BACKGROUND CONTEXT: Controversy exists regarding the ideal utilization of prophylactic anticoagulation for venous thromboembolism prevention following spine surgery. There is an opportunity to improve clinical outcomes if these indications can be clarified.

PURPOSE: The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (ie, reasonable) post-surgical recommendations for use of pharmacologic anticoagulation in patients following spine surgery across a spectrum of common clinical scenarios.

STUDY DESIGN: A Modified Delphi process was used.

METHODS: The methodology was based on the RAND/UCLA Appropriateness Method. The topic of antithrombotic therapy was selected by NASS for its Clinical Practice Guideline (CPG) development. In conjunction, the AUC committee was formed. The standard definitions created by the CPG were adopted and then key modifiers established to develop the scenarios. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Clinical scenarios were generated based on a matrix of modifiers considered to be key features in decision-making for antithrombotic therapy following spine surgery. Based on the literature, provider experience, and group discussion, each scenario was scored on a 9-point scale on two separate occasions: once without discussion and a second time following discussion of the initial responses. The median rating for each scenario and level of agreement were then used to determine final indications as rarely appropriate with agreement (1 – 3), uncertain or disagreement (4-6), or appropriate with agreement (7-9). Consensus was not mandatory.

RESULTS: Of the scenarios reviewed, 74% were rated as 'Appropriate with Agreement' for initiating anticoagulation within 24 hours postsurgery. Spinal cord injury and other high-risk factors were significant predictors of appropriateness (p<0.001 and p=0.005, respectively). The timing of surgery was a major point of contention, with 25 scenarios rated as 'Uncertain or Disagreement' within 24 hours. Conversely, 98% of scenarios for initiating anticoagulation between 1-4 days postoperatively were rated as ‘Appropriate with Agreement’. Decompression versus decompression and fusion, duration of procedure, and anterior versus posterior surgery did not significantly influence rating.

CONCLUSIONS: Appropriate use for antithrombotic therapy in adults undergoing spine surgery was determined using the RAND/UCLA methodology. This document provides comprehensive evidence-based recommendations based on 96 common clinical scenarios. The document in its entirety will be found on the NASS website.

Keywords: antithrombotic treatment, spine surgery, appropriate use criteria