DOES ANTICOAGULANT THROMBOPROPHYLAXIS INCREASE BLEEDING COMPLICATIONS IN SPINAL SURGERY AND SPINAL CORD INJURY? A SYSTEMATIC REVIEW AND META-ANALYSIS
Basrah Journal of Surgery,
2020, Volume 26, Issue 1, Pages 9-20
AbstractThis study is a systematic review and meta-analysis. The routine use of anticoagulants for the prevention of venothromboembolism in spinal patients is controversial and the risk benefit analysis is poorly described. The objective of this study is to collate the current evidence and quantify the risk of bleeding associated with anticoagulant thrombophylaxis in the spinal patient, both in the elective and trauma settings.
Medline, Embase, Cochrane Trial Register databases and the grey literature were searched. Data were pooled via a meta-analysis from randomized trials and cohort studies comparing the rates of spinal epidural haematoma and wound haemorrhagic complications in spinal surgery patients receiving low molecular weight and low dose unfractionated heparin (LMWH/UFH) thromboprophylaxis and those not anticoagulated. The risk of bias within individual studies and across all the studies was assessed using the Cochrane risk of bias tools and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool, respectively.
The meta-analysis included 10 studies of 96,042 patients with 1,007 relevant bleeding complications. A significant increase in the risk of extra-spinal wound haemorrhage was found in patients receiving peri-operative LMWH/UFH thromboprophylaxis compared to controls (OR 1.56, 95% CI 1.18-2.06, p=0.002, I2=8%). The same comparison revealed no significant increase in the risk of spinal epidural haemorrhage (OR 1.20, 95% CI 0.65-2.22, p=0.56, I2=0%). The quality of evidence for both outcomes was low. There was insufficient data to conclude about the risk of haemorrhagic complications in spinal trauma and in patients receiving non-heparin thromboprophylaxis agents.
In conclusion, the results of this study raise concern about a possible increased risk of extraspinal wound haemorrhage associated with LMWH/LDUFH thromboprophylaxis in spinal surgery. Level of evidence: Therapeutic level III.
Anh TV Nguyen*, Sonia Tran@, Thamer Hamdan#, Robin Turner$, Ahmed-Ramadan Sadek^, Darren Lui**, & Alexander S Montgomery!
*MBChB, MRCS(Eng), PGDipSurgAnat, MSc(Orth Tr Sci), Orthopaedic registrar, Saint George’s University Hospitals, London, UK. @BMed, MS (Surg Sci), Surgical registrar, The Children’s Hospital at Westmead, New South Wales, Australia. #FRCS, FRCP, FACS, FICS, American Board (Neuro Ortho) Professor of Orthopaedic Surgery, Research fellow, Saint George's University Hospital, London, UK. $PhD, MBiostat, Associate Professor and Director, Biostatistics Unit, University of Otago, Dunedin, New Zealand. ^MBBS(Hons) BSc(Hons) DPhil.(Oxon), FRCS(SN), Spinal neurosurgeon, Department of Spinal Surgery, Royal London Hospital, London, United Kingdom. **FRCS, Saint George's University Hospital, London, UK. !MBChB, MRCS(Eng), Dipl Orth(Eng), FRCS(Orth), Spinal surgeon and Clinical Lead, Department of Spinal Surgery, Royal London Hospital, London, United Kingdom.
Investigation performed at the Department of Spinal Surgery, Royal London Hospital, London in conjunction with the Centre for Biostatistics, Division of Health Sciences, University of Otago
1.National Institute for Health and Clinical Excellence. Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. NICE guideline (NG89)2018.
2.Bono CM, Watters WC, 3rd, Heggeness MH, Resnick DK, Shaffer WO, Baisden J, et al. An evidence-based clinical guideline for the use of antithrombotic therapies in spine surgery. The spine journal : official journal of the North American Spine Society. 2009;9(12):1046-51.
3.Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e227S-e77S.
4.Schizas C, Neumayer F, Kosmopoulos V. Incidence and management of pulmonary embolism following spinal surgery occurring while under chemical thromboprophylaxis. European Spine Journal. 2008;17(7):970-4.
5.Frim DM, Barker FG, 2nd, Poletti CE, Hamilton AJ. Postoperative low-dose heparin decreases thromboembolic complications in neurosurgical patients. Neurosurgery. 1992;30(6):830-2; discussion 2-3.
6.Wetzel N, Anderson MC, Shields TW. Pulmonary embolism as a cause of death in the neurosurgical patient. Journal of neurosurgery. 1960;17:664-8.
7.Tribe CR. Causes of Death in the Early and Late Stages of Paraplegia. Paraplegia. 1963;1:19-47.
8.Teasell RW, Hsieh JT, Aubut J-AL, Eng JJ, Krassioukov A, Tu L. Venous Thromboembolism After Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation. 2009;90(2):232-45.
