Low-dose aspirin before spinal surgery: results of a survey among neurosurgeons in Germany

Abstract

The main problem faced by the increasing numbers of patients presenting for spinal surgery are receiving concurrent medication with low-dose aspirin, leading to dysfunctional circulating platelets. The contribution of low-dose aspirin to increased peri-operative risk of bleeding and blood loss is a contentious issue with conflicting published results from different surgical groups. Data from neurosurgical spine patients is sparse, but aspirin has been identified as an important risk factor in the development of post-operative hematoma following intracranial surgery. We surveyed the opinions and working practices of the neurosurgical facilities performing spinal operations in Germany regarding patients who present for elective spinal surgery. Identical questionnaires were sent to 210 neurosurgical facilities and proffered five main questions: (1) the adherence of any policy of stopping aspirin pre-operatively, (2) the personal risk assessment for patients with spinal surgery under low-dose aspirin medication, (3) the preferred method of treatment for excessive bleeding in this context, (4) personal knowledge of hemorrhagic complications in this group of patients, and (5) the characteristics of the neurosurgical units concerned. There were 145 (69.1%) responses of which 142 (67.6%) were valid. Of the respondents, 114 (80.3%) had a (written) departmental policy for the discontinuation of pre-operative aspirin treatment, 28 (19.7%) were unaware of such a policy. The mean time suggested for discontinuation of aspirin pre-operatively was 6.9 days (range: 0-21 days), with seven respondents who perform the operations despite the ongoing aspirin medication. Ninety-four respondents (66.2%) considered that patients taking low-dose aspirin were at increased risk for excessive peri-operative hemorrhage or were indetermined (8.6%), and 73 (51.4%) reported having personal experience of such problems. Ninety-two respondents (65.5%) would use special medical therapy, preferably Desmopressin alone or in combination with other blood products or prohemostatic agents (46.1%), if hemorrhagic complications developed intra- or post-operatively. The average number of spinal operations per year in each service was 607.9 (range: 40-1,500). Despite the existence of distinct departmental policies concerning the discontinuation of low-dose aspirin pre-operatively in the majority of neurosurgical facilities performing spinal operations, there is a wide range of the moment of this interruption with an average of 7 days. Two-thirds of the respondents felt that aspirin was a risk factor for hemorrhagic complications associated with spinal procedures, and more than half of the interviewees reported having personal experience of such problems. Finally, various medicamentous methods of counteracting aspirin-induced platelet dysfunction and excessive bleeding in this context are elicited, discussed and evaluated.

Should More Patients Continue Aspirin Therapy Perioperatively?

“…The first group consists of procedures where any additional or excessive blood loss would lead to worse outcomes related to morbidity or mortality. 76 This group of procedures includes intracranial surgery, 77 spinal canal procedures, 78 poster chamber eye surgery, middle ear surgery, and possibly prostate surgery. The other group consists of those procedures in which an increase in surgical blood loss may have minimal consequences (no change in transfusion requirements or no increase in major morbidity or mortality).…”

Effects of discontinuance of preoperative anti-platelet medication in multi-level thoracolumbar spine surgery

“…Nevertheless, it is important that we did not observe significant epidural hematoma among the major complication lists. There are some studies that say that aspirin can significantly enhance such risks (16). Although spinal epidural hematoma has been reported in rare cases (13), our cases required a wider incision and a longer operation time than other studies.…”

“…Aspirin is thought to increase the risk of hemorrhage, and even a small hemorrhage can cause significant morbidity in spinal surgery. In a survey of 201 spine surgeons, two-thirds recognized that aspirin is a risk factor for excessive perioperative hemorrhage, and half of them had experienced excessive perioperative hemorrhage during surgery in patients who were taking aspirin (16). This is why spine surgeons have been reluctant to perform multi-level spine surgery on patients who are taking anti-platelet medication.…”

Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition)

“…Aspirin has been identified as an important risk factor for postoperative bleeding and the development of hematomas including epidural hematomas in other surgical fields. [147][148][149][150][151][152] Furthermore, the use of low-dose ASA before spine surgery, even when discontinued for at least 7 days, has been suggested to lead to further blood drainage after surgery. 153 In an extensive review, low-dose ASA has also been shown to increase the rate of bleeding complications by a factor of 1.5 (median; interquartile range, 1.0-2.5).…”