Post-Operative Spinal Epidural Hematoma: Are We Discontinuing Aspirin Early Enough?

Saitta, Bradley Hart; Shultz, Paul; Hanson, Kathryn J.; Mikhael, Mark M.

doi:10.1177/21925682221079259

Cited by 5 publications

(27 citation statements)

References 23 publications

(51 reference statements)

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“…They also demonstrated that nonsteroidal anti-inflammatory drugs increased surgical blood loss. Saitta et al found that preoperative aspirin was associated with an increased risk of SEH even when appropriately discontinued in their retrospective cohort study 11) . They also suggested that surgeons should observe these patients more carefully after surgery and consider extending aspirin discontinuation to prevent the serious postoperative complication of SEH.…”

Section: ) Reports Of Increased Hemorrhagic Complications Related To ...mentioning

confidence: 96%

Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan

Tezuka

Sakai

Imagama

et al. 2023

Spine Surg Relat Res

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Introduction:The number of patients on antithrombotic drugs for coronary heart disease or cerebrovascular disease has been increasing with the aging of society. We occasionally need to decide whether to continue or discontinue antithrombotic drugs before spine surgery. The purpose of this study is to understand the current perioperative management of antithrombotic drugs before elective spine surgery in Japan. Methods:In 2021, members of the Japanese Society for Spine Surgery and Related Research (JSSR) were asked to complete a web-based questionnaire survey that included items concerning the respondents' surgical experience, their policy regarding discontinuation or continuation of antithrombotic drugs, their reasons for decisions concerning the management of antithrombotic drugs, and their experience of perioperative complications related to the continuation or discontinuation of these drugs.Results: A total of 1,181 spine surgeons returned completed questionnaires, giving a response rate of 32.0%. JSSR board-certified spine surgeons comprised 75.1% of the respondents.Depending on the management policy regarding antithrombotic drugs for each comorbidity, approximately 73% of respondents discontinued these drugs before elective spine surgery, and about 80% also discontinued anticoagulants. Only 4%-5% of respondents reported continuing antiplatelet drugs, and 2.5% reported continuing anticoagulants. Among the respondents who discontinued antiplatelet drugs, 20.4% reported having encountered cerebral infarction and 3.7% reported encountering myocardial infarction; among those who discontinued anticoagulants, 13.6% reported encountering cerebral embolism and 5.4% reported encountering pulmonary embolism. However, among the respondents who continued antiplatelet drugs and those who continued anticoagulants, 26.3% and 27.2%, respectively, encountered an unexpected increase in

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Section: ) Reports Of Increased Hemorrhagic Complications Related To ...mentioning

confidence: 96%

Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan

Tezuka

Sakai

Imagama

et al. 2023

Spine Surg Relat Res

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“…The surgical sites were divided into cervical [8,10,11,13,14,19,28,36,37,[40][41][42][43][44][45], thoracic [8,11,13,19,28,31,[40][41][42][44][45][46] and lumbar [5, 8, 9, 11, 13, 16-22, 28, 29, 32-35, 40-42, 44-46] surgery with 15, 12 and 25 studies including 27,779, 16,897, 80,766 patients, respectively, and 72, 104 and 356 patients developed SSEH, respectively. The pooled incidence of SSEH was 0.32% (95% CI 0.002-0.005, P < 0.01, I 2 = 63%) for cervical surgery, 0.84% (95% CI 0.004-0.017, P < 0.01, I 2 = 88%) for thoracic surgery, and 0.63% (95% CI 0.004-0.010, P < 0.01, I 2 = 92%) for lumbar surgery.…”

Section: Surgical Sitementioning

confidence: 99%

Incidence of postoperative symptomatic spinal epidural hematoma requiring surgical evacuation: a systematic review and meta-analysis

et al. 2022

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Purpose This systematic review and meta-analysis aimed to determine the incidence of symptomatic spinal epidural hematoma (SSEH) following spine surgery. Methods We systematically searched for all relevant articles that mentioned the incidence of SSEH following the spine surgery published in the PubMed, Embase, and Cochrane Library databases through March 2022 and manually searched the reference lists of included studies. The Newcastle–Ottawa quality assessment scale (NOS) was used to assess the quality of the included studies. A fixed-effects or random-effects model was performed to calculate the pooled incidence of the totality and subgroups based on the heterogeneity. The potential publication bias was assessed by Egger's linear regression and a funnel plot. Sensitivity analysis was also conducted. Results A total of 40 studies were included in our meta-analysis based on our inclusion and exclusion criteria. The overall pooled incidence of SSEH was 0.52% (95% CI 0.004–0.007). In the subgroup analysis, the pooled incidence of SSEH in males and females was 0.86% (95% CI 0.004–0.023) and 0.68% (95% CI 0.003–0.017). Among the different indications, a higher incidence (2.9%, 95% CI 0.006–0.084) was found in patients with deformity than degeneration (1.12%, 95% CI 0.006–0.020) and tumor (0.30%, 95% CI 0.006–0.084). For different surgical sites, the incidences of SSEH in cervical, thoracic and lumbar spine were 0.32% (95% CI 0.002–0.005), 0.84% (95% CI 0.004–0.017) and 0.63% (95% CI 0.004–0.010), respectively. The incidences of SSEH in anterior and posterior approach were 0.24% (95% CI 0.001–0.006) and 0.70% (95% CI 0.004–0.011), respectively. The pooled incidence of SSEH was five times higher with minimally invasive surgery (1.94%, 95% CI 0.009–0.043) than with open surgery (0.42%, 95% CI 0.003–0.006). Delayed onset of SSEH had a lower incidence of 0.16% (95% CI 0.001–0.002) than early onset. There were no significant variations in the incidence of SSEH between patients who received perioperative anticoagulation therapy and those who did not or did not report getting chemopreventive therapy (0.44%, 95% CI 0.006–0.084 versus 0.42%, 95% CI 0.003–0.006). Conclusion We evaluated the overall incidence proportion of SSEH after spine surgery and performed stratified analysis, including sex, surgical indication, site, approach, minimally invasive surgery, and delayed onset of SSEH. Our research would be helpful for patients to be accurately informed of their risk and for spinal surgeons to estimate the probability of SSEH after spine surgery.

