Timing and risks of chemoprophylaxis after spinal surgery: a single-center experience with 6869 consecutive patients

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Venous thromboembolism (VTE) after spinal surgery is a major cause of morbidity, but chemoprophylactic anticoagulation can prevent it. However, there is variability in the timing and use of chemoprophylactic anticoagulation after spine surgery, particularly given surgeons’ concerns for spinal epidural hematomas. The goal of this study was to provide insight into the safety, efficacy, and timing of anticoagulation therapy after spinal surgery.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors retrospectively examined records from 6869 consecutive spinal surgeries performed in their departments at Northwestern University. Data on patient demographics, surgery, hospital course, timing of chemoprophylaxis, and complications, including deep venous thrombosis (DVT), pulmonary embolism (PE), and spinal epidural hematomas requiring evacuation, were collected. Data from the patients who received chemoprophylaxis (n = 1904) were compared with those of patients who did not (n = 4965). The timing of chemoprophylaxis, the rate of VTEs, and the incidence of spinal epidural hematomas were analyzed.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The chemoprophylaxis group had more risk factors, including greater age (59.70 vs 51.86 years, respectively; p &lt; 0.001), longer surgery (278.59 vs 145.66 minutes, respectively; p &lt; 0.001), higher estimated blood loss (995 vs 448 ml, respectively; p &lt; 0.001), more comorbid diagnoses (2.69 vs 1.89, respectively; p &lt; 0.001), history of VTE (5.8% vs 2.1%, respectively; p &lt; 0.001), and a higher number were undergoing fusion surgery (46.1% vs 24.7%, respectively; p &lt; 0.001). The prevalence of VTE was higher in the chemoprophylaxis group (3.62% vs 2.03%, respectively; p &lt; 0.001). The median time to VTE occurrence was shorter in the nonchemoprophylaxis group (3.6 vs 6.8 days, respectively; p = 0.0003, log-rank test; hazard ratio 0.685 [0.505–0.926]), and the peak prevalence of VTE occurred in the first 3 postoperative days in the nonchemoprophylaxis group. The average time of initiation of chemoprophylaxis was 1.46 days after surgery. The rates of epidural hematoma were 0.20% (n = 4) in the chemoprophylaxis group and 0.18% (n = 9) in the nonchemoprophylaxis group (p = 0.622).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The risks of spinal epidural hematoma among patients who receive chemoprophylaxis and those who do not are low and equivalent. Administering anticoagulation therapy from 1 day before to 3 days after surgery is safe for patients at high risk for VTE.</jats:p></jats:sec>

Does Anticoagulant Thromboprophylaxis Increase Bleeding Complications in Spinal Surgery and Spinal Cord Injury? A Systematic Review and Meta-Analysis

“…Sensitivity analysis revealed no significant difference in the results when randomised trials, studies of surgery on trauma patients and anticoagulant regimen other than LMWH exclusively were excluded. Spinal epidural haematoma: There were five studies 19,[26][27][28][29] reporting 49 SEHs in 14,788 patients undergoing spinal surgery for elective indications and trauma. Two studies reported three patients who were discharged with persistent neurological deficits, a C6 quadriplegia, lower extremity weakness and bladder dysfunction 26,28 .…”

“…Two studies reported three patients who were discharged with persistent neurological deficits, a C6 quadriplegia, lower extremity weakness and bladder dysfunction 26,28 . Three studies reported that the onset of most SEH events was within a week of surgery, ranging from day 1 to day 56 post operatively 19,27,28 . Pooled analysis of the five studies demonstrated that SEH was found in 0.3% of all patients (49 in 14,788), with 0.2% (32 patients) required surgical evacuation and 0.1% (22 patients) with neurological deficits in both intervention and control groups.…”

“…With regard to future research, the optimal time frame of anticoagulant thromboprophylaxis administration, within which it is both safe and effective, needs to be investigated 11,17,21,39 . Currently, recommended time frames 1,44,45 are not supported by robust evidence and often are too vague to be helpful in the clinical setting 19,45,52 .…”

“…However, most spinal surgeons are reluctant to use anticoagulant thromboprophylaxis 2,[10][11][12][13][14][15][16][17] due to a perceived fear of haemorrhagic complications in the spinal patient with potentially disastrous consequences. Whether such fear is warranted is unknown due to the paucity of the evidence 2,15,[18][19][20][21] . Recognizing such gap in the literature, the North American Spine Society (NASS) 2 recommend that a priority for future research be an evaluation of the bleeding risk associated with pharmacologic thromboprophylaxis use in spinal patients.…”

Use of Fondaparinux Following Elective Lumbar Spine Surgery Is Associated With a Reduction in Symptomatic Venous Thromboembolism

“…Current literature on VTE prophylaxis after elective spine surgery is underpowered, 17 heterogeneous, 18 or utilizes nonvalidated surgeon-response metrics. 19 Survey studies by Ploumis et al 20 and Glotzbecker et al 21 criticize the inconsistent application of VTE prophylaxis after high-risk spine procedures, noting that even spinal cord injuries did not clearly delineate common practice.…”