167 – Concerning VTE risk, which surgeries can be considered high-risk, and which surgeries can be considered low-risk in spine surgery?

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:

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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.

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