Adwin Denasty, Addisu Mesfin.
Response/Recommendation: Patients suffering from traumatic spine injury are at an increased risk for venous thromboembolism (VTE). Recommendations for VTE prophylaxis before and after surgery in spine trauma varies based on pertinent factors such as presence of spinal cord injury (SCI), segment of the spine involved, and age.
Strength of Recommendation: Moderate.
Rationale: Understanding the use VTE prophylaxis in surgical spinal trauma is very important in clinical practice as it aids in surgical planning and management. The current literature is lacking in terms of a standard of practice and future research is warranted.
VTE which includes deep venous thrombosis (DVT) and pulmonary embolism (PE) is one the most common complications following major joint surgery, with an incidence between 2.9% and 3.7%1. While there has been a focus on the incidence of VTE in other major orthopaedic procedures such as emergency hip fracture care and total hip/knee arthroplasty, there exists a gap in the literature in examining the incidence of VTE after spinal surgery. The range of VTE in spinal surgery ranges from 3% to 31% based on the patient population and diagnostic methodology2,3. To date, there is no clear consensus or standard of practice with regards to VTE prophylaxis in spinal trauma surgery. In a major study conducted by Glotzbecker et al., in 2008, 94 orthopedic and neurological spine surgeons with established clinical interest and volume in spine trauma surgery responded to questions focused on varying issues that included the perceived risk of DVT, PE, postoperative epidural hematoma, preferred chemoprophylactic agents, the safe time point for initiation of chemoprophylaxis, and use of inferior vena cava (IVC) filters. The authors concluded that there is wide variability in practices regarding thromboprophylaxis in spinal trauma surgery, which likely occurred due to the paucity of scientific evidence in the literature4,5.
VTE prophylaxis in spinal trauma surgery can be stratified based on the presence or absence of SCI. In patients without significant SCI, there is preservation of neurologic function with mobility of the extremities and decreased venous blood stasis. The reported incidence of VTE in patients with SCI has a wide range of 2% to 45.2%6–9. In a large population study of a total of 47,916 Taiwanese patients with SCI, the authors found a 2.5-fold increased risk of DVT and a 1.6-fold increased risk of PE when compared with controls10. Also, in an analysis by Ploumis et al., the authors found that the prevalence of DVT was significantly lower in patients without SCI as compared to patients with SCI (odds ratio [OR] = 6.0; 95% confidence interval [CI] = 2.9-12.7). Furthermore, patients with an acute SCI who were receiving oral anticoagulants had significantly fewer episodes of PE (OR = 0.1; 95% CI = 0.01 to 0.63) than those who were not receiving oral anticoagulants. Starting thromboprophylaxis within the first two weeks after the injury resulted in significantly fewer DVT events than delayed initiation did (OR = 0.2; 95% CI = 0.1 to 0.4)11. In spine trauma patients with associated SCI, the recommendation is to start VTE prophylaxis as early as possible and once it is deemed safe.
Risk factors for VTE in patients with SCI include increased age, obesity, flaccid paralysis, and cancer. Age as a risk factor is very important, several studies have shown that among patients with SCI, older patients are more likely to develop VTE12,13. In a study conducted by Jones T. et al., with a total of 16,240 SCI patients, the authors concluded that patients with age <30 years had a lower risk of developing a thromboembolic event14. The risk is greatest in the first three months post-injury. In elderly SCI patients, VTE prophylaxis should be administered rigorously pre- and post-operatively.
In addition to the presence or absence of SCI, the segment of the spine also plays an important role in deciding whether DVT prophylaxis should be administered before and after surgery. In another article by Ploumis et al,. the authors surveyed twenty-five spine trauma surgeons pertaining to the management of VTE prophylaxis in patients with spine fractures (with and without concomitant SCI). It was concluded that in most surgical cases of cervical spine trauma with associated SCI and thoracolumbar spine trauma with or without SCI, postoperative VTE prophylaxis is necessary. However, postoperative VTE prophylaxis after cervical spine injuries without SCI was agreed not to be needed. VTE prophylaxis is recommended to be started as early as possible in SCI cases or any cases with surgical delay. The current recommendation is that pharmacologic VTE prophylaxis needs to be administered for at least three months post-injury1515.
