Is chemical antithrombotic prophylaxis effective in elective thoracolumbar spine surgery? Results of a systematic review

ABSTRACT

Study design: Systematic review

Study rationale and context: There is controversy regarding the efficacy and safety of chemical prophylaxis to prevent deep venous thrombosis (DVT) and pulmonary embolism (PE) in elective spinal procedures.Commonly performed elective spine surgeries done through a posterior approach have a very low associated risk of DVT/PE. The lack of consensus is due in part to a limited amount of quality evidence based literature dealing with this issue.

Objective: To compare chemical prophylaxis with no chemical prophylaxis in preventing venous thromboembolism in elective thoracolumbar spine surgery.

Methods: We undertook a systematic review of the literature to assess the efficacy and safety of chemical prophylaxis in preventing venous thromboembolism in elective thoracolumbar spine surgery. Pubmed, EMBASE, Cochrane, National Guideline Clearinghouse Databases as well as bibliographies of key articles were searched. Articles were reviewed by two independently working reviewers. Inclusion and exclusion criteria were set and each article was subject to a predefined quality rating scheme.

Results: We identified only two articles meeting our inclusion criteria. Neither study demonstrated a significant difference between chemical prophylaxis versus no prophylaxis in preventing thromboembolic events. There was an increased incidence of perioperative bleeding with low dose Coumadin in one of the studies.

Conclusion: The incidence of DVT and PE in commonly performed elective posterior spinal procedures is very low. While there is a limited amount of randomized literature looking at this issue, the current literature does not support the routine use of chemical prophylaxis for low risk patients undergoing these procedures.

Keywords: Venous thromboembolism, deep venous thrombosis, pulmonary embolism, chemical prophylaxis, spine surgery, bleeding

 

STUDY RATIONALE AND CONTEXT There is a lack of consensus regarding the utility of chemical prophylaxis in preventing deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing elective spine surgery. There is also concern for the possibility of increased perioperative bleeding with chemical prophylaxis 1, 2 in these patients. OBJECTIVES To compare chemical prophylaxis with no chemical prophylaxis in preventing venous thromboembolism in elective thoracolumbar spine surgery. MATERIALS AND METHODS Study design: Systematic review Sampling: Search: Pubmed, EMBASE, Cochrane, and National Guideline Clearinghouse Databases; bibliographies of key articles Dates searched: 1970–February 2010. Inclusion criteria Elective thoracolumbar spine surgery, comparative studies assessing venous thromboembolic (VTE) complications Exclusion criteria Nonelective thoracolumbar spine surgery (trauma, neoplasm), pediatric patients Outcomes: risk of VTE, risk of complications from anticoagulation therapy Analysis: descriptive statistics Details about methods can be found in the web appendix at www.aospine.org / ebsj.

REFERENCES

• 1 Voth D, Schwarz M, Hahn K. et al . Prevention of deep vein thrombosis in neurosurgical patients: a prospective double-blind comparison of two prophylactic regimen.  Neurosurg Rev. 1992;  15(4) 289-294
• 2 Cheng , JS , Arnold P M, Anderson P A. et al . Anticoagulation risk in spine surgery.  Spine. 2010;  35(9S) S117-S124
• 3 Gruber U F, Rem J, Meisner C. et al . Prevention of thromboembolic complications with miniheparin-dihydroergotamine in patients undergoing lumbar disc operations.  Eur Arch Psychiatry Neurol Sci. 1984;  234(3) 157-161
• 4 Rokito S E, Schwartz M C, Neuwirth M G. Deep vein thrombosis after major reconstructive spinal surgery.  Spine. 1996;  21(7) 853-858; discussion 859
• 5 Geerts W H, Bergqvist D, Pineo G F. et al . Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).  Chest. 2008;  133(6 Suppl) 381S-453S
• 6 Committee NE-BGD .Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care. Antithrombotic Therapies in Spine Surgery. Burr Ridge, IL: North American Spine Society 2009
• 7 Cheng J S, Arnold P M, Anderson P A. et al . Anticoagulation risk in spine surgery.  Spine. 2010;  35 (9S) S117-124.

EDITORIAL STAFF PERSPECTIVE

Thromboembolic events can lead to significant morbidity and mortality. Although this systematic review suggests the incidence of DVT and PE may be low in elective posterior spinal procedures, keeping in mind the major risk factors for thromboembolism is important. Some of the major risk factors for thromboembolism in general include:

• Spinal cord injury

• Fractures of hip or leg

• History of prior venous thromboembolism

• Polytrauma

• Neoplasia

• Major anterior lumbo-sacral surgery

• Hormone replacement therapy / oral contraceptive use

• Immobility (time period unclear)

• Increasing age

• Obesity

While this is not an extensive list, it provides a reminder that consideration of clinical circumstances in addition to consideration of the evidence is a necessary part of quality patient care.