Thromboprophylaxis in elective spinal surgery

Abstract

Background: Venous thromboembolism (VTE) is a serious, sometimes life-threatening complication that can occur following spine surgery. The incidence of VTE, and the optimal type and timing of thromboprophylaxis for this complication in elective spine surgery is a matter of debate. Objective: To perform a systematic review with the aim of clarifying the efficacy and adverse effects of mechanical and chemical prophylaxis for preventing thromboembolic complications in elective spine surgery for conditions other than trauma and malignant disease. Methods/design: A search strategy of related articles up to March 2018 was designed and executed in Medline and Embase. Patients: adolescents (>10 years) and adults undergoing elective surgery for spinal deformity or degenerative disease (from C1 to S1). Intervention: Perioperative mechanical and chemical thromboprophylaxis. Studies could be randomized controlled trials or observational studies that reported data on any relevant clinical outcomes. Results: In total, 2451 uniquecitations were identified and 35 studies were ultimately included in the systematic review. The overall mean incidence of complications was 3.7% for deep venous thrombosis, 0.0% for pulmonary embolism, and 3.7% for bleeding in chemoprophylaxis group; 2.9% for deep venous thrombosis, 0.4% for pulmonary embolism and 0.0% for bleeding in mechanoprophylaxis; and 0.7% for deep venous thrombosis, 0.1% for pulmonary embolism and 0.2% for bleeding in mixed prophylaxis group with no specific data on these rates for the type of patient and type and location of surgery. None of the articles retrieved provided information on the adolescent population. Discussion and Conclusions: The poor design and high variability among the studies regarding characteristics of study population, details of interventions, and definitions of outcomes, determines a low quality of the available evidence and limits the interpretation of the results. We were unable to identify a clear advantage of one type of thromboprophylaxis over the other, although there was an increased risk of bleeding with chemoprophylaxis, which could favor the use of mechanoprophylaxis in this scenario.

Chemical prophylaxis and venous thromboembolism following elective spinal surgery: A systematic review and meta-analysis

“…Venous thromboembolism is a common postoperative complication that can raise the risks of morbidity and mortality [7 , 11] . Because of this, prevention of VTE has been heavily studied among other orthopedic and trauma surgery populations [12] . For instance, there is robust evidence to suggest that prophylactic anticoagulation significantly reduces the occurrence of VTE after hip and knee arthroplasty [41] .…”

“…Although SEHs are infrequent, they can cause devastating neurologic injury [9] , leading many surgeons to avoid the use of anticoagulants during elective spinal surgery [10] . When VTE chemoprophylaxis is used, the optimal timing of administration to maximize the benefits of anticoagulation whereas minimizing bleeding risks remains unclear [11 , 12] .…”

“…Most reviews conducted to date are weakened by the inclusion of all types of spine surgery. For example, studies that include patients with known individual risk factors for DVT and PE [17 , 18] , such as trauma, cancer, or spinal injuries, add confounding populations to the overall review and limit the generalizability of any conclusions they are able to draw [12] .…”

Erector spinae plane block for perioperative pain management in neurosurgical lower-thoracic and lumbar spinal fusion: a single-centre prospective randomised controlled trial

“…Reduced pain and opioid consumption, together with a comprehensive ERAS approach and reduced LOS, should theoretically hasten the mobilisation of the patients and reduce their need for thromboprophylaxis or risk for venous thromboembolism, which is a crucial issue in neurosurgery [ 18 , 19 ].…”

Trauma-induced pulmonary thromboembolism: What's update?

“… 82 , 83 It is difficult to decide the optimal strategy for VTE prevention because trauma patients may have real or perceived contraindications to prophylaxis, which affects the timing of preventive measures. A meta-analysis 84 showed that the optimal plan for the prevention of traumatic VTE has not been reached, due to many factors such as the poor study quality, study design, population characteristics, outcome definition, etc. Chemical anticoagulation has clear therapeutic effects, but there is an unavoidable risk of bleeding.…”