9.El Masri WS, Silver JR. Prophylactic anticoagulant therapy in patients with spinal cord injury. Paraplegia. 1981;19(6):334-42.
10.Mosenthal WP, Landy DC, Boyajian HH, Idowu OA, Shi LL, Ramos E, et al. Thromboprophylaxis in Spinal Surgery. Spine. 2018;43(8):E474-E81.
11.Singh S, Haut ER, Brotman DJ, Sharma R, Chelladurai Y, Shermock KM, et al. Pharmacologic and Mechanical Prophylaxis of Venous Thromboembolism Among Special Populations. Rockville (MD); 2013.
12.Bryson DJ, Uzoigwe CE, Braybrooke J. Thromboprophylaxis in spinal surgery: a survey. Journal of Orthopaedic Surgery and Research 2012;7(14).
13.Jacobs LJ, Woods BI, Chen AF, Lunardini DJ, Hohl JB, Lee JY. Safety of thromboembolic chemoprophylaxis in spinal trauma patients requiring surgical stabilization. Spine. 2013;38(16):E1041-7.
14.Glotzbecker MP, Bono CM, Harris MB. Surgeon practices regarding postoperative thromboembolic prophylaxis after high- risk spinal surgery. Spine. 2008;33:2915-21.
15.Glotzbecker MP, Bono CM, Wood KB, Harris MB. Postoperative spinal epidural hematoma: a systematic review. Spine. 2010;35(10):E413-20.
16.Ploumis A, Ponnappan RK, Sarbello J, Dvorak M, Fehlings MG, Baron E, et al. Thromboprophylaxis in traumatic and elective spinal surgery: analysis of questionnaire response and current practice of spine trauma surgeons. Spine. 2010;35(3):323-9.
17.Hamidi S, Riazi M. Incidence of venous thromboembolic complications in instrumental spinal surgeries with preoperative chemoprophylaxis. Journal of Korean Neurosurgical Society. 2015;57(2):114-8.
18.Chang R, Scerbo MH, Schmitt KM, Adams SD, Choi TJ, Wade CE, et al. Early chemoprophylaxis is associated with decreased venous thromboembolism risk without concomitant increase in intraspinal hematoma expansion after traumatic spinal cord injury. The journal of trauma and acute care surgery. 2017;83(6):1088-94.
19.Dhillon ES, Khanna R, Cloney M, Roberts H, Cybulski GR, Koski TR, et al. Timing and risks of chemoprophylaxis after spinal surgery: a single-center experience with 6869 consecutive patients. Journal of Neurosurgery: Spine. 2017;27(6):681-93.
20.Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). CHEST. 2008;133(6):381S-453S.
21.Cheng JS, Arnold PM, Anderson PA, Fischer D, Dettori JR. Anticoagulation risk in spine surgery. Spine. 2010;35(9 Suppl):S117-24.
22.The Cochrane Collaboration. Review Manager (RevMan). 5.3 ed. Copenhagen: The Nordic Cochrane Centre; 2014.
23.Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355.
24.Schünemann H, Brożek J, Guyatt G, Oxman A. The GRADE handbook published year 2013. Available from: http://gdt.guidelinedevelopment.org/app/handbook/handbook.html.
25.The Cochrane Consumers & Communication Review Group. GRADE approach to evaluating the quality of evidence: a pathway 2017 [Available from: http://training.cochrane.org/path/grade-approach-evaluating-quality-evidence-pathway.
26.Zeng X-J, Peng H. Prevention of Thromboembolic Complications After Spine Surgery by the Use of Low-Molecular-Weight Heparin. World Neurosurgery. 2017;104:856-62.
27.Cox JB, Weaver KJ, Neal DW, Jacob RP, Hoh DJ. Decreased incidence of venous thromboembolism after spine surgery with early multimodal prophylaxis. Journal of Neurosurgery: Spine. 2014;21(4):677-84.
28.Cunningham JE, Swamy G, Thomas KC. Does preoperative DVT chemoprophylaxis in spinal surgery affect the incidence of thromboembolic complications and spinal epidural hematomas? Journal of spinal disorders & techniques. 2011;24(4):E31-4.
29.Dewan MC, Godil SS, McGirt MJ. Mechanical vs Chemical Prophylaxis for Deep Venous Thrombosis in Patients Undergoing Lumbar Spinal Fusion: Comparative Effectiveness and Cost-Benefit. Neurosurgery. 2013;60:S158.
30.Rokito SE, Schwartz MC, Neuwirth MG. Deep vein thrombosis after major reconstructive spinal surgery. Spine. 1996;21(7):853-8; discussion 9.
31.Green D, Rossi EC, Yao JS, Flinn WR, Spies SM. Deep vein thrombosis in spinal cord injury: effect of prophylaxis with calf compression, aspirin, and dipyridamole. Paraplegia. 1982;20(4):227-34.
