Is There Value in Venous Thromboembolism Chemoprophylaxis After Pediatric Scoliosis Surgery? A 28-Year Single Center Study

Abstract

Background: With a recognized increase in the incidence of venous thromboembolism (VTE) in children, especially in those with complex, chronic conditions, it is important for patient safety and risk management to identify subgroups that would benefit from prophylactic treatment. The aim of our study was to assess whether scoliosis surgery in children was associated with an increased incidence of VTE, including deep venous thrombosis (DVT) and pulmonary embolism, and if chemoprophylaxis is warranted. Methods: We reviewed our institution’s Pediatric Orthopaedic Spine Database (1992-2019) to identify patients who had a symptomatic VTE postoperatively. Results: There were 1471 patients (1035 female, 436 male) with a mean age at surgery of 12.1±3.2 years (range, 1 to 18 y) underwent posterior spinal fusion and instrumentation (2131 procedures). No patients were given pharmacological VTE prophylaxis, and no routine screening for VTE was performed. Two patients had a lower extremity DVT (0.13%) within 6 months following surgery, (range, 55 to 161 d). Neither patient had a subsequent pulmonary embolism. They were 9 and 17 years of age with a diagnosis of neuromuscular scoliosis (1 each postpolio and myelodysplasia). One affected patient had a central venous line inserted perioperatively, a known risk factor for thromboembolism. All DVTs were treated with appropriately dosed anticoagulants. None had a family history of hypercoagulation. Conclusions: The risk of symptomatic VTE is extraordinarily low after pediatric spinal deformity surgery. Mechanical prophylaxis is sufficient in most cases. Further multi-center studies may help identify patient specific risk factors.

Recommendations from the ICM-VTE: Spine

“…Low-risk spine surgeries: While most elective pediatric procedures are considered low VTE risk 70,71 , patients undergoing surgery for congenital scoliosis, syndromic scoliosis/kyphoscoliosis, thoracolumbar fractures, and the ones requiring ICU admission or prolonged immobilization have a relatively increased VTE risk compared to those undergoing surgery for idiopathic scoliosis 72 . Additionally, microdiscectomy, ACDF, and lumbar or cervical decompression (i.e., laminectomy, hemi-laminectomy and laminotomy) have demonstrated a low risk of postoperative VTE, with rates < 0.2% for each procedure 73 .…”

“…The estimated incidence of VTE following spinal fusion in children is 0.21% and risk factors include adolescent children and children with diagnoses of congenital scoliosis, syndromic spinal deformities, kyphoscoliosis, or thoracolumbar fractures 226 . In a 28-year follow up study on pediatric scoliosis surgery, Erkilinc et al, found a lower extremity deep venous thrombosis (DVT) rate of 0.13% in 1,471 patients and zero patients were diagnosed with pulmonary embolism (PE) 227 .…”

Paediatric Spinal Deformity Surgery: Complications and Their Management

“…However, the overall incidence of VTE complications is very low at <1% in these patients [ 65 ]. As the overall incidence of VTE complications is very low, postoperative anticoagulation in paediatric patients undergoing spinal fusion surgery is not indicated [ 66 ]. For patients with a known hypercoagulable condition, assessment by a haematological specialist should be obtained preoperatively to inform need for anticoagulation and balance risks of increased bleeding and haematoma formation.…”

Recommendations from the ICM-VTE: Pediatric

“…Of the 40 patients, two cases of transient thromboses were identified, both of which resolved spontaneously 187 . Additionally, in a study of 1,471 pediatric patients undergoing scoliosis surgery, Erkilinc et al 188 , reported that the incidence of DVT was 0.13%. Therefore, the authors concluded that mechanical prophylaxis was sufficient in this setting.…”

“…Several studies have shown that the presence of a CVC carries the single greatest risk for DVT development in the pediatric population. Furthermore, some studies have esti-mated that 33% to 80% of all pediatric DVT can be attributed to the presence of a CVC 188,[197][198][199][200] .…”