Harold Fogel, Ali Parsa, Stephen DiMaria.
Response/Recommendation: Routine administration of pharmacologic venous thromboembolism (VTE) prophylaxis for major spinal procedures in pediatric patients is not supported by current evidence. Chemoprophylaxis should be limited to patients with multiple risk factors. Controversy exists on the utility of mechanical prophylaxis although poses minimal risk.
Strength of Recommendation: Limited.
Rationale: Currently, there is no widely accepted guideline for VTE prophylaxis in pediatric orthopaedic patients and a majority of pediatric orthopaedic surgeons are unaware of their own institution’s VTE prophylaxis protocol1. In a multi-national study on critically ill children, 17.6 % of 2,484 patients met the criteria of the American College of Chest Physicians (ACCP) guidelines for pharmacologic prophylaxis, however, almost 2/3 of those patients did not receive prophylaxis due to lack of evidence2.
The incidence of VTE in pediatric orthopaedic patients primarily derives from three main existing registries (Canada, Germany, and the Netherlands) and is reported to be 5.3 per 10,000 hospital admissions and 0.7 per 100,000 children. Previously documented risk factors for VTE in pediatric patients include intubation, intensive care unit (ICU) admission, blood transfusion, major surgery, central venous catheter placement, and longer length of ICU stay3. The estimated incidence of VTE following spinal fusion in children is 0.21% and risk factors include adolescent children and children with diagnoses of congenital scoliosis, syndromic spinal deformities, kyphoscoliosis, or thoracolumbar fractures4. In a 28-year follow-up study on pediatric scoliosis surgery, Erkilinc et al., found a lower extremity deep venous thrombosis (DVT) rate of 0.13% in 1,471 patients, and zero patients were diagnosed with pulmonary embolism (PE)8.
There is a paucity of data on the utility of VTE prophylaxis in pediatric patients undergoing major spine procedures. However, due to the extremely low incidence of VTE in pediatric patients, no studies have identified a clear benefit thus far. In a retrospective review of 73 patients aged 14 – 19 undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS), there were no DVT, or PE identified in any patients, regardless of whether chemoprophylaxis was used7. In a 2020, multi-center retrospective study, the incidence of VTE after elective spine and lower-extremity surgery in children with neuromuscular complex chronic conditions was 4 per 10,000, and only 4% used chemoprophylaxis. Moreover, only 10% used compression devices, raising the question of whether mechanical prophylaxis should even be recommended in this cohort3. Asian literature also has shown that except for spinal cord injury patients the routine use of anticoagulation for spine surgery in children is not recommended12-14.
There is minimal research on potential complications of chemoprophylaxis in pediatric spinal patients. A 2019 study on VTE chemoprophylaxis in AIS patients showed a higher but statistically non-significant difference in post-operative drain output as well as the amount of wound oozing in patients who received post-operative chemoprophylaxis compared to those who didn’t. Length of stay was significantly shorter in the non-chemoprophylaxis group. The authors did not find a correlation between when chemoprophylaxis was initiated and the reported complications7.
To evaluate the standard of care among experts, forty-seven spine surgeons (orthopaedic spine surgeon and neurosurgeon) were surveyed on current trends in the perioperative administration of thromboprophylaxis in spinal surgery. Pharmacologic prophylaxis was used for spinal cord injury (SCI) by 91% of surgeons compared to 62% for non-SCI. Similar results were seen in anterior thoracolumbar procedures vs. posterior thoracolumbar surgeries. Almost half of the surgeons experienced complications with low-molecular-weight heparin (LMWH) including epidural hematomas, retropharyngeal hematoma, thrombocytopenia, and wound hematoma9.
1. Murphy RF, Williams D, Hogue GD, Spence DD, Epps H, Chambers HG, Shore BJ. Prophylaxis for pediatric venous thromboembolism: current status and changes across pediatric orthopaedic society of North America From 2011. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2020 May 1;28(9):388-94.
2. Otten D. A Multinational Study of Thromboprophylaxis Practice in Critically Ill Children: Faustino E, Hanson S, Spinella P, et al. Crit Care Med 2014; 42: 1232–40. Journal of Emergency Medicine. 2014 Aug 1;47(2):258.
3. 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?. Journal of Pediatric Orthopaedics. 2020 May 12;40(5):e375-9.
4. Jain A, Karas DJ, Skolasky RL, Sponseller PD. Thromboembolic complications in children after spinal fusion surgery. Spine. 2014 Jul 15;39(16):1325-9.
5. Van Ommen CH, Heijboer H, Büller HR, et al. Venous thromboembolism in childhood: a prospective two-year registry in the Netherlands. J Pediatr 2001;139:676–781.
6. Monagle P, Adams M, Mahoney M, et al. Outcome of pediatric thromboembolic disease: a report from the Canadian childhood thrombophilia registry. Pediatr Res 2000;47:763–6.
7. Kochai A, Cicekli O, Bayam L, Türker M, Sariyilmaz K, Erkorkmaz Ü. Is pharmacological anticoagulant prophylaxis necessary for adolescent idiopathic scoliosis surgery?. Medicine. 2019 Jul;98(29).
8. Erkilinc M, Clarke A, Poe-Kochert C, Thompson GH, Hardesty CK, O’Malley N, Mistovich RJ. Is there value in venous thromboembolism chemoprophylaxis after pediatric scoliosis surgery? A 28-year single center study. Journal of Pediatric Orthopaedics. 2021 Mar 1;41(3):138-42.
9. Ploumis A, Ponnappan RK, Sarbello J, Dvorak M, Fehlings MG, Baron E, Anand N, Okonkwo DO, Patel A, Vaccaro AR. Thromboprophylaxis in traumatic and elective spinal surgery: analysis of questionnaire response and current practice of spine trauma surgeons. Spine. 2010 Feb 1;35(3):323
10. Sharpe JP, Gobbell WC, Carter AM, Pahlkotter MK, Muhlbauer MS, Camillo FX, Fabian TC, Croce MA, Magnotti LJ. Impact of venous thromboembolism chemoprophylaxis on postoperative hemorrhage following operative stabilization of spine fractures. Journal of Trauma and Acute Care Surgery. 2017 Dec 1;83(6):1108-13.
11. Al-Dujaili TM, Majer CN, Madhoun TE, Kassis SZ, Saleh AA. Deep venous thrombosis in spine surgery patients: incidence and hematoma formation. International surgery. 2012 Oct;97(2):150-4.
12. 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 journal of surgery. 2019 Jul;89(7-
13. Do JG, Kim DH, Sung DH. Incidence of deep vein thrombosis after spinal cord injury in Korean patients at acute rehabilitation unit. Journal of Korean medical science. 2013 Sep 1;28(9):1382-7.
14. Rathore MF, Hanif S, New PW, Butt AW, Aasi MH, Khan SU. The prevalence of deep vein thrombosis in a cohort of patients with spinal cord injury following the Pakistan earthquake of October 2005. Spinal Cord 2008; 46: 523-6.