Chronic Antiplatelet Use Associated With Increased Blood Loss in Lumbar Spinal Surgery Despite Adherence to Protocols

Abstract

There are conflicting reports regarding postoperative bleeding risks associated with discontinuation of antiplatelet therapy at least 7 days preoperatively. Most of the studies in the spine literature are based on surveys or anecdotal evidence. The majority of surgeons discontinue therapy 7 days preoperatively, but this varies widely from 5 to 21 days. The purpose of this retrospective study was to assess whether chronic antiplatelet use is associated with increased intraoperative blood loss, need for transfusion, and perioperative complications. Of 454 patients who underwent elective lumbar spinal surgery, 85 were on antiplatelet therapy and 369 were not. All patients stopped antiplatelet therapy at least 7 days preoperatively with approval from their cardiologist or primary care provider. Multiple regression analysis was performed and corrected for age, sex, antiplatelet therapy, number of levels decompressed/fused/instrumented, preoperative hematocrit, and postoperative hematocrit. Results showed that preoperative antiplatelet therapy, despite at least 7 days of discontinuation, is a statistically significant predictor (P=.04) of increased intraoperative blood loss. Blood transfusion was not associated with antiplatelet use but was associated with the number of levels fused, age, and low preoperative hematocrit (all P<.01). There were no recorded complications in either group. The authors conclude that antiplatelet therapy is associated with an increased risk of intraoperative blood loss in spine patients despite discontinuation at least 7 days preoperatively, but the clinical significance of this is unclear given the lack of association with blood transfusions and perioperative complications. [Orthopedics. 2016; 39(4):e695-e700.].

Red Blood Cell Transfusion Need for Elective Primary Posterior Lumbar Fusion in A High-Volume Center for Spine Surgery

“…The greater use of medications interfering with coagulation or platelet function in aged people with comorbidities has been hypothesized as an additional explanation [ 24 , 25 ]. Indeed, our data confirmed past research that suggested such treatments significantly increased the risk of bleeding, either intraoperatively and/or from postoperative blood drainages, in patients undergoing lumbar fusion, despite discontinuation of therapy at least 1 week preoperatively [ 26 , 27 , 28 ].…”

Anticoagulation and Spine Surgery

“…McCunniff et al 28 performed a retrospective analysis in patients undergoing elective lumbar surgery, excluding known hypercoagulable states (eg, malignancy) or coagulopathies (eg, on warfarin). All patients stopped antiplatelet agents 7 days prior to surgery.…”

“…Additionally, clopidogrel had 444.39 ± 239.42 versus 447.83 ± 312.06 cm 3 per level of fusion blood loss and 447.88 ±249.97 versus 512.77 ± 332.66 cm 3 per level of instrumentation blood loss ( P < .01). 28…”

“…It may be reasonable to maintain patients on 81 mg ASA if extensive cardiac history (ie, cardiac stents that are drug eluding) as there are data suggesting continuing this drug can lead to fewer cardiac complications and these benefits could potentially far outweigh the risks of a surgical bleed major complication. 28 performed a retrospective analysis in patients undergoing elective lumbar surgery, excluding known hypercoagulable states (eg, malignancy) or coagulopathies (eg, on warfarin). All patients stopped antiplatelet agents 7 days prior to surgery.…”

“…Global Spine Journal 10(1S) 3 per level of instrumentation blood loss (P < .01). 28 Akhavan-Sigari et al 29 published a prospective cohort of 100 patients undergoing spinal surgery without discontinuation of aspirin or clopidogrel due to medical contraindication for antiplatelet discontinuation. Sixty-three patients were on both clopidogrel and ASA and 37 on ASA only.…”