Even though patients with spinal fractures are likely to receive VTE prophylaxis pre- and post-operatively, it has been shown in the literature that these patients still have a high rate of VTE when compared to patients undergoing elective spine surgery16. One of the major reasons why many spine trauma surgeons may be reluctant to initiate VTE prophylaxis in the early stages of injury or even immediately after surgery is the possible increased risk of bleeding (especially epidural hematoma), neurologic, and wound healing complications that may occur in certain patients17,18. In a study by Kim DY et al,. the authors analyzed 206 patients who underwent operative fixation for spine fractures. Forty-eight (23%) patients received early (<48 hours) VTE prophylaxis, and 158 patients (76.7%) received late (>48 hours) VTE prophylaxis. They found no difference in bleeding or neurologic complications between the two groups. In fact, none of the patients developed any bleeding complications in either group19. In a more recent study by Zeeshan M. et al,. the authors found similar results. A total of 3,554 patients were equally matched (1,772, early VTE prophylaxis; 1,772 late). Patients who received early VTE prophylaxis (<48 hours) had decreased rates of DVT versus those who did not (2.1% vs. 10.8%, p < 0. 01) in operative spinal trauma without increasing the risk of bleeding and mortality20. Despite the research, there remains a wide variation in VTE prophylaxis for patients with spine trauma, based on the survey of spine surgeons4,5.
In spinal trauma patients with concomitant SCI, low-molecular-weight heparin (LMWH) is more effective in preventing DVT than unfractionated heparin with fewer bleeding complications. Use of vitamin K antagonist was also more effective in preventing PE11,21. Furthermore, according to Glotzbecker MP et. Al., the majority of surgeons surveyed selected LMWH as their agent of choice for chemoprophylaxis, with subcutaneous heparin and coumadin as the second and third most common choices, respectively. In many cases in the post-operative period, chemical anticoagulation may be delayed due to concerns of bleeding or neurologic complications. Instead, IVC filters may be used in preventing a PE5.
As previously mentioned, there is no clear standard of practice regarding the administration of VTE prophylaxis to patients suffering from spine trauma. There is a wide variability of practice regarding thromboprophylaxis in spinal trauma surgery. Further research examining the epidemiology of VTE in spinal surgery and the risks-benefit relationship of thromboprophylaxis is warranted.
1. Bjørnarå BT, Gudmundsen TE, Dahl OE. Frequency and timing of clinical venous thromboembolism after major joint surgery. J Bone Joint Surg Br. 2006;88(3):386-391. doi:10.1302/0301-620X.88B3.17207
2. Brambilla S, Ruosi C, La Maida GA, Caserta S. Prevention of venous thromboembolism in spinal surgery. Eur Spine J. 2004;13(1):1-8. doi:10.1007/s00586-003-0538-7
3. Glotzbecker MP, Bono CM, Wood KB, Harris MB. Thromboembolic disease in spinal surgery: a systematic review. Spine (Phila Pa 1976). 2009;34(3):291-303. doi:10.1097/BRS.0b013e318195601d
4. Bryson DJ, Uzoigwe CE, Braybrooke J. Thromboprophylaxis in spinal surgery: a survey. J Orthop Surg Res. 2012;7:14. doi:10.1186/1749-799X-7-14
5. Glotzbecker MP, Bono CM, Harris MB, Brick G, Heary RF, Wood KB. Surgeon practices regarding postoperative thromboembolic prophylaxis after high-risk spinal surgery. Spine (Phila Pa 1976). 2008;33(26):2915-2921. doi:10.1097/BRS.0b013e318190702a
