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 author||Year||Level of Evidence||No cases||Methods of screening||Timing||Prophylaxis||Incidence of VTE|
|Ferree et al 22||1993||Level IV||87||DUS||Within 2 weeks 2-7 days after surgery||CS||6% DVT|
|Napolitano et al 23||1995||Level IV||458||DUS||Biweekly||Heparin + PCD||10% DVT|
|Wood et al 24||1997||Level II||134||DUS||5 and 7 days after surgery||Mixed||1.5% VTE|
|Dearborn et al 25||1999||Level IV||318||DUS and CT||3-20 days after surgery||CS + PCD||2.2% symptomatic PE 0.9% asymptomatic DVT|
|Oda et al 5||2000||Level III||110||Bilateral ascending venography||Within 14 days after surgery||None||15.5% DVT|
|Lee et al 26||2000||Level IV||313||DUS||5 and 7 days after surgery||None||0.3% symptomatic DVT|
|Leon et al 3||2005||Level IV||74||DUS||weekly||Inferior vena cava filters in high-risk patients||1.3% PE|
|Epstein et al 27||2006||Level IV||139||DUS||2 days after surgery||CS||2.8% DVT and 0.7% PE|
|Platzer et al 28||2006||Level IV||978||Clinical||–||Mixed||2.2% VTE|
|Schizas et al 29||2008||Level IV||270||Clinical and eCT||When clinical suspicion of PE||CS and chemical||2.2% symptomatic PE|
|Strowell et al 30||2009||Level III||680||DUS||4 days after surgery||Standard care vs chemical (Epoetin Alfa)||4.7% in the epoetin alfa group and 2.1% in the standard care group|
|Kaabachi et al 31||2010||Level IV||40||DUS||Before surgery and 3, 7, 15 days after surgery||None||None|
|Epstein et al 32||2011||Level IV||240||DUS, clinical and eCT||1 to 2 days after surgery||CS||3.6-6.7% PE (US negative)|
|Yoshikawa et al 33||2011||Level IV||88||DD combined with eCT||Before and 1, 4, 7, 10, and 14 days after surgery||CS and PCD||5.7% DVT|
|Kim et al 34||2011||Level IV||130||eCT||NR||CS||25.4% PE only, 3.8% PE and DVT, 2.3% DVT only|
|Al-Djalili et al 35||2012||Level IV||158||Clinical + DUS||2 or 3 days after surgery||CS + chemical||0.6% DVT|
|Takahashi et al 36||2012||Level IV||1975||Clinical and/or eCT/DD||1 week after surgery||None or CS||1.5% symptomatic PE in non-prophylaxis group and 0.2% symptomatic PE in CS group|
|Houl et al 37||2015||Level IV||5766||Clinical and/or DUS/eCT||NR||PCD||1.5% VTE (0.88% PE and 0.66% PE)|
|Hamidi et al 38||2015||Level IV||89||DUS||NR||CA and Chemical or not||3.3% VTE|
|Weber et al 39||2016||Level IV||107||Clinical and DUS, and or eCT||4 or 5 days after surgery||Mixed||3.7% VTE (1.9% DVT and 1.9% PE)|
|Liu et al 40||2016||Level IV||396||DUS||Before surgery||NR||4% had DVT in patients with CSM preoperatively|
|Ikeda et al 18||2017||Level IV||194||DD combined with DUS||US 5 days DD 1, 3, 7, 10, and 14 days after surgery||CS and PCD||29.4% DVT|
|Inoue et al 41||2018||Level IV||72||DD combined with eCT||CT: before and 3 days after surgery DD: before and 1, 3, and 7 days after surgery||PCD||8.3% asymptomatic PE and 8.3% asymptomatic DVT|
|Koo et al 42||2018||Level III||122||DD combined with DUS||7 days after surgery||NR||0.8% DVT in the TXA group and 1.2% DVT in the control group|
|Cheang et al 43||2019||Level IV||170||DUS||3 and 7 days after surgery||Chemical||10% DVT|
|Zhang et al 44||2021||Level IV||2053||Clinical + DUS||NR||None||2.39% 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.
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