Evidence-Based Clinical Guidelines
Multidisciplinary Spine Care Antithrombotic Therapies for Adults Undergoing Spine Surgery
Second Edition
Summary of Questions & Recommendations
Clinical Question | Guideline Recommendation: See recommendation section for supporting text A:Recommended; B: Suggested; C: May Be Considered; I: Insufficient or Conflicting Evidence |
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A systematic review of the literature yielded no studies to adequately address this question. | |
A systematic review of the literature yielded no studies to adequately address this question. | |
A systematic review of the literature yielded no studies to adequately address this question. | |
Question 4. 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) with one or more of the following prophylaxis measures: compression stockings, mechanical sequential compression devices, chemoprophylaxis medication? | There is good evidence that the incidence of VTE in elective spine surgery with mechanical and/or chemoprophylaxis is 0-10% in the absence of significant risk factors. Grade of Recommendation: A
There is insufficient evidence to make a recommendation for or against a specific treatment protocol (mechanoprophylaxis, chemoprophylaxis) for elective spine surgery; however, the rate of VTE may be higher in anterior versus posterior lumbar surgery, lumbar versus cervical surgery, and surgery of more than four levels. Grade of Recommendation: I
There is insufficient evidence to make a recommendation for or against the timing of the occurrence of venous thromboembolism in the perioperative period; the range appears to vary from prior to surgery up to 30 days post-op depending on the protocol used for screening. Grade of Recommendation: I
There is insufficient and conflicting evidence to make a recommendation for or against the superior effectiveness of combined chemoprophylaxis and mechanical prophylaxis vs. either alone. Grade of Recommendation: I |
Question 5: What is the incidence (symptomatic and asymptomatic) and timing of venous thromboembolism (VTE) following spinal surgery (cervical, thoracic or lumbar) for spine trauma (with spinal cord injury and without spinal cord injury) with one or more of the following prophylaxis measures: compression stockings, mechanical sequential compression devices, chemoprophylaxis medication? | There is fair evidence to suggest that the incidence of VTE in patients who have been operated on for spinal trauma without spinal cord injuries, with prophylactic measures is 1.4-6%. Patients with spinal cord injury have a higher incidence of VTE. Grade of Recommendation: B |
Question 6: What is the incidence (symptomatic and asymptomatic) and timing of venous thromboembolism (VTE) following spinal surgery (cervical, thoracic or lumbar) for malignancy (with spinal cord injury and without spinal cord injury) with one or more of the following prophylaxis measures: compression stockings, mechanical sequential compression devices, chemoprophylaxis medication? | There is fair evidence to suggest that the incidence of VTE in patients undergoing spine surgery for malignancy is 0-22%. Grade of Recommendation: B |
Question 7: What risk factors are associated with increased DVT/PE incidence in patients who receive at least one prophylaxis measure (eg, compression stockings, mechanical sequential compression devices, chemoprophylaxis medication) undergoing elective spine surgery not performed for tumor or trauma (cervical, thoracic or lumbar) compared to those who do not receive prophylaxis treatment? | A systematic review of the literature yielded no studies to adequately address this question. |
Question 8: What risk factors are associated with increased DVT/PE incidence in patients who receive at least one prophylaxis measure (eg, compression stockings, mechanical sequential compression devices, chemoprophylaxis medication) undergoing spinal surgery (cervical, thoracic or lumbar) for spine trauma (with spinal cord injury and without spinal cord injury) compared to those who do not receive prophylaxis treatment? | A systematic review of the literature yielded no studies to adequately address this question. |
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Question 9: What risk factors are associated with increased DVT/PE incidence in patients who receive at least one prophylaxis measure (eg, compression stockings, mechanical sequential compression devices, chemoprophylaxis medication) undergoing spinal surgery (cervical, thoracic or lumbar) for malignancy (with spinal cord injury and without spinal cord injury) compared to those who do not receive prophylaxis treatment? | A systematic review of the literature yielded no studies to adequately address this question. |
Continuation of Anticoagulant There is fair evidence to suggest that the use of chemoprophylaxis is not associated with increased hemorrhagic complication rates in patients undergoing elective spine surgery. Grade of Recommendation: B
Cessation of Anticoagulant A systematic review of the literature yielded no studies to adequately address the portion of this question associated with the incidence of complication from cessation of anticoagulant. | |
It is suggested that the use of chemoprophylaxis is not associated with an increased hemorrhagic complication rate in patients undergoing surgery for spine trauma Grade of Recommendation: B | |
A systematic review of the literature yielded no studies to adequately address this question. | |
Question 13: 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 elective spinal surgery not performed for tumor or trauma (cervical, thoracic, or lumbar)? | There is fair evidence to suggest that the addition of chemoprophylaxis to mechanical prophylaxis does not appear to provide additional benefit in the prevention of thromboembolic events in the majority of patients undergoing routine elective spine surgery. Grade of Recommendation: B
The addition of chemoprophylaxis to mechanical prophylaxis may be considered to reduce the risk of VTE in high risk patients and those undergoing anterior approaches for elective spine surgery. Grade of Recommendation: C
Early postoperative rehabilitation may be considered as a route to reduce VTE risk in patients undergoing elective spine surgery. Grade of Recommendation: C |
Question 14: 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 spine trauma (with spinal cord injury and without spinal cord injury)? | Administration of chemoprophylaxis may be considered in trauma patients requiring spine surgery, after ensuring there are no active contraindications/coagulopathy. While the evidence is low-level, it is all consistent. If chemoprophylaxis is to be used, it may be initiated within 24-48 hours of injury or surgery. Grade of Recommendation: C |
Question 15: 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)? | There is insufficient evidence to make a recommendation for or against early vs. delayed use of chemoprophylaxis for decreasing the rate of VTE in patients operated upon for malignant disease of the spine. Grade of Recommendation: I
There is insufficient evidence to make a recommendation for or against the use of chemo prophylaxis for decreasing the rate of VTE in patients operated upon for malignant disease of the spine. Grade of Recommendation: I |
A systematic review of the literature yielded no studies to adequately address this question. | |
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A systematic review of the literature yielded no studies to adequately address this question. | |
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 | |
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 | |
A systematic review of the literature yielded no studies to adequately address this question. | |
There is insufficient evidence to make a recommendation for or against one specific chemoprophylaxis agent to prevent DVT/PE events following spine surgery. Grade of Recommendation: I
There is insufficient evidence supporting the use of fondaparinux as opposed to administration of aspirin at discharge following spine surgery. Grade of Recommendation: I | |
A systematic review of the literature yielded no studies to adequately address this question. | |
A systematic review of the literature yielded no studies to adequately address this question. |
A systematic review of the literature yielded no studies to adequately address this question. | |
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A systematic review of the literature yielded no studies to adequately address this question. | |
There is poor quality evidence that routine postoperative assessment for DVT does not reduce the risk of PE in patients undergoing spine surgery; however, screening for high-risk patients may be considered, as it may offer benefit. Grade of Recommendation: C |