173 – Is routine screening for DVT required in the pre-operative and/or post-operative period for patients undergoing spine procedures?

173 – Is routine screening for DVT required in the pre-operative and/or post-operative period for patients undergoing spine procedures?

Andrea Angelini, Gentaro Kumagai, Olivier Q. Groot.

Response/Recommendation: There is no role for routine screening for deep venous thrombosis (DVT) in patients undergoing spine procedures. Doppler ultrasonography surveillance may be considered in high-risk surgical patients including those who are older, with spine injury, personal history of VTE, malignancy, cervical spondylotic myelopathy (CSM), and/or non-ambulatory.

Strength of Recommendation: Limited.

Rationale: Venous thromboembolism (VTE) is a well-known complication of major orthopaedic and spine surgeries. The reported incidence of VTE in patients undergoing spine surgery ranges from 0.29% – 31%1-3. Moreover, the overall rates of pulmonary (PE) and associated fatality after spinal surgery are 1.38% and 0.34%, respectively2-5.

Although contrast venography has been used for diagnosis of DVT, it is not suitable for the routine screening of asymptomatic patients due to potential complications, technical issues, expense, and invasiveness6. Similarly, the use of D-dimer, a byproduct of fibrinolysis7, as a screening tool lacked sensitivity and specificity in detecting VTE after hip arthroplasty8-12. Ultrasonography, on the other hand, has become the primary non-invasive method for investigating suspected DVT of the femoral and popliteal veins9. Standard ultrasound showed relatively high sensitivity (> 90%) for proximal or (around 60%) for below-the-knee DVT in a systematic review of diagnostic cohort studies13. Duplex ultrasonography (DUS) has also improved precision and efficiency in diagnosing DVT compared to most non-invasive techniques14. Furthermore, combined D-dimer and ultrasound screening in patients with acute spinal cord injury have improved the detection of VTE compared to D-dimer screening alone15.

However, controversy remains regarding the use of routine screening for DVT in the perioperative period for patients undergoing spine procedures. We performed an extensive systematic review of all publications. A total of 26 articles that satisfied all inclusion criteria were selected for data extraction after full review. Information about these studies with respect to year of publication, level of evidence, number of patients, methods of screening, timing of screening, methods of prophylaxis, and incidence of VTE are summarized in Table 13,5,18,22-44. Studies suggest against screening for patients undergoing spine surgery while others recognize that only patients at high risk may benefit. Based on the available literature, the risk factors for an increased risk of VTE in patients undergoing spine surgery may be seen in older patients, long periods of bed rest from paralysis and pain, high D-dimer level, longer duration of operation, intraoperative blood loss, and transfusion, previous history of VTE, fracture, comorbid disease burden and tumor surgery16-44. Studies reporting DVT and/or PE rates vary in the type of surgery included and the methods used to detect DVT ranging from clinical examination28-29 to screening DUS3,22,24-27,30-32,35,38-40,43-44, screening enhanced computer tomography (CT)34, D-dimer testing combined with DUS and/or enhanced CT18,33,36-37,41-42, and venography5.

