Jose A. Canseco, Arun Kanhere, Ana Castel-Oñate, Alexander R. Vaccaro.
Recommendation: There is some evidence suggesting that chemoprophylaxis should be considered in patients undergoing multi-level lumbar spine surgery, especially when performed through an anterior approach.
Strength of Recommendation: Limited.
Rationale: There are many thromboprophylaxis methods used in spinal surgery, including elastic compression stockings (CS), pneumatic sequential compression devices (SCD), low-molecular-weight heparin (LMWH), heparin, and inferior vena cava (IVC) filters. However, the lack of clear clinical evidence of superiority has led to a wide variability in surgeon preference compared to those for other orthopaedic procedures, such as lower extremity trauma or knee/hip arthroplasty, where the clinical evidence is more robust1. The American College of Chest Physicians (ACCP) recommended against routine prophylaxis for elective spinal surgeries in patients with no significant risk factors, and a combination of mechanical and chemoprophylaxis in patients with multiple risk factors2.
One obvious confounding variable is that multi-level surgeries have a longer operative time, which is a known independent risk factor for venous thromboembolism (VTE)3–5. Despite this, in a prospective trial comparing the effect of SCD on 100 patients undergoing single-level anterior cervical corpectomy and fusion (ACCF) to 100 patients undergoing multilevel ACCF/posterior fusion, Epstein et al., found one VTE event in the former group and 7 in the latter group6. Additionally, in a case-control study, Hohl et al., observed that when treated with mechanical compression alone, patients undergoing elective degenerative thoracolumbar surgery involving ≥ 5 segment fusion exhibited a 2.3% prevalence of pulmonary embolism (PE)7. Patients at high risk of VTE, namely those undergoing surgery on more than 5 segments, combined anterior-posterior approaches, and iliocaval manipulation, have been observed to have a lowered rate (odds ratio [OR] 3.7) of PE when receiving IVC filter and post-operative chemoprophylaxis with LMWH8,9. A few other studies have found that placement of IVC in high-risk patients was protective against VTE10–12.
In terms of anatomic location, Oda et al., found in a trial of 134 patients a higher incidence of venographic deep venous thrombosis (DVT) during lumbar surgery (26.5%) compared to cervical (5.6%) and thoracic (14.3%) surgeries. It is important to note that no patients in this cohort received any VTE prophylaxis, nor did any of the patients develop clinical signs of PE; all VTE events were detected by routine venography13. Rokito et al., conducted a randomized control trial investigating the use of CS, CS + SCD, and SCD + warfarin in a study population of 329 patients undergoing major reconstructive spinal procedures in the cervical, thoracic, and/or lumbar spine. There was no benefit to using warfarin and that CS + SCD were adequate for most procedures regardless of spinal level being operated on14. The reported rate of DVT after spine surgery, ranging from 0.6%-6% is very low7,12,15–17.
Anterior and combined anterior/posterior approaches are one of the high-risk factors for VTE according to the 7th ACCP venous thrombosis prevention guidelines2. It becomes difficult to elucidate causality associated to these approach-specific risk factors from other high-risk patient factors. It is thought that the risk associated with anterior and anterior/posterior approaches is related to intraoperative manipulation of the iliac and great vessels8,9,12,18,19. Oda et al., found a 15.5% incidence of asymptomatic DVT (by venography screening) after posterior spinal surgery without any prophylaxis13. Dearborn et al., found in their retrospective cohort a 6.1% PE incidence in spine patients undergoing anterior and posterior approaches compared to a 0.5% in the posterior approach group20. These patients had only mechanical prophylaxis. Pateder et al., conducted a similar study with the addition of pharmacologic prophylaxis using warfarin, LMWH or heparin, according to availability and surgeon judgment. They observed a PE incidence of 3% with anterior and combined approaches and 0.65% with posterior approaches. The apparent decrease in anterior incidence compared to Dearborn et al., was attributed to the chemoprophylaxis preventing thrombi formation after endothelial injury to the great vessels19. This mechanism is supported by the posterior approach incidence of 0.65%, similar to Dearborn et al., suggesting a posterior approach may not equally benefit from the added pharmacologic prophylaxis. Interestingly, Pateder et al., also noted that right-side anterior approaches, which require manipulation of the vena cava, had a higher rate of PE compared to left-side approaches, which require manipulation of the aorta (13.3% vs. 2.3%)19.
Adding to the debate, McLynn et al., compared the National Surgical Quality Improvement Program (NSQIP) database to a retrospective cohort and found conflicting evidence for the necessity of prophylaxis, demonstrating no associated increased risk of VTE with multi-level procedures or due to a specific surgical approach15. They also did not find a reduction in VTE with pharmacologic prophylaxis (relative risk [RR]=1.32 p=0.421) but did find an increase in the occurrence of hematoma requiring reoperation with prophylaxis compared to without (0.62% vs. 0.08%; RR=7.80, p=0.020). Pendharker et al., found a decreased rate of VTE in microscopic lumbar discectomy group in a study on 42,025 patients which was compared outcomes of lumbar macro discectomy versus micro discectomy21.
The risk associated with undue pharmacologic VTE prophylaxis is excessive bleeding, specifically epidural hematomas, due to the potential for devastating neurologic injury. Thus, the risk of possible VTE needs to be weighed against the risk of administration of VTE prophylaxis to patients undergoing spine procedures.
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