Jose A. Canseco, Gregory R. Toci, Olivier Q. Groot, Joseph H. Schwab.

Response/Recommendation: Concerning venous thromboembolism (VTE) risk in spine surgery, high-risk procedures include those performed for oncologic, traumatic, or infection, as well as those requiring intensive care unit (ICU) admission, multiple stages, or combined approaches. Lumbar procedures including long-segment fusions or procedures utilizing an anterior approach, as well as posterior cervical fusions, should also be considered high-risk. On the other hand, most elective pediatric procedures, microdiscectomies, anterior cervical fusions, and lumbar or cervical decompressions may be considered low-risk procedures.

Strength of Recommendation: Moderate.

Rationale: Patient characteristics (age, obesity, personal history of VTE, etc.), clinical factors (length of hospital stay, operative time, etc.), and neurologic impairment are associated with increased risk of postoperative VTE^1-3. Nonetheless, there is no consensus regarding the VTE risk profile when it comes to surgical indications, operative techniques, and extent of surgery.

High-risk spine surgeries: Oncologic indication for spinal surgery has been shown to increase the risk of VTE with a reported incidence nearing 11.3%^4-9. In a National Surgical Quality Improvement Project (NSQIP) database study of 22,434 patients, a diagnosis of tumor resulted in an odds ratio (OR) of 5.07 for postoperative VTE development, whereas a diagnosis of disseminated cancer carried an OR of 6.83⁵. This relationship has also been elucidated separately for cervical and thoracolumbar procedures, with studies reporting OR of 5.2 or 1.8, respectively^6,7. Furthermore, any surgery for infection or requiring an ICU admission should be considered high-risk^7,10,11. Infection has been shown to increase VTE risk in multiple studies, with an OR of 18.5 in a 1:2 matched cohort of 85 VTE, and an incidence of 10.7% in a database study of 357,926 patients^7,11. Similarly, a retrospective study of 6,869 patients with 1,269 postoperative ICU admissions reported a VTE incidence of 10.2% in the ICU group and 2.5% in the non-ICU group despite an increased use of chemoprophylaxis in the former group¹⁰.

Trauma or fracture as an indication for spinal surgery has also been shown to increase the risk of VTE, and these procedures should therefore be considered high-risk^7,9,12-14. In a retrospective study of 7,156 patients, a diagnosis of fracture was associated with an increased risk of VTE (OR 8.3) despite an increased use of chemoprophylaxis in this group of patients¹⁴. In another retrospective study of 195 patients, the rate of VTE was 9.2% among fracture patients compared to 2.3% in the non-fracture group (OR 4.5)¹³. Fracture has also been shown to be an independent predictor of pulmonary embolism (PE) (OR 6.9) in a retrospective study of 6,869 patients⁹.

Staged procedures and combined surgical approaches have also been shown to increase the risk of VTE^1,7,11,15,16. A 1:2 matched cohort analysis of 85 postoperative VTEs found both staged surgery (OR 28.0) and combined approach (OR 7.5) to increase the risk of VTE⁷. Additionally, multiple studies have shown that lumbar procedures have an increased risk of VTE compared to cervical procedures^{2,4,11,14,17-21}. However, an anterior approach to the lumbar spine and a posterior approach to the cervical spine have been shown to increase VTE risk compared to their posterior and anterior counterparts, respectively^1,11,22. A Nationwide Inpatient Sample (NIS) database study of 273,396 cervical procedures found a postoperative VTE incidence of 2.0% in posterior cervical fusion compared to 0.4% in anterior cervical discectomy and fusion (ACDF)²².

The number of surgical levels is another factor that could increase the risk of VTE^7,13,23-25. A 1:2 matched cohort analysis of 85 postoperative VTE identified two or more surgical levels as a risk factor (OR 7.5), and other studies reported an increased risk using various cut-offs for number of levels^7,11,23-25. Furthermore, one French database demonstrated a “dose-effect” for pedicle screw implantation, with a 40% increased risk of VTE for 1 – 5 screws, 69% for 6 – 9 screws, and 117% for > 10 screws¹.

Low-risk spine surgeries: While most elective pediatric procedures are considered low VTE risk^26,27, patients undergoing surgery for congenital scoliosis, syndromic scoliosis/kyphoscoliosis, thoracolumbar fractures, and the ones requiring ICU admission or prolonged immobilization have a relatively increased VTE risk compared to those undergoing surgery for idiopathic scoliosis²⁸. Additionally, microdiscectomy, ACDF, and lumbar or cervical decompression (i.e., laminectomy, hemi-laminectomy, and laminotomy) have demonstrated a low risk of postoperative VTE, with rates < 0.2% for each procedure²⁹. Some studies have suggested that fusion procedures may increase the risk of VTE^11,23,30,31. However, this claim has been widely disputed, and one retrospective study of 6,869 patients found that fusion actually decreased the risk of 30-day readmission for VTE (OR 0.59). Furthermore, no increased risk has been shown in revision procedures¹¹. Consequently, the VTE risk profile of spinal fusion and revision surgery could not be absolutely determined, and surgeons should rather consider the surgical indication, location, approach, and number of levels when performing VTE risk assessment.