Five articles recommended preoperative and/or postoperative routine screening for DVT. Liu et al., investigated routine DVT screening in a retrospective cross-sectional study40. Of 396 patients with CSM, 16 (4%) had preoperative DVT. They concluded that preoperative screening should be considered for patients with CSM, and in particular those who are older, have had longer duration of CSM, have poor lower limb mobility, and have a heart disease history. Oda et al., evaluated DVT occurrence after posterior spinal surgery5. Neither mechanical methods nor anticoagulation medications were used for prophylaxis against VTE in their cohort. Bilateral ascending venography was performed within 14 days after surgery. There were no patients with clinical signs of DVT and PE. However, 17 patients (15.5%) showed venographic evidence of DVT, of whom 16 had distal thrombi, and only one had a proximal thrombus. They suggested that the prevalence of DVT after posterior spinal surgery is higher than generally recognized. Ikeda et al., examined predictable factors of DVT after spine surgery. Postoperative DVT was detected using DUS18. Age, sex, body mass index (BMI), operation time, amount of bleeding, preoperative ambulatory status, usage of instrumentation, and preoperative serum levels of D-dimer were compared between the DVT and non-DVT groups to establish predictors for postoperative DVT. Cut-off value of the preoperative level of D-dimer was calculated using receiver operating curve (ROC) analysis. It was suggested that perioperative application of DUS for detecting DVT in the lower extremities should be performed in patients undergoing spine surgery who are female, non-ambulatory, and with higher preoperative D-dimer serum levels. Inoue et al., examined changes in blood markers with PE or DVT after low-risk spine surgery, namely cervical laminoplasty or lumbar laminectomy41. Elevated D-dimer at postoperative days 3 and 7 was found to be a predictive factor for the early diagnosis of PE after spine surgery. A retrospective study reported an incidence of asymptomatic DVT identified by duplex screening of 10% (45 of 458 trauma patients), significantly higher in older patients, those with major length of stay, higher injury scores, and with spinal injury23. The authors recommended surveillance in trauma patients with these risk factors.

There are other publications that recommend against routine screening for DVT in patients undergoing spine surgery. Kaabachi et al., investigated asymptomatic DVT and prothrombotic diseases in non-syndromic children undergoing scoliosis surgery31. The protocol was designed for active screening of DVT using color DUS on the day before surgery and repeated on the 3rd, 7th, and 15th day postoperatively. Evaluation of prothrombotic disorders included antithrombin and protein-C activities, and total protein-S antigen level. No patient manifested clinical symptoms of VTE in their study. Preoperative Doppler and ultrasound examinations were normal in all patients. They concluded that VTE events are rare after scoliosis surgery, and routine screening is not justified. Ko et al., investigated the incidence of thromboembolism in patients who received tranexamic acid (TXA) after lumbar spine fusion and explored the diagnostic value of lower limb DUS as a screening test42. They found comparable incidence of VTE (0.8%) in the TXA and non-TXA groups, and they concluded that lower limb DUS was not recommended as a screening test of DVT because of high false-positive rate.

Based on the available literature, there does not seem to be a role for routine screening for DVT in patients undergoing spine surgery. Screening should be reserved for patients at high-risk of VTE, as determined by studies on the subject and highlighted above.

Table 1:          Summary of the 26 articles selected for inclusion in the review.

