Prevention of thromboembolism in spinal cord injury -S1 guideline

Abstract

Introduction Traumatic and non-traumatic spinal cord injury bears a high risk for thromboembolism in the first few months after injury. So far, there is no consented guideline regarding diagnostic and prophylactic measures to prevent thromboembolic events in spinal cord injury. Based on a Pubmed research of related original papers and review articles, international guidelines and a survey conducted in German-speaking spinal cord injury centers about best practice prophylactic procedures at each site, a consensus process was initiated, which included spinal cord medicine experts and representatives from medical societies involved in the comprehensive care of spinal cord injury patients. The recommendations comply with the German S3 practice guidelines on prevention of venous thromboembolism. Recommendations Specific clinical or instrument-based screening methods are not recommended in asymptomatic SCI patients. Based on the severity of neurological dysfunction (motor completeness, ambulatory function) low dose low molecular weight heparins are recommended to be administered up to 24 weeks after injury. Besides, mechanical methods (compression stockings, intermittent pneumatic compression) can be applied. In chronic SCI patients admitted to the hospital, thromboembolism prophylactic measures need to be based on the reason for admission and the necessity for immobilization. Conclusions Recommendations for thromboembolism diagnostic and prophylactic measures follow best practice in most spinal cord injury centers. More research evidence needs to be generated to administer more individually tailored risk-adapted prophylactic strategies in the future, which may help to further prevent thromboembolic events without causing major side effects. The present article is a translation of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/179-015l_S1_Thromboembolieprophylaxe-bei-Querschnittlaehmung_2020-09.pdf).

Risk factors for venous thromboembolism in patients with spinal cord injury: A single-center Turkish study

“…The reason for this has not been determined in previous studies. [18] Spasticity is known to protect against the development of VTE in SCI patients; [19] however, in the present study there wasn't an association between developing VTE and spasticity. Similarly, Green et al observed that SCI patients with flaccid paralysis had a higher risk of VTE than those with spasticity.…”

Risk Factors for Pulmonary Embolism in Patients with Paralysis and Deep Venous Thrombosis

“…Overall, 1.6% of all hospitalized patients with paralysis developed an event of VTE. As known from other studies, the prevalence of DVT (symptomatic and asymptomatic) differs in surgical and non-surgical medicine without VTE prophylaxis-between 10% and 20% in internal medicine diseases, distinctly higher in stroke (20-50%) and polytrauma (40-80%), and highest in patients with spinal cord injury (60-80%) [36]. Other studies reported that without VTE prophylaxis, approximately 50-75% of stroke patients with hemiplegia or paralysis develop DVT [1,5,6].…”

“…Other studies reported that without VTE prophylaxis, approximately 50-75% of stroke patients with hemiplegia or paralysis develop DVT [1,5,6]. Thus, VTE is a common complication in spinal cord injury and stroke with resulting paresis [3,5,[7][8][9][10][11]36]. Among traumatic injuries, traumatic spine injuries of the spinal cord and/or the cauda equina are connected with the highest VTE risk [36].…”

“…Thus, VTE is a common complication in spinal cord injury and stroke with resulting paresis [3,5,[7][8][9][10][11]36]. Among traumatic injuries, traumatic spine injuries of the spinal cord and/or the cauda equina are connected with the highest VTE risk [36]. Remarkably, the primary reasons for this high risk are related to the failure of the muscle pump driven by the paresis in combination with a presumed transient hypercoagulative phase, and, particularly, endothelial damage [36].…”

“…Among traumatic injuries, traumatic spine injuries of the spinal cord and/or the cauda equina are connected with the highest VTE risk [36]. Remarkably, the primary reasons for this high risk are related to the failure of the muscle pump driven by the paresis in combination with a presumed transient hypercoagulative phase, and, particularly, endothelial damage [36]. Moreover, decoupling from supraspinal control seems to be another important contributing prothrombotic factor [36].…”