The explanation for these relationships is multifactorial. When evaluating these surgeries, it is important to consider the Virchow’s Triad, which constitutes blood flow stasis, endothelial injury, and hypercoagulability³². Postoperative immobility may explain the increased risk in traumatic, ICU, multistage, combined approach, and long-segment procedures, while hypercoagulability may explain the increased risk in oncologic, traumatic, and infectious procedures^33,34. Further research including various surgical procedures and VTE risk assessments should be conducted to further delineate high- and low-risk procedures within spine surgery.

References:

1.         Bouyer B, Rudnichi A, Dray‐Spira R, Zureik M, Coste J. Thromboembolic risk after lumbar spine surgery: a cohort study on 325 000 French patients. J Thromb Haemost. 2018;16(8):1537–45.

2.         Buchanan IA, Lin M, Donoho DA, Ding L, Giannotta SL, Attenello F, et al. Venous Thromboembolism After Degenerative Spine Surgery: A Nationwide Readmissions Database Analysis. World Neurosurg. 2019;125:e165–74.

3.         Glotzbecker MP, Bono CM, Wood KB, Harris MB. Thromboembolic Disease in Spinal Surgery. Spine. 2009;34(3):291–303.

4.         Yoshioka K, Murakami H, Demura S, Kato S, Hayashi H, Inoue K, et al. Comparative Study of the Prevalence of Venous Thromboembolism After Elective Spinal Surgery. Orthopedics. 2013;36(2):e223-8.

5.         Piper K, Algattas H, DeAndrea-Lazarus IA, Kimmell KT, Li YM, Walter KA, et al. Risk factors associated with venous thromboembolism in patients undergoing spine surgery. J Neurosurg Spine. 2017;26(1):90–6.

6.         Sebastian AS, Currier BL, Kakar S, Nguyen EC, Wagie AE, Habermann ES, et al. Risk Factors for Venous Thromboembolism following Thoracolumbar Surgery: Analysis of 43,777 Patients from the American College of Surgeons National Surgical Quality Improvement Program 2005 to 2012. Global Spine J. 2016;06(08):738–43.

7.         Sebastian AS, Currier BL, Clarke MJ, Larson D, Huddleston PM, Nassr A. Thromboembolic Disease after Cervical Spine Surgery: A Review of 5,405 Surgical Procedures and Matched Cohort Analysis. Global Spine J. 2015;06(05):465–71.

8.         Groot OQ, Ogink PT, Pereira NRP, Ferrone ML, Harris MB, Lozano-Calderon SA, et al. High Risk of Symptomatic Venous Thromboembolism After Surgery for Spine Metastatic Bone Lesions: A Retrospective Study. Clin Orthop Relat Res. 2019;477(7):1674–86.

9.         Cloney MB, Driscoll CB, Yamaguchi JT, Hopkins B, Dahdaleh NS. Comparison of inpatient versus post-discharge venous thromboembolic events after spinal surgery: A single institution series of 6869 consecutive patients. Clin Neurol Neurosur. 2020;196:105982.

10.       Cloney MB, Goergen J, Hopkins BS, Dhillon ES, Dahdaleh NS. Factors associated with venous thromboembolic events following ICU admission in patients undergoing spinal surgery: an analysis of 1269 consecutive patients: Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves. J Neurosurg Spine. 2019;30(1):99–105.

11.       Schairer WW, Pedtke AC, Hu SS. Venous Thromboembolism After Spine Surgery. Spine. 2014;39(11):911–8.

12.       Cloney M, Dhillon ES, Roberts H, Smith ZA, Koski TR, Dahdaleh NS. Predictors of Readmissions and Reoperations Related to Venous Thromboembolic Events After Spine Surgery: A Single-Institution Experience with 6869 Patients. World Neurosurg. 2018;111:e91–7.

13.       Cloney MB, Yamaguchi JT, Dhillon ES, Hopkins B, Smith ZA, Koski TR, et al. Venous thromboembolism events following spinal fractures: A single center experience. Clin Neurol Neurosur. 2018;174:7–12.

14.       FISCHER CR, WANG E, STEINMETZ L, VASQUEZ-MONTES D, BUCKLAND A, BENDO J, et al. Prevalence of Risk Factors for Hospital-Acquired Venous Thromboembolism in Neurosurgery and Orthopedic Spine Surgery Patients. Int J Spine Surg. 2020;14(1):79–86.

