A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis

Abstract

Introduction:The objective of this study is to develop evidence-based guidelines that recommend effective, safe and cost-effective thromboprophylaxis strategies in patients with spinal cord injury (SCI).Methods:A systematic review of the literature was conducted to address key questions relating to thromboprophylaxis in SCI. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest.”Results:Based on conclusions from the systematic review and expert panel opinion, the following recommendations were developed: (1) “We suggest that anticoagulant thromboprophylaxis be offered routinely to reduce the risk of thromboembolic events in the acute period after SCI;” (2) “We suggest that anticoagulant thromboprophylaxis, consisting of either subcutaneous low-molecular-weight heparin or fixed, low-dose unfractionated heparin (UFH) be offered to reduce the risk of thromboembolic events in the acute period after SCI. Given the potential for increased bleeding events with the use of adjusted-dose UFH, we suggest against this option;” (3) “We suggest commencing anticoagulant thromboprophylaxis within the first 72 hours after injury, if possible, in order to minimize the risk of venous thromboembolic complications during the period of acute hospitalization.”Conclusions:These guidelines should be implemented into clinical practice in patients with SCI to promote standardization of care, decrease heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.

Perioperative Anticoagulation Management in Spine Surgery: Initial Findings From the AO Spine Anticoagulation Global Survey

“…[31][32][33] The global adherence to thromboprophylactic principles in SCI patients are likely a result of the various well-studied and widely established/distributed recommendations and protocols for this presentation. 24,[34][35][36][37] Despite the large amount of data published on specific thromboprophylactic therapies for various spine surgery indications, well-established guidelines and algorithms have had difficulty gaining widespread acceptance and adherence. 2,[15][16][17][18][20][21][22][23][38][39][40][41][42][43] Although spine surgery VTE prophylaxis recommendations from North American Spine Society and American College of Chest Physicians have been Abbreviations: NA, not applicable, no response given; Hx, history; ASA, aspirin.…”

Time is spine: a review of translational advances in spinal cord injury

“…Comprehensive systematic reviews were conducted to synthesize the body of evidence. 11,19,49,89,177 A multidisciplinary guideline development group then used the results of these reviews, in conjunction with their clinical expertise, to develop clinical practice guideline recommendations 39,42,43,45,50 in accordance with the methodology proposed by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) working group. [61][62][63] A summary of the guideline recommendations is provided in Table 1.…”

“…We suggest not offering a 48-hr infusion of high-dose MPSS to adult patients w/ acute SCI. No included studies Weak Type & timing of anticoagulant thromboprophylaxis 42 We suggest that anticoagulant thromboprophylaxis be offered routinely to reduce the risk of thromboembolic events in the acute period after SCI.…”

Thromboprophylaxis in Patients with Acute Spinal Cord Injury: A Narrative Review

“…The ACCP, 24 the AOSpine, 36 the North American Spine Society, 37 and the National Institute for Health and Clinical Excellence 38 guidelines recommend that patients with SCI should receive thromboprophylaxis. However, the AOSpine guideline is the only guideline that provides any recommendation, albeit weak, to initiate thromboprophylaxis in the first 72 hours after SCI.…”

“…However, the AOSpine guideline is the only guideline that provides any recommendation, albeit weak, to initiate thromboprophylaxis in the first 72 hours after SCI. 36 The optimal timing of starting LMWH after acute SCI is unknown. The decision to start thromboprophylaxis should be based on having a net clinical benefit of balancing the risks of therapy (major bleeding or progression of bleeding) and the benefits (preventing symptomatic VTE and fatal PE).…”