6. Dhall SS, Hadley MN, Aarabi B, et al. Deep venous thrombosis and thromboembolism in patients with cervical spinal cord injuries. Neurosurgery. 2013;72 Suppl 2:244-254. doi:10.1227/NEU.0b013e31827728c0
7. Teasell RW, Hsieh JT, Aubut J-AL, et al. Venous thromboembolism after spinal cord injury. Arch Phys Med Rehabil. 2009;90(2):232-245. doi:10.1016/j.apmr.2008.09.557
8. Germing A, Schakrouf M, Lindstaedt M, Grewe P, Meindl R, Mügge A. Serial compression B-scan and Doppler sonography for the screening of deep venous thrombosis in patients with spinal cord injuries. J Clin Ultrasound. 2010;38(1):17-20. doi:10.1002/jcu.20634
9. Giorgi Pierfranceschi M, Donadini MP, Dentali F, et al. The short- and long-term risk of venous thromboembolism in patients with acute spinal cord injury: a prospective cohort study. Thromb Haemost. 2013;109(1):34-38. doi:10.1160/TH12-06-0390
10. Chung W-S, Lin C-L, Chang S-N, Chung H-A, Sung F-C, Kao C-H. Increased risk of deep vein thrombosis and pulmonary thromboembolism in patients with spinal cord injury: a nationwide cohort prospective study. Thromb Res. 2014;133(4):579-584. doi:10.1016/j.thromres.2014.01.008
11. Ploumis A, Ponnappan RK, Maltenfort MG, et al. Thromboprophylaxis in patients with acute spinal injuries: an evidence-based analysis. J Bone Joint Surg Am. 2009;91(11):2568-2576. doi:10.2106/JBJS.H.01411
12. Maung AA, Schuster KM, Kaplan LJ, Maerz LL, Davis KA. Risk of venous thromboembolism after spinal cord injury: not all levels are the same. J Trauma. 2011;71(5):1241-1245. doi:10.1097/TA.0b013e318235ded0
13. Paffrath T, Wafaisade A, Lefering R, et al. Venous thromboembolism after severe trauma: incidence, risk factors and outcome. Injury. 2010;41(1):97-101. doi:10.1016/j.injury.2009.06.010
14. Jones T, Ugalde V, Franks P, Zhou H, White RH. Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in 16,240 adults and children. Arch Phys Med Rehabil. 2005;86(12):2240-2247. doi:10.1016/j.apmr.2005.07.286
15. Green D, Hartwig D, Chen D, Soltysik RC, Yarnold PR. Spinal Cord Injury Risk Assessment for Thromboembolism (SPIRATE Study). Am J Phys Med Rehabil. 2003;82(12):950-956. doi:10.1097/01.PHM.0000098043.88979.BA
16. Ploumis A, Ponnappan RK, Bessey JT, Patel R, Vaccaro AR. Thromboprophylaxis in spinal trauma surgery: consensus among spine trauma surgeons. Spine J. 2009;9(7):530-536. doi:10.1016/j.spinee.2009.01.008
17. Cloney MB, Yamaguchi JT, Dhillon ES, et al. Venous thromboembolism events following spinal fractures: A single center experience. Clin Neurol Neurosurg. 2018;174:7-12. doi:10.1016/j.clineuro.2018.08.030
18. Awad JN, Kebaish KM, Donigan J, Cohen DB, Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. J Bone Joint Surg Br. 2005;87(9):1248-1252. doi:10.1302/0301-620X.87B9.16518
19. Kim DY, Kobayashi L, Chang D, Fortlage D, Coimbra R. Early pharmacological venous thromboembolism prophylaxis is safe after operative fixation of traumatic spine fractures. Spine (Phila Pa 1976). 2015;40(5):299-304. doi:10.1097/BRS.0000000000000754
20. Zeeshan M, Khan M, O’Keeffe T, et al. Optimal timing of initiation of thromboprophylaxis in spine trauma managed operatively: A nationwide propensity-matched analysis of trauma quality improvement program. J Trauma Acute Care Surg. 2018;85(2):387-392. doi:10.1097/TA.0000000000001916
21. Green D, Rossi EC, Yao JS, Flinn WR, Spies SM. Deep vein thrombosis in spinal cord injury: effect of prophylaxis with calf compression, aspirin, and dipyridamole. Paraplegia. 1982;20(4):227-234. doi:10.1038/sc.1982.41