First authorYearLevel of EvidenceNo casesMethods of screeningTimingProphylaxisIncidence of VTE
Ferree et al 221993Level IV87DUSWithin 2 weeks 2-7 days after surgeryCS6% DVT
Napolitano et al 231995Level IV458DUSBiweeklyHeparin + PCD10% DVT
Wood et al 241997Level II134DUS5 and 7 days after surgeryMixed1.5% VTE
Dearborn et al 251999Level IV318DUS and CT3-20 days after surgeryCS + PCD2.2% symptomatic PE 0.9% asymptomatic DVT
Oda et al 52000Level III110Bilateral ascending venographyWithin 14 days after surgeryNone15.5% DVT
Lee et al 262000Level IV313DUS5 and 7 days after surgeryNone0.3% symptomatic DVT
Leon et al 32005Level IV74DUSweeklyInferior vena cava filters in high-risk patients1.3% PE
Epstein et al 272006Level IV139DUS2 days after surgeryCS2.8% DVT and 0.7% PE
Platzer et al 282006Level IV978ClinicalMixed2.2% VTE
Schizas et al 292008Level IV270Clinical and eCTWhen clinical suspicion of PECS and chemical2.2% symptomatic PE
Strowell et al 302009Level III680DUS4 days after surgeryStandard care vs chemical (Epoetin Alfa)4.7% in the epoetin alfa group and 2.1% in the standard care group
Kaabachi et al 312010Level IV40DUSBefore surgery and 3, 7, 15 days after surgeryNoneNone
Epstein et al 322011Level IV240DUS, clinical and eCT1 to 2 days after surgeryCS3.6-6.7% PE (US negative)
Yoshikawa et al 332011Level IV88DD combined with eCTBefore and 1, 4, 7, 10, and 14 days after surgeryCS and PCD5.7% DVT
Kim et al 342011Level IV130eCTNRCS25.4% PE only, 3.8% PE and DVT, 2.3% DVT only
Al-Djalili et al 352012Level IV158Clinical + DUS2 or 3 days after surgeryCS + chemical0.6% DVT
Takahashi et al 362012Level IV1975Clinical and/or eCT/DD1 week after surgeryNone or CS1.5% symptomatic PE in non-prophylaxis group and 0.2% symptomatic PE in CS group
Houl et al 372015Level IV5766Clinical and/or DUS/eCTNRPCD1.5% VTE (0.88% PE and 0.66% PE)
Hamidi et al 382015Level IV89DUSNRCA and Chemical or not3.3% VTE
Weber et al 392016Level IV107Clinical and DUS, and or eCT4 or 5 days after surgeryMixed3.7% VTE (1.9% DVT and 1.9% PE)
Liu et al 402016Level IV396DUSBefore surgeryNR4% had DVT in patients with CSM preoperatively
Ikeda et al 182017Level IV194DD combined with DUSUS 5 days DD 1, 3, 7, 10, and 14 days after surgeryCS and PCD29.4% DVT
Inoue et al 412018Level IV72DD combined with eCTCT: before and 3 days after surgery DD: before and 1, 3, and 7 days after surgeryPCD8.3% asymptomatic PE and 8.3% asymptomatic DVT
Koo et al 422018Level III122DD combined with DUS7 days after surgeryNR0.8% DVT in the TXA group and 1.2% DVT in the control group
Cheang et al 432019Level IV170DUS3 and 7 days after surgeryChemical10% DVT
Zhang et al 442021Level IV2053Clinical + DUSNRNone2.39% DVT

Level I is high-quality randomized control study; Level II, lesser quality randomized control trial, prospective comparative study, prospective study with historical controls; Level III, case-control study, retrospective comparative study; Level IV, case series; Level Y, expert opinion, case report.

VTE=Venous thromboembolism; DUS=Duplex ultrasonography; CS=Compression stocking; DVT=Deep venous thrombosis; PCD=Pneumatic compression device; PE=Pulmonary embolism; eCT=enhance contrast computed tomography; US=Ultrasound; DD=D-dimer; NR=No record; CSM=Cervical spondylotic myelopathy; TXA=Tranexamic acid.


1.      Glotzbecker MP, Bono CM, Wood KB, Harris MB. Thromboembolic disease in spinal surgery: a systematic review. Spine (Phila Pa 1976). 2009 Feb 1;34(3):291-303. doi: 10.1097/BRS.0b013e318195601d.

2.      Nicol M, Sun Y, Craig N, Wardlaw D. Incidence of thromboembolic complications in lumbar spinal surgery in 1,111 patients. Eur Spine J. 2009 Oct;18(10):1548-52. Epub 2009/06/02.

3.      Leon L, Rodriguez H, Tawk RG, Ondra SL, Labropoulos N, Morasch MD. The prophylactic use of inferior vena cava filters in patients undergoing high-risk spinal surgery. Ann Vasc Surg. 2005 May;19(3):442-7. Epub 2005/05/03.

4.      Smith JS, Fu KM, Polly DW, Jr., 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: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine (Phila Pa 1976). 2010 Nov 15;35(24):2140-9. Epub 2010/06/29.

5.      Oda T, Fuji T, Kato Y, Fujita S, Kanemitsu N. Deep venous thrombosis after posterior spinal surgery. Spine (Phila Pa 1976). 2000 Nov 15;25(22):2962-7. Epub 2000/11/14.