32.Chunhong L, Jin L, Qin Z, Guohui X. Anticoagulant effects of Rivaroxaban after surgical fixation of spinal fracture. Pakistan journal of pharmaceutical sciences. 2018;31(3(Special)):1131-5.
33.Epstein. N, Hood. D.C, Ransohoff. J. Gastrointestinal bleeding in patients with spinal cord trauma. Journal of neurosurgery. 1981;54(1):16-20.
34.Sansone JM, del Rio AM, Anderson PA. The Prevalence of and Specific Risk Factors for Venous Thromboembolic Disease Following Elective Spine Surgery. 2010;92(2):304-13.
35.Brooks F, Lau S, Baddour E, Rao P, Bhagat S, Ahuja S. Thromboprophylaxis in Spinal Surgery – Current UK Practice. 2013.
36.Fang MC, Maselli J, Lurie JD, Lindenauer PK, Pekow PS, Auerbach AD. Use and Outcomes of Venous Thromboembolism Prophylaxis after Spinal Fusion Surgery. Journal of thrombosis and haemostasis : JTH. 2011;9(7):1318-25.
37.Glotzbecker MP, Bono CM, Wood KB, Harris MB. Thromboembolic disease in spinal surgery: a systematic review. Spine. 2009;34(3):291-303.
38.Smith JS, Fu K-MG, Polly JDW, Sansur CA, Berven SH, Broadstone PA, et al. Complication rates of three common spine procedures and rates of thromboembolism following spine surgery based on 108,419 procedures: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine. 2010;35(24):2140-9.
39.Piran S, Bednar D, Drew B, Schulman S. Optimal timing of starting thromboprophylaxis for patients with acute spinal cord injury: A survey of Canadian spine surgeons. Thromb Res. 2017;160:38-40.
40.Dearborn JT, Hu SS, Tribus CB, Bradford DS. Thromboembolic complications after major thoracolumbar spine surgery. Spine. 1999;24(14):1471-6.
41.Nazareth A, D’Oro A, Liu JC, Schoell K, Heindel P, Jakoi A, et al. Risk Factors for Postoperative Venous Thromboembolic Events in Patients Undergoing Lumbar Spine Surgery. Global Spine Journal. 2018:2192568218797094.
42.Brambilla S, Ruosi C, La Maida GA, Caserta S. Prevention of venous thromboembolism in spinal surgery. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2004;13(1):1-8.
43.Oda T, Fuji T, Kato Y, Fujita S, Kanemitsu N. Deep venous thrombosis after posterior spinal surgery. Spine. 2000;25(22):2962-7.
44.Consortium for Spinal Cord Medicine. Prevention of Venous Thromboembolism in Individuals with Spinal Cord Injury: Clinical Practice Guidelines for Health Care Providers, 3rd ed. Topics in Spinal Cord Injury Rehabilitation. 2016;22(3):209-40.
45.Fehlings MG, Tetreault LA, Aarabi B, Anderson P, Arnold PM, Brodke DS, et al. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis. Global Spine Journal. 2017;7(3_suppl):212S-20S.
46.Velmahos GC, Kern J, Chan LS, Oder D, Murray JA, Shekelle P. Prevention of venous thromboembolism after injury: an evidence-based report--part II: analysis of risk factors and evaluation of the role of vena caval filters. The Journal of trauma. 2000;49(1):140-4.
47.Halim TA, Chhabra HS, Arora M, Kumar S. Pharmacological prophylaxis for deep vein thrombosis in acute spinal cord injury: an Indian perspective. Spinal cord. 2014;52(7):547-50.
48.Agarwal NK, Mathur N. Deep vein thrombosis in acute spinal cord injury. Spinal cord. 2009;47:769.
49.Merli GJ, Herbison GJ, Ditunno JF, Weitz HH, Henzes JH, Park CH, et al. Deep vein thrombosis: prophylaxis in acute spinal cord injured patients. Arch Phys Med Rehabil. 1988;69(9):661-4.
50.Smith MD, Bressler EL, Lonstein JE, Winter R, Pinto MR, Denis F. Deep venous thrombosis and pulmonary embolism after major reconstructive operations on the spine. A prospective analysis of three hundred and seventeen patients. The Journal of bone and joint surgery American volume. 1994;76(7):980-5.
51.Silver JR. The prophylactic use of anticoagulant therapy in the prevention of pulmonary emboli in one hundred consecutive spinal injury patients. Paraplegia. 1974;12:188.
52.Kim DY, Kobayashi L, Chang D, Fortlage D, Coimbra R. Early pharmacological venous thromboembolism prophylaxis is safe after operative fixation of traumatic spine fractures. Spine. 2015;40(5):299-304.
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