Evidence-Based Clinical Guidelines

Multidisciplinary Spine Care Antithrombotic Therapies for Adults Undergoing Spine Surgery

Second Edition

Recommendations:

Timing & Duration of Prophylaxis

Question 16. When indicated, what is the ideal time to begin mechanical prophylaxis in relation to spinal surgery?
Question 17. When indicated, how long should mechanical prophylaxis continue following spinal surgery?
Question 18. When indicated, what is the ideal time to begin chemoprophylaxis in relation to spinal surgery?
Question 19. Do prophylactic antithrombotic measures, including compression stockings, mechanical sequential compression devices and chemoprophylaxis medications, decrease the rate of clinically symptomatic DVT and/or PE (including fatal PE) following spinal surgery (cervical, thoracic or lumbar) for malignancy (with spinal cord injury and without spinal cord injury)?
Question 20. In patients who are being treated with chemical anticoagulants for a nonspine-related disorder (eg, valve replacement), what is the ideal “bridge” therapy between stopping and starting the usual agent before and after spine surgery?

Question 16: When indicated, what is the ideal time to begin mechanical prophylaxis in relation to spinal surgery?

A systematic review of the literature yielded no studies to adequately address this question.

Work Group Consensus Statement

In the absence of reliable evidence, it is the work group’s opinion to initiate mechanical prophylaxis as soon as practical in patients undergoing spine surgery. Although no studies were available to directly answer this question, the work group agrees with the use of mechanical prophylaxis in spine surgery. All studies reviewed started mechanical prophylaxis early and there are no apparent additional costs or disadvantages to starting as soon as practical.

References

  1. Cox JB, Weaver KJ, Neal DW, Jacob RP, Hoh DJ. Decreased incidence of venous thromboembolism after spine surgery with early multimodal prophylaxis: Clinical article. J Neurosurg Spine. 2014;21(4):677-684. doi:10.3171/2014.6.SPINE13447
  2. Epstein NE. Efficacy of pneumatic compression stocking prophylaxis in the prevention of deep venous thrombosis and pulmonary embolism following 139 lumbar laminectomies with instrumented fusions. J Spinal Disord Tech. 2006;19(1):28-31. doi:10.1097/01.bsd.0000173454.71657.02
  3. Epstein NE. Intermittent pneumatic compression stocking prophylaxis against deep venous thrombosis in anterior cervical spinal surgery: a prospective efficacy study in 200 patients and literature review. Spine (Phila Pa 1976). 2005;30(22):2538-2543. doi:10.1097/01.brs.0000186318.80139.40
  4. Hamidi S, Riazi M. Incidence of venous thromboembolic complications in instrumental spinal surgeries with preoperative chemoprophylaxis. J Korean Neurosurg Soc. 2015;57(2):114-118. doi:10.3340/jkns.2015.57.2.114
  5. Piasecki DP, Poynton AR, Mintz DN, Roh JS, Peterson MGE, Rawlins BA, Charles G, Boachie-Adjei O (2008) Thromboembolic disease after combined anterior/posterior reconstruction for adult spinal deformity: a prospective cohort study using magnetic resonance venography. Spine. 33(6):668–672
  6. Shapiro JA, Stillwagon MR, Padovano AG, Moll S, Lim MR. An Evidence-Based Algorithm for Determining Venous Thromboembolism Prophylaxis After Degenerative Spinal Surgery. Int J Spine Surg. 2020;14(4):599-606. doi:10.14444/7080
  7. Zeeshan M, Khan M, O’Keeffe T, et al. Optimal timing of initiation of thromboprophylaxis in spine trauma managed operatively: A nationwide propensity-matched analysis of trauma quality improvement program. J Trauma Acute Care Surg. 2018;85(2):387-392. doi:10.1097/TA.0000000000001916

Future Directions for Research

The work group does not have any recommendations for future research on this topic.

Question 17: What is the incidence (symptomatic and asymptomatic) and timing of venous thromboembolism (VTE) following elective spinal surgery not performed for tumor or trauma (cervical, thoracic or lumbar) without any form of prophylaxis?

A systematic review of the literature yielded no studies to adequately address this question.

Work Group Consensus Statement

In the absence of reliable evidence, it is the work group’s opinion to continue mechanical prophylaxis in elective spine surgery until patients can ambulate which is mostly supported by the literature.1-3 Although no studies were available to directly answer this question, by comparing different durations, the work group agrees with the use of mechanical prophylaxis in spinal surgery until patients can ambulate or are discharged. Durations varied widely in the published literature1,4,5 and are different from the population of SCI.

