefit. Based on the available literature, the risk factors for an increased risk of VTE in patients undergoing spine surgery may be seen in older patients, long periods of bedrest from paralysis and pain, high D-dimer level, longer duration of operation, intraoperative blood loss and transfusion, previous history of VTE, fracture, comorbid disease burden and tumor surgery...

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“…In recent practice guidelines from the International Consensus Meeting delegates, obesity is acknowledged as one of the patient characteristics associated with increased risk of venous thromboembolism (VTE), along with age, length of hospital stay, operative time, combined approaches, longsegment lumbar fusions, and posterior cervical fusions. 47 As discussed previously in this review, obese patients also typically have longer operative times and length of stays, even with MIS intervention, which increases VTE event risk. 36,48 These compounding risk factors demand vigilance from the care team to ensure all measures are taken to reduce risk of VTE in obese patients after spine surgery.…”

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