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“…[2,6,17] Major predisposing factors for pSEH included; perioperative/postoperative coagulation disorders, multilevel spinal surgery, prior spine surgery, and intraoperative cerebrospinal fluid leaks (CSF) [Tables 1 and 3]. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] The times to onset of symptomatic postoperative pSEH following all-level spine surgery ranged from an average of 2.7 postoperative hours, [1] to less than 24, [2] to between 24-48 postoperative hrs. [5] [Tables 1-4].…”

Section: Introductionmentioning

confidence: 99%

“…[4] The most critical factors to limit/avert permanent neurological sequelae of pSEH included; early recognition of new postoperative neurological deficits, obtaining immediate magnetic resonance imaging (MR) studies, and performing emergency spine surgery where indicated [Tables 1-4]. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Incidence of pSEH e incidence of symptomatic postoperative spinal epidural hematomas (pSEH) involving all spinal levels ranged in 7 studies from 0.1% to 1%, [1,2,4,8,9,15,16] in 5 series from <1% to 2.9%, [11,12,15,17,18] and in 3 series between 3%-4.46% (i.e., the 1 of 10 patients with a 10% incidence of pSEH was considered an outlier) [2,6,17] [Tables 1 and 2]. [1][2][3][4][5][6][7][8][9][10]…”

Section: Introductionmentioning

confidence: 99%

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Incidence of pSEH e incidence of symptomatic postoperative spinal epidural hematomas (pSEH) involving all spinal levels ranged in 7 studies from 0.1% to 1%, [1,2,4,8,9,15,16] in 5 series from <1% to 2.9%, [11,12,15,17,18] and in 3 series between 3%-4.46% (i.e., the 1 of 10 patients with a 10% incidence of pSEH was considered an outlier) [2,6,17] [Tables 1 and 2]. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]…”

Section: Introductionmentioning

confidence: 99%

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Perspective: Postoperative spinal epidural hematomas (pSEH) should be treated, not ignored

Epstein,

Agulnick

2023

Surgical Neurology International

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Background: Patients with postoperative spinal epidural hematomas (pSEH) typically require emergency treatment to avoid paralysis; these hematomas should not be ignored. pSEH patients need to undergo immediate MR studies to document the location/extent of their hematomas, and emergent surgical decompression with/ without fusion if warranted. Methods: The frequencies of symptomatic pSEH ranged in various series from 0.1%-4.46%. Major predisposing factors included; perioperative/postoperative coagulation abnormalities/disorders, multilevel spine surgeries, previous spine surgery, and intraoperative cerebrospinal fluid (CSF) leaks. For surgery at all spinal levels, one study observed pSEH developed within an average of 2.7 postoperative hours. Another series found 100% of cervical/thoracic, and 50% of lumbar pSEH were symptomatic within 24 postoperative hrs., while a third series noted a 24-48 postoperative window for pSEH to develop. Results: Early recognition of postoperative symptoms/signs of pSEH, warrant immediate MR examinations to diagnose the local/extent of hemorrhages. Subsequent emergent spinal decompressions/fusions are critical to limit/avert permanent postoperative neurological deficits. Additionally, patients undergoing open or minimally invasive spinal procedures where pSEH are suspected, warrant immediate postoperative MR studies. Conclusion: Patients undergoing spinal surgery at any level typically become symptomatic from pSEH within 2.7 to 24 postoperative hours. Early recognition of new neurological deficits, immediate MR studies, and emergent surgery (i.e., if indicated) should limit/minimize postoperative neurological sequelae. Thus, pSEH should be treated, not ignored.

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Post-Operative Spinal Epidural Hematoma: Are We Discontinuing Aspirin Early Enough?

Cited by 5 publications

References 23 publications

Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan

Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan

Incidence of postoperative symptomatic spinal epidural hematoma requiring surgical evacuation: a systematic review and meta-analysis

Perspective: Postoperative spinal epidural hematomas (pSEH) should be treated, not ignored

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