References

  1. Dazley JM, Wain R, Vellinga RM, Cohen B, Agulnick MA. Prophylactic inferior vena cava filters prevent pulmonary embolisms in high-risk patients undergoing major spinal surgery. J Spinal Disord Tech. 2012;25(4):190-195. doi:10.1097/BSD.0b013e31821532bd
  2. Ozturk C, Ganiyusufoglu K, Alanay A, Aydogan M, Onat L, Hamzaoglu A. Efficacy of prophylactic placement of inferior vena cava filter in patients undergoing spinal surgery. Spine (Phila Pa 1976). 2010;35(20):1893-1896. doi:10.1097/BRS.0b013e3181e91dad
  3. Yoshioka K, Murakami H, Demura S, Kato S, Tsuchiya H. Prevalence and risk factors for development of venous thromboembolism after degenerative spinal surgery. Spine (Phila Pa 1976). 2015;40(5):E301-E306. doi:10.1097/BRS.0000000000000727
  4. Epstein NE. Efficacy of pneumatic compression stocking prophylaxis in the prevention of deep venous thrombosis and pulmonary embolism following 139 lumbar laminectomies with instrumented fusions. J Spinal Disord Tech. 2006;19(1):28-31. doi:10.1097/01.bsd.0000173454.71657.02
  5. Shapiro JA, Stillwagon MR, Padovano AG, Moll S, Lim MR. An Evidence-Based Algorithm for Determining Venous Thromboembolism Prophylaxis After Degenerative Spinal Surgery. Int J Spine Surg. 2020;14(4):599-606. doi:10.14444/7080

Future Directions for Research

In high-risk populations there may be some utility in prospective cohort studies on this topic, but in the general spine surgery population this is likely not a research priority.

Question 18: When indicated, what is the ideal time to begin chemoprophylaxis in relation to spinal surgery?

For adults with spinal cord injury or metastatic tumors, starting chemoprophylaxis within 24 hours may be considered to help prevent VTE. Grade of Recommendation: C

Ahlquist et al1 provide a retrospective cohort study of 79 patients undergoing surgery for spinal cord injury treated with chemoprophylaxis (mostly unfractionated heparin) beginning 24 hours after surgery (N=49), between 24 and 72 hours after surgery (N=20), or greater than 72 hours after surgery (N=10). The decision as to when to begin prophylaxis was left to the treating surgeon and was multifactorial. Patients treated with early chemoprophylaxis had lower rates of VTE but not PE. There were no complications associated with early chemoprophylaxis. This study provides Level III evidence that chemoprophylaxis started within 24 hours is safe and effective. De la Garza et al2 reported that in a small cohort of patients undergoing surgery for cancer of the spine, VTE rates were lower when chemoprophylaxis was started on POD 1-3 as opposed to POD 4 or later. One patient who received prophylaxis on POD 2 developed an epidural hematoma. This was a small and uncontrolled study with multiple tumor types and no consistent screening for VTE. This study provides Level IV evidence that early (POD 1-3) chemoprophylaxis provides better protection against VTE than late (4 or more days) chemoprophylaxis.

References

  1. Ahlquist S, Park HY, Kelley B, Holly L, Shamie AN, Park DY. Venous Thromboembolism Chemoprophylaxis Within 24 Hours of Surgery for Spinal Cord Injury: Is It Safe and Effective?. Neurospine. 2020;17(2):407-416. doi:10.14245/ns.1938420.210
  2. De la Garza Ramos R, Longo M, Gelfand Y, Echt M, Kinon MD, Yassari R. Timing of Prophylactic Anticoagulation and Its Effect on Thromboembolic Events After Surgery for Metastatic Tumors of the Spine. Spine (Phila Pa 1976). 2019;44(11):E650-E655. doi:10.1097/BRS.0000000000002944

Future Directions for Research

The work group recommends comparative studies to delineate the appropriate postoperative timing of administration of VTE chemoprophylaxis for different patient cohorts.

Question 19: Do prophylactic antithrombotic measures, including compression stockings, mechanical sequential compression devices and chemoprophylaxis medications, decrease the rate of clinically symptomatic DVT and/or PE (including fatal PE) following spinal surgery (cervical, thoracic or lumbar) for malignancy (with spinal cord injury and without spinal cord injury)?

Chemoprophylaxis may be considered for up to two weeks following spine surgery or until patients are ambulatory to reduce the incidence of venothromboembolic events. Grade of Recommendation: C

Shiqing et al1 performed a prospective, randomized, controlled trial on spinal cord injury patients surgically stabilized with pedicle screw instrumentation to evaluate the impact of low molecular weight heparin (LMWH) therapy for 7 days on 1) serological coagulation parameters and 2) prevention of DVT. The authors found that the levels of endothelin (ET), tissue plasminogen activator (tPA), interleukin-8 (IL-8), IL-6 and procalcitonin (PCT) decreased significantly in patients treated with LMWH after surgery. Compared to controls, the LMWH cohort had lower plasma viscosity, erythrocyte electrophoresis time and platelet aggregation rate and D-dimer (D-D) levels after surgery, and the incidence of deep venous thrombosis in the LMWH group was significantly lower than in the. control group. The study provides Level II evidence that administration of LMWH for 7 days postoperatively may be beneficial in reducing hypercoagulability and inflammatory markers and rection of DVT rates in surgically treated spinal cord injury patients stabilized with pedicle screw instrumentation compared to control patients not receiving LMWH. Shapiro et al2 performed a combined prospective and retrospective analysis of the efficacy of the VTE Prophylaxis Risk/Benefit Score for adult patients undergoing elective degenerative spine surgery. The authors found patients at moderate and high risk for VTE may benefit from chemoprophylaxis with enoxaparin 40mg daily during the entire hospitalization only for patients that are mobile and recommended that treatment extend for 2-weeks for patients that are less mobile to reduce VTE rates. This paper provides Level IV evidence that use of the VTE Prophylaxis Risk/Benefit Scores and treatment with enoxaparin 40mg daily during the hospitalization and for up to 2 weeks postoperatively for patients at moderate and high risk for VTE and may reduce VTE rates with no reported increase in wound and epidural rates.