6.      Kelly J, Rudd A, Lewis RR, Hunt BJ. Screening for subclinical deep-vein thrombosis. QJM. 2001 Oct;94(10):511-9.

7.      Wada M, Iizuka M, Iwadate Y, Yamakami I, Yoshinaga K, Saeki N. Effectiveness of deep vein thrombosis screening on admission to a rehabilitation hospital: a prospective study in 1043 consecutive patients. Thromb Res. 2013 Jun;131(6):487-92.

8.      Matsumoto S, Suda K, Iimoto S, Yasui K, Komatsu M, Ushiku C, et al. Prospective study of deep vein thrombosis in patients with spinal cord injury not receiving anticoagulant therapy. Spinal Cord. 2015 Apr;53(4):306-9. Epub 2015/02/04.

9.      Becker DM, Philbrick JT, Bachhuber TL, Humphries JE. D-dimer testing and acute venous thromboembolism. A shortcut to accurate diagnosis? Arch Intern Med. 1996 May 13;156(9):939-46.

10.    Furlan JC, Fehlings MG. Role of screening tests for deep venous thrombosis in asymptomatic adults with acute spinal cord injury: an evidence-based analysis. Spine (Phila Pa 1976). 2007 Aug 1;32(17):1908-16.

11.    Chen CJ, Wang CJ, Huang CC. The value of D-dimer in the detection of early deep-vein thrombosis after total knee arthroplasty in Asian patients: a cohort study. Thromb J. 2008 May 28;6:5. Epub 2008/05/29.

12.    Shiota N, Sato T, Nishida K, Matsuo M, Takahara Y, Mitani S, et al. Changes in LPIA D-dimer levels after total hip or knee arthroplasty relevant to deep-vein thrombosis diagnosed by bilateral ascending venography. J Orthop Sci. 2002;7(4):444-50. Epub 2002/08/16.

13.    Goodacre S, Sampson F, Thomas S, van Beek E, Sutton A. Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Med Imaging. 2005 Oct 3;5:6. Epub 2005/10/06.

14.    Fraser DG, Moody AR, Morgan PS, Martel AL, Davidson I. Diagnosis of lower-limb deep venous thrombosis: a prospective blinded study of magnetic resonance direct thrombus imaging. Ann Intern Med. 2002 Jan 15;136(2):89-98. Epub 2002/01/16.

15.    Kumagai G, Wada K, Kudo H, Asari T, Ichikawa N, Ishibashi Y. D-dimer monitoring combined with ultrasonography improves screening for asymptomatic venous thromboembolism in acute spinal cord injury. J Spinal Cord Med. 2020 May;43(3):353-7. Epub 2018/09/11.

16.    Wei J, Li W, Pei Y, Shen Y, Li J. Clinical analysis of preoperative risk factors for the incidence of deep venous thromboembolism in patients undergoing posterior lumbar interbody fusion. J Orthop Surg Res. 2016 Jun 13;11(1):68. doi: 10.1186/s13018-016-0403-0.

17.    Akins PT, Harris J, Alvarez JL, Chen Y, Paxton EW, Bernbeck J, Guppy KH. Risk Factors Associated With 30-day Readmissions After Instrumented Spine Surgery in 14,939 Patients: 30-day readmissions after instrumented spine surgery. Spine (Phila Pa 1976). 2015 Jul 1;40(13):1022-32. doi: 10.1097/BRS.0000000000000916.

18.    Ikeda T, Miyamoto H, Hashimoto K, Akagi M. Predictable factors of deep venous thrombosis in patients undergoing spine surgery. J Orthop Sci. 2017 Mar;22(2):197-200. doi: 10.1016/j.jos.2016.11.014.

19.    Zhang L, Cao H, Chen Y, Jiao G. Risk factors for venous thromboembolism following spinal surgery: A meta-analysis. Medicine (Baltimore). 2020 Jul 17;99(29):e20954. doi: 10.1097/MD.0000000000020954..

