Objective

The objective of the North American Spine Society (NASS) Clinical Guideline for Antithrombotic Therapies in Adults Undergoing Spine Surgery is to provide evidence-based recommendations to address key clinical questions surrounding antithrombotic therapies in adults undergoing spine surgery. This guideline is intended to update the original guideline on this topic, published in 2009. This guideline is based upon a systematic review of the evidence and reflects contemporary treatment concepts as reflected in the highest quality clinical literature available on this subject as of March 2021. The goals and expected benefits of the guideline recommendations are to assist in delivering optimum, efficacious treatment with the goal of preventing thromboembolic events.

Scope, Purpose and Intended User

This document was developed by the North American Spine Society’s Clinical Practice Guidelines Committee as an educational tool to assist practitioners who treat adult patients undergoing spine surgery. The goal is to provide a tool that assists practitioners in improving the quality and efficiency of care delivered to these patients. The NASS Clinical Guideline for Antithrombotic Therapies in Adults Undergoing Spine Surgery outlines a reasonable approach to the use of antithrombotic modalities in the treatment of spine disease.

THIS GUIDELINE DOES NOT REPRESENT A “STANDARD OF CARE,” nor is it intended as a fixed treatment protocol. It is anticipated that there will be patients who will require less or more treatment than the average. It is also acknowledged that in atypical cases, treatment falling outside this guideline will sometimes be necessary. This guideline should not be seen as prescribing the type, frequency, or duration of intervention. Treatment should be based on the individual patient’s need and provider’s professional judgment and experience. This document is designed to function as a guideline and should not be used as the sole reason for authorization or denial of treatment and services. This guideline is not intended to expand or restrict a health care provider’s scope of practice or to supersede applicable ethical standards or provisions of law.

Patient Population

The patient population for this guideline encompasses adults (18 years or older) undergoing spine surgery.

Definition: Antithrombotic therapies in spine surgery are defined as modalities utilized in the perioperative setting to prevent venous thromboembolic events (VTE) including deep venous thrombosis (DVT) and pulmonary embolus (PE).

Inclusion Criteria: Adults (18 years or older) undergoing spine surgery

Exclusion Criteria:

• Nonadults (under 18 years old)
• Not exclusively undergoing elective spine surgery or spine surgery for malignancy or trauma, or when populations are mixed or unclear

Glossary:

• Surgical Treatment: Any treatment provided involving the direct manipulation of tissue to decompress neural elements, realign, or stabilize the spine.
• Chemoprophylaxis: The use of systemically administered medications to prevent VTE.
• Mechanoprophylaxis: The use of mechanical devices such as compression stockings or sequential compression devices to prevent VTE.

Acronyms:

• ALIF: anterior lumbar interbody fusion
• ASA: aspirin
• BMI: body mass index
• CT: computed tomography
• DHE: dihydroergotamine
• DOAC: direct oral anticoagulants
• DVT: deep venous thrombosis
• HDHE: heparin + dihydroergotamine
• IVC: inferior vena cava
• LMWH: low molecular weight heparin
• MIS: minimally invasive surgery
• ODI: Oswestry Disability Index
• PCD: pneumatic compression devices
• PE: pulmonary embolus
• PLIF: posterior lumbar interbody fusion
• POD: postoperative day
• SCD: sequential compression device
• SSI: surgical site infection
• TLIF: transforaminal lumbar interbody fusion
• VAS: visual analogue scale
• VTE: venous thromboembolism