Zhang et al3 performed a retrospective analysis of the safety and efficacy of apixaban vs. rivaroxaban for preventing VTE after elective lumbar spine surgery. The authors found that treatment with apixaban and rivaroxaban for 14 days postoperatively were equally effective in preventing postoperative VTE after lumbar spine surgery. This study provides Level IV evidence that treatment with apixaban and rivaroxaban for 14 days postoperatively following elective lumbar spine surgery are equally effective in preventing postoperative VTE. Moayer et al4 performed a prospective analysis of 120 patients undergoing thoraco-lumbar and cervical spine surgery for degenerative conditions. They assessed the efficacy and safety of utilizing 5000 units daily of subcutaneous Dalteparin (LMWH) starting on postoperative day 1, for 3-5 days. This study provides Level IV evidence that use of LMWH, specifically daily Dalteperin (Fragmin), is effective in reducing the DVT rate to 0.83% safely in elective degenerative spine surgery without any bleeding complications.

References

  1. Shiqing W, Shengzhong M, Cheng Z, Guangqing C, Chunzheng G. Efficacy of low molecular weight heparin in spinal trauma patients after part concentrated screw surgery and its influence on blood parameters and the incidence of deep venous thrombosis. Med Hypotheses. 2019;132:109330. doi:10.1016/j.mehy.2019.109330
  2. Shapiro JA, Stillwagon MR, Padovano AG, Moll S, Lim MR. An Evidence-Based Algorithm for Determining Venous Thromboembolism Prophylaxis After Degenerative Spinal Surgery. Int J Spine Surg. 2020;14(4):599-606. doi:10.14444/7080
  3. Zhang K, Zhao S, Kan W, Xiao J, Pu F, Li K. Comparison of apixaban and rivaroxaban for anticoagulant effect after lumbar spine surgery: a single-center report. Future Sci OA. 2018;4(5):FSO297. Published 2018 Mar 14. doi:10.4155/fsoa-2017-0123
  4. Moayer A, Mohebali N, Razmkon A. Incidence of Deep Vein Thrombosis in Patients Undergoing Degenerative Spine Surgery on Prophylactic Dalteparin; A Single Center Report. Bull Emerg Trauma. 2016;4(1):38-42.

Future Directions for Research

The work group recommends further research to identify the appropriate agents and postoperative duration of anticoagulant use to prevent venothromboembolic events following spine surgery.

Question 20: In patients who are being treated with chemical anticoagulants for a nonspine-related disorder (eg, valve replacement), what is the ideal “bridge” therapy between stopping and starting the usual agent before and after spine surgery?

There is insufficient evidence to make a recommendation for or against bridge therapy, or its timing, following elective spine surgery. Grade of Recommendation: I

Croci et al1 published a retrospective review utilizing a data registry to evaluate bleeding and thrombotic outcomes on patients taking direct oral anticoagulants - DOAC (eg, Rivaroxaban, apixaban, dabigatran, endoxaban) undergoing spine surgery. The primary endpoint analyzed was postoperative bleeding and secondary endpoints included postoperative thrombosis, anemia, perioperative PRBC transfusion, operative time, hospital stay, morbidity and mortality. Postoperative thromboembolic events happened in 4.9% of patients; all events happened if direct anticoagulants were restarted > 72 hours after surgery. Postoperative bleeding and postoperative neurological deficits rate was 4.9%. Preoperative discontinuation of direct oral anticoagulant agents < 24 hours increased transfusion rates. Treatment with concomitant blood thinners showed an increased trend towards bleeding and preexisting kidney failure increased the rate of postoperative anemia. This study provides Level III evidence that discontinuation of DOAC can be justified or considered at a short interval prior to spine surgery, even <24 hours, however there is an increased risk of perioperative blood transfusion.

References

  1. Gerlach R, Raabe A, Beck J, Woszczyk A, Seifert V. Postoperative nadroparin administration for prophylaxis of thromboembolic events is not associated with an increased risk of hemorrhage after spinal surgery. Eur Spine J. 2004;13(1):9-13. doi:10.1007/s00586-003-0642-8

Future Directions for Research

There is further research needed to identify the appropriate bridge therapy agent as well as the timing of administration of a specific bridge agent, prior to and following elective spine surgery.