15.       Edwards CC, Lessing NL, Ford L, Edwards CC. Deep Vein Thrombosis After Complex Posterior Spine Surgery: Does Staged Surgery Make a Difference? Spine Deformity. 2018;6(2):141–7.

16.       Gephart MGH, Zygourakis CC, Arrigo RT, Kalanithi PSA, Lad SP, Boakye M. Venous Thromboembolism After Thoracic/Thoracolumbar Spinal Fusion. World Neurosurg. 2012;78(5):545–52.

17.       Platzer P, Thalhammer G, Jaindl M, Obradovic A, Benesch T, Vecsei V, et al. Thromboembolic complications after spinal surgery in trauma patients. Acta Orthop. 2009;77(5):755–60.

18.       Yoshioka K, Murakami H, Demura S, Kato S, Tsuchiya H. Prevalence and Risk Factors for Development of Venous Thromboembolism After Degenerative Spinal Surgery. Spine. 2015;40(5):E301–6.

19.       Wang T, Yang S-D, Huang W-Z, Liu F-Y, Wang H, Ding W-Y. Factors predicting venous thromboembolism after spine surgery. Medicine. 2016;95(52):e5776.

20.       Xin W, Xin Q, Ming H, Gao Y, Zhao Y, Gao Y, et al. Predictable Risk Factors of Spontaneous Venous Thromboembolism in Patients Undergoing Spine Surgery. World Neurosurg. 2019;127:451–63.

21.       Oda T, Fuji T, Kato Y, Fujita S, Kanemitsu N. Deep Venous Thrombosis after Posterior Spinal Surgery. Spine. 2000;25(22):2962–7.

22.       Oglesby M, Fineberg SJ, Patel AA, Pelton MA, Singh K. The Incidence and Mortality of Thromboembolic Events in Cervical Spine Surgery. Spine. 2013;38(9):E521–7.

23.       Rojas-Tomba F, Gormaz-Talavera I, Menéndez-Quintanilla IE, Moriel-Durán J, Quevedo-Puerta DG de, Villanueva-Pareja F. Incidencia y factores de riesgo de enfermedad tromboembólica venosa en cirugía mayor espinal, sin profilaxis química o mecánica. Revista Española De Cirugía Ortopédica Y Traumatología. 2016;60(2):133–40.

24.       Hohl JB, Lee JY, Rayappa SP, Nabb CE, Devin CJ, Kang JD, et al. Prevalence of Venous Thromboembolic Events After Elective Major Thoracolumbar Degenerative Spine Surgery. J Spinal Disord Tech. 2015;28(5):E310–5.

25.       Yamasaki K, Hoshino M, Omori K, Igarashi H, Tsuruta T, Miyakata H, et al. Prevalence and risk factors of deep vein thrombosis in patients undergoing lumbar spine surgery. J Orthop Sci. 2017;22(6):1021–5.

26.       Shore BJ, Hall M, Matheney TH, Snyder B, Trenor CC, Berry JG. Incidence of Pediatric Venous Thromboembolism After Elective Spine and Lower-Extremity Surgery in Children With Neuromuscular Complex Chronic Conditions: Do we Need Prophylaxis? J Pediatr Orthoped. 2020;40(5):e375–9.

27.       Erkilinc M, Clarke A, Poe-Kochert C, Thompson GH, Hardesty CK, O’Malley N, et al. Is There Value in Venous Thromboembolism Chemoprophylaxis After Pediatric Scoliosis Surgery? A 28-Year Single Center Study. J Pediatr Orthoped. 2021;41(3):138–42.

28.       Jain A, Karas DJ, Skolasky RL, Sponseller PD. Thromboembolic Complications in Children After Spinal Fusion Surgery. Spine. 2014;39(16):1325–9.

29.       Smith JS, Fu K-MG, Polly DW, Sansur CA, Berven SH, Broadstone PA, et al. Complication Rates of Three Common Spine Procedures and Rates of Thromboembolism Following Spine Surgery Based on 108,419 Procedures. Spine. 2010;35(24):2140–9.

30.       Zhang L, Cao H, Chen Y, Jiao G. Risk factors for venous thromboembolism following spinal surgery: A meta-analysis. Medicine. 2020;99(29):e20954.

31.       Sansone JM, Rio AM del, Anderson PA. The Prevalence of and Specific Risk Factors for Venous Thromboembolic Disease Following Elective Spine Surgery. J Bone Jt Surg. 2010;92(2):304–13.

32.       Bagot CN, Arya R. Virchow and his triad: a question of attribution. Brit J Haematol. 2008;143(2):180–90.

33.       Kawai K, Watanabe T. Colorectal cancer and hypercoagulability. Surg Today. 2014;44(5):797–803.

34.       Chu AJ. Tissue Factor, Blood Coagulation, and Beyond: An Overview. Int J Inflamm. 2011;2011:367284.