Tranexamic acid-induced focal convulsions after spinal surgery: a rare case report and literature review on side effects of accidental spinal administration of tranexamic acid

Abstract

Convulsions are a neurological illness that has complexity. In clinical treatment, drug-induced convulsions appear from time to time. Drug-induced convulsions often begin as isolated acute seizures but may progress to persistent seizures. In orthopedics, topical administration of tranexamic acid is commonly used in conjunction with intravenous drip to achieve hemostasis during artificial joint replacement surgery. However, side effects induced by tranexamic acid accidental spinal administration should be taken seriously. We report a case of a middle-aged male treated with tranexamic acid locally in combination with intravenous drip for intraoperative hemostasis when undergoing spinal surgery. The patient had involuntary convulsions in both lower limbs after the operation. After symptomatic administration, the symptoms of convulsions gradually resolved. During the follow-up, the convulsions never occurred again. We reviewed the literature on cases with side effects of local tranexamic acid application in spinal surgery and discussed the mechanism of tranexamic acid-induced convulsions. Tranexamic acid is associated with an increased incidence of postoperative seizures. However, many clinicians are unaware that tranexamic acid causes seizures. This rare case summarized the risk factors and clinical features of these seizures. Moreover, it highlights several clinical and preclinical studies that offer mechanistic insights into the potential causes and treatments for tranexamic acid-associated seizures. A clear understanding of tranexamic acid-induced convulsions-related adverse reactions can help the first-line clinical screening of causes and adjustment of drug treatment. This review will aid the medical community by increasing awareness about tranexamic acid-associated seizures and translating scientific findings into therapeutic interventions for patients.

Letter to the Editor. Is spinal surgery appropriate for topical tranexamic acid?

“…Wang and colleagues express concern that topical TXA can enter the intrathecal sac in the setting of dural and arachnoid tears, leading to adverse neurological events. 8 This concern was also raised in our review. However, our meta-analysis of 2045 patients revealed no reported neurological events.…”

“…Such cases have already occurred in clinical applications. 8,9 In such cases, the potential neurotoxic and epileptogenic properties associated with topical TXA could pose a real danger that leads to life-threatening conditions such as seizures or arrhythmias, significantly increasing morbidity and mortality.Moreover, in terms of the efficacy of TXA, many studies in recent years have shown that the use of local TXA…”

Efficacy and safety of tranexamic acid in cervical spine surgery: a systematic review and meta-analysis

“…In our pooled results, there were five cases of thrombosis-related complications in the TXA group and nine in the control group, with no marked difference between the two groups. Luo et al found that use of TXA in spine surgery may induce epilepsy ( 36 ), and the incidence of convulsions increased from 0.5–1.0% to 6.4–7.3% with administration of TXA 50–100 mg/kg in cardiac surgery ( 37 ). No convulsion-related complications were reported in the studies included in our meta-analysis and review.…”

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

“…However, Luo et al reported a case of persistent convulsions in both lower extremities after topical tranexamic acid. After analysis, it is considered that high concentrations of tranexamic acid entering the cerebrospinal fluid led to direct inhibition of γ-aminobutyric acid and glycine receptors in the posterior site of neurons in the dorsal horns of the spinal cord, thereby increasing excitability and leading to the development of persistent convulsions in patient ( 31 ). TLIF is prone to damage to the dura because it is performed next to the dura.…”