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

Abstract

Study Design: Cross-sectional, international survey. Objectives: This study addressed the global perspectives concerning perioperative use of pharmacologic thromboprophylaxis during spine surgery along with its risks and benefits. Methods: A questionnaire was designed and implemented by expert members in the AO Spine community. The survey was distributed to AO Spine’s spine surgeon members (N = 3805). Data included surgeon demographic information, type and region of practice, anticoagulation principles, different patient scenarios, and comorbidities. Results: A total of 316 (8.3% response rate) spine surgeons completed the survey, representing 64 different countries. Completed surveys were primarily from Europe (31.7%), South/Latin America (19.9%), and Asia (18.4%). Surgeons tended to be 35 to 44 years old (42.1%), fellowship-trained (74.7%), and orthopedic surgeons (65.5%) from academic institutions (39.6%). Most surgeons (70.3%) used routine anticoagulation risk stratification, irrespective of geographic location. However, significant differences were seen between continents with anticoagulation initiation and cessation methodology. Specifically, the length of a procedure ( P = .036) and patient body mass index ( P = .008) were perceived differently when deciding to begin anticoagulation, while the importance of medical clearance ( P < .001) and reference to literature ( P = .035) differed during cessation. For specific techniques, most providers noted use of mobilization, low-molecular-weight heparin, and mechanical prophylaxis beginning on postoperative 0 to 1 days. Conversely, bridging regimens were bimodal in distribution, with providers electing anticoagulant initiation on postoperative 0 to 1 days or days 5-6. Conclusion: This survey highlights the heterogeneity of spine care and accentuates geographical variations. Furthermore, it identifies the difficulty in providing consistent perioperative anticoagulation recommendations to patients, as there remains no widely accepted, definitive literature of evidence or guidelines.

Factors Affecting the Decision to Initiate Anticoagulation After Spine Surgery: Findings From the AOSpine Anticoagulation Global Initiative

“…Additionally, the lack of a global perspective in the NASS guidelines weaken their generalizability. In the preliminary findings from our survey data, Louie and colleagues 22 reported that only 14% of respondents described following hospital, national, or other unspecified guidelines when deciding on the use of anticoagulation. Despite this notion by our survey respondents, the AOSpine group has released thromboprophylaxis guidelines for patients suffering from spinal cord injury, which is the highest risk group for VTE in patients undergoing spine surgery.…”

“…12 Given the growing need for consensus surrounding recommendations regarding perioperative anticoagulation management in spine surgery, we conducted a global survey of spine surgeons within the AOSpine network to gauge their knowledge, attitudes and practices on this topic. Our preliminary findings have been reported by Louie et al 22 With that serving as a foundation, the specific focus of this study was to identify factors that contribute to the decision making of the initiation of anticoagulation after spine surgery among a global group of spine surgeons. We hypothesized that the survey responses will show heterogeneity in anticoagulation start times, with few instances of consensus of important patient or surgical factors influencing initiation decisionmaking.…”

“…We have previously reported the initial findings from The AOSpine Anticoagulation Global Survey regarding the demographics of the respondents. 22 Briefly, 316 spine surgeons from 64 countries completed the survey ( Table 1 ). When stratified by continent, Europe had the largest survey representation (31.7%), South America/Latin America (19.9%), and Asia (18.4%).…”

“…AOSpine Anticoagulation Global Survey methodology and overall findings are detailed in Louie et al 22 In brief, a survey questionnaire was developed and included surgeon demographics, rationale for anticoagulation following spine surgery, risk stratification, the use of published/unpublished guidelines to guide treatment, and the use of multidisciplinary teams. This survey was distributed to the AOSpine membership that opted to receive such requests via email (n = 3805 members out of approximately 6000 members).…”

Research Practices and Needs Among Spine Surgeons Worldwide

“…The survey received a 7% response rate, and although low, this is consistent with past surveys that have been conducted and published using the AO Spine community. 15,16 In addition, we believe the data are representative as not all AO Spine members are researchers, and the proportion of respondents from each region is similar to that of the AO Spine community. While there was a respectable number of respondents that participated in the survey, not all participants completed all questions.…”