20.    Yoshioka K, Murakami H, Demura S, Kato S, Tsuchiya H. Prevalence and risk factors for development of venous thromboembolism after degenerative spinal surgery. Spine (Phila Pa 1976). 2015 Mar 1;40(5):E301-6. doi: 10.1097/BRS.0000000000000727.

21.    Tominaga H, Setoguchi T, Tanabe F, Kawamura I, Tsuneyoshi Y, Kawabata N, Nagano S, Abematsu M, Yamamoto T, Yone K, Komiya S. Risk factors for venous thromboembolism after spine surgery. Medicine (Baltimore). 2015 Feb;94(5):e466. doi: 10.1097/MD.0000000000000466.

22.    Ferree BA, Stern PJ, Jolson RS, Roberts JMt, Kahn A, 3rd. Deep venous thrombosis after spinal surgery. Spine (Phila Pa 1976). 1993 Mar 1;18(3):315-9. Epub 1993/03/01.

23.    Napolitano LM, Garlapati VS, Heard SO, Silva WE, Cutler BS, O’Neill AM, Anderson FA Jr, Wheeler HB. Asymptomatic deep venous thrombosis in the trauma patient: is an aggressive screening protocol justified? J Trauma. 1995 Oct;39(4):651-7; discussion 657-9. doi: 10.1097/00005373-199510000-00006.

24.    Wood KB, Kos PB, Abnet JK, Ista C. Prevention of deep-vein thrombosis after major spinal surgery: a comparison study of external devices. J Spinal Disord. 1997 Jun;10(3):209-14. Epub 1997/06/01.

25.    Dearborn JT, Hu SS, Tribus CB, Bradford DS. Thromboembolic complications after major thoracolumbar spine surgery. Spine (Phila Pa 1976). 1999 Jul 15;24(14):1471-6. Epub 1999/07/29.

26.    Lee HM, Suk KS, Moon SH, Kim DJ, Wang JM, Kim NH. Deep vein thrombosis after major spinal surgery: incidence in an East Asian population. Spine (Phila Pa 1976). 2000 Jul 15;25(14):1827-30. Epub 2000/07/11.

27.    Epstein NE. Efficacy of pneumatic compression stocking prophylaxis in the prevention of deep venous thrombosis and pulmonary embolism following 139 lumbar laminectomies with instrumented fusions. J Spinal Disord Tech. 2006 Feb;19(1):28-31. Epub 2006/02/08.

28.    Platzer P, Thalhammer G, Jaindl M, Obradovic A, Benesch T, Vecsei V, et al. Thromboembolic complications after spinal surgery in trauma patients. Acta Orthop. 2006 Oct;77(5):755-60. Epub 2006/10/28.

29.    Schizas C, Neumayer F, Kosmopoulos V. Incidence and management of pulmonary embolism following spinal surgery occurring while under chemical thromboprophylaxis. Eur Spine J. 2008 Jul;17(7):970-4. Epub 2008/04/19.

30.    Stowell CP, Jones SC, Enny C, Langholff W, Leitz G. An open-label, randomized, parallel-group study of perioperative epoetin alfa versus standard of care for blood conservation in major elective spinal surgery: safety analysis. Spine (Phila Pa 1976). 2009 Nov 1;34(23):2479-85. Epub 2009/11/21.

31.    Kaabachi O, Alkaissi A, Koubaa W, Aloui N, Toumi Nel H. Screening for deep venous thrombosis after idiopathic scoliosis surgery in children: a pilot study. Paediatr Anaesth. 2010 Feb;20(2):144-9. Epub 2010/01/19.

32.    Epstein NE, Staszewski H, Garrison M, Hon M. Pulmonary embolism diagnosed on computed tomography contrast angiography despite negative venous Doppler ultrasound after spinal surgery. J Spinal Disord Tech. 2011 Aug;24(6):358-62. Epub 2011/02/22.

33.    Yoshiiwa T, Miyazaki M, Takita C, Itonaga I, Tsumura H. Analysis of measured D-dimer levels for detection of deep venous thrombosis and pulmonary embolism after spinal surgery. J Spinal Disord Tech. 2011 Jun;24(4):E35-9. Epub 2010/10/27.

34.    Kim HJ, Walcott-Sapp S, Adler RS, Pavlov H, Boachie-Adjei O, Westrich GH. Thromboembolic Complications Following Spine Surgery Assessed with Spiral CT Scans: DVT/PE Following Spine Surgery. HSS J. 2011 Feb;7(1):37-40. Epub 2012/02/02.

35.    Al-Dujaili TM, Majer CN, Madhoun TE, Kassis SZ, Saleh AA. Deep venous thrombosis in spine surgery patients: incidence and hematoma formation. Int Surg. 2012 Apr-Jun;97(2):150-4. Epub 2012/10/30.

36.    Takahashi H, Yokoyama Y, Iida Y, Terashima F, Hasegawa K, Saito T, et al. Incidence of venous thromboembolism after spine surgery. J Orthop Sci. 2012 Mar;17(2):114-7. Epub 2012/01/10.

37.    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 Jun;28(5):E310-5. Epub 2013/03/21.

38.    Hamidi S, Riazi M. Incidence of venous thromboembolic complications in instrumental spinal surgeries with preoperative chemoprophylaxis. J Korean Neurosurg Soc. 2015 Feb;57(2):114-8. Epub 2015/03/04.

39.    Weber B, Seal A, McGirr J, Fielding K. Case series of elective instrumented posterior lumbar spinal fusions demonstrating a low incidence of venous thromboembolism. ANZ J Surg. 2016 Oct;86(10):796-800. Epub 2014/06/06.

40.    Liu L, Liu YB, Sun JM, Hou HF, Liang C, Li T, et al. Preoperative deep vein thrombosis in patients with cervical spondylotic myelopathy scheduled for spinal surgery. Medicine (Baltimore). 2016 Nov;95(44):e5269. Epub 2016/11/20.

41.    Inoue H, Watanabe H, Okami H, Kimura A, Seichi A, Takeshita K. D-dimer predicts pulmonary embolism after low-risk spine surgery. Spine Surg Relat Res. 2018;2(2):113-20. Epub 2018/02/28.

42.    Ko BS, Cho KJ, Kim YT, Park JW, Kim NC. Does Tranexamic Acid Increase the Incidence of Thromboembolism After Spinal Fusion Surgery? Clin Spine Surg. 2020 Mar;33(2):E71-E5. Epub 2019/08/07.

43.    Cheang MY, Yeo TT, Chou N, Lwin S, Ng ZX. Is anticoagulation for venous thromboembolism safe for Asian elective neurosurgical patients? A single centre study. ANZ J Surg. 2019 Jul;89(7-8):919-24. Epub 2019/07/12.

44.    Zhang H, Weng H, Yu K, Qiu G. Clinical Risk Factors and Perioperative Hematological Characteristics of Early Postoperative Symptomatic Deep Vein Thrombosis in Posterior Lumbar Spinal Surgery. Spine (Phila Pa 1976). 2021 Jan 25. Epub 2021/01/27.

45.    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 Neurosurg. 2020 Sep;196:105982. doi: 10.1016/j.clineuro.2020.105982.

46.    Pham H, Russell T, Seiwert A, Kasper G, Lurie F. Timing of Hospital-acquired Venous Thromboembolism and Its Relationship with Venous Thromboembolism Prevention Measures in Immobile Patients. Ann Vasc Surg. 2019 Apr;56:24-28. doi: 10.1016/j.avsg.2018.09.014

47.    Groot OQ, Ogink PT, Paulino Pereira NR, Ferrone ML, Harris MB, Lozano-Calderon SA, Schoenfeld AJ, Schwab JH. High Risk of Symptomatic Venous Thromboembolism After Surgery for Spine Metastatic Bone Lesions: A Retrospective Study. Clin Orthop Relat Res. 2019 Jul;477(7):1674-1686. doi: 10.1097/CORR.0000000000000733.

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