Brief intraoperative heparinization and blood loss in anterior lumbar spine surgery (original) (raw)
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Incidence of Thromboembolic Complications in Lumbar Spinal Surgery
Orthopaedic Proceedings, 2009
Subtherapeutic international normalized ratio (INR) is frequently encountered in clinical practice, and patients with high-risk atrial fibrillation (AF) and with mechanical heart valve (MHV) with inadequate anticoagulation may be exposed to an increased risk of thromboembolic events (TE). However, there are no prospective data evaluating this risk. Consecutive patients with a history of stable anticoagulation, but with a subtherapeutic INR, were prospectively included. Data on use and dose of low-molecular weight heparin (LMWH) bridging therapy were collected. The incidence of objectively confirmed TE and of major bleeding events within 90 days after the index INR was assessed. Five hundred and one patients with INR value 0.5-1 INR units below the lower limit of the patient-specific target INR were included in the study (280 with MHV and 221 with AF and CHADS2 score 3). LMWH was prescribed for 64 patients (12.8%). During follow-up, seven patients had a TE (1.40%; 95% confidence interval 0.68, 2.86%; 5.58 events for 100 patients year). All the events occurred within 14 days after the index INR. When we consider only patients who did not receive bridging therapy, the incidence of TE was 1.14% (5 of 437 patients; 95% confidence interval 0.49, 2.64%; 4.58 events for 100 patients year). There were no major bleeding events. The risk of TE in this population was not negligible. Given the frequent observation of subtherapeutic INR levels when monitoring vitamin K antagonists, this finding warrants additional investigation to improve the management of these patients.
International Journal of Spine Surgery, 2021
Objective: To determine the safety and efficacy of the proposed venous thromboembolism (VTE) prophylaxis regime in patients undergoing anterior lumbar interbody fusion (ALIF) surgery. Background: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are recognized complications after spine surgery, with rates in the literature ranging from 0% to 14% with some form of prophylaxis. Pharmacological thromboprophylaxis can cause postoperative bleeding and hematomas, which can result in significant neural compromise or permanent injury, and wound complications. ALIF surgery involves the handling and compression of major abdominal vessels during surgery and this adds to the risk of both arterial thrombosis and VTE. Methods: A retrospective review of data, which were prospectively collected to evaluate the incidence of VTE in 200 consecutive patients undergoing ALIF following our VTE prophylaxis protocol. All patients had low molecular weight heparin, tinzaparin 4500 units subcutaneously on the evening before surgery, then daily for 3 to 5 days, then aspirin (acetylsalicylic acid) 150 mg daily plus lansoprazole 30 mg daily for 4 weeks after surgery. All patients had intermittent pneumatic compression of their calves and thighs intraoperatively and for 24 hours postoperatively then had early mobilization and thromboembolic deterrent stockings for 6 weeks. Results: There was no incidence of any symptomatic VTE in the any of the 200 patients and no loss to follow-up. There was a 0% incidence of injury to the iliac vessels, symptomatic arterial occlusion, wound hematoma, major intraoperative bleeding, need for transfusion, symptomatic GI bleed, or retroperitoneal hematoma requiring intervention. Conclusions: The proposed VTE prophylactic regime is safe and efficacious and may decrease the incidence of symptomatic VTE in patients undergoing an ALIF procedure, and despite the use of chemical thromboprophylaxis, there is no evidence of bleeding complications as a result of using this regime. Level of Evidence: 4.
Incidence of thromboembolic complications in lumbar spinal surgery in 1,111 patients
European Spine Journal, 2009
Deep venous thrombosis (DVT) and pulmonary embolism (PE) cause significant morbidity and mortality in orthopaedic surgical practice, although the incidence following surgery to the lumbosacral spine is less than following lower limb surgery. Our objective was to compare our rate of thromboembolic complications with those published elsewhere and investigate whether the adoption of additional pharmacological measures reduced the incidence of clinically evident DVT and PE. This retrospective study was undertaken to investigate the incidence of DVT/ PE during the 10 years from 1 January 1985 to 31 December 1994, and then to assess the effectiveness of an anticoagulant policy introduced during 1995 using low dose aspirin or LMH in high risk cases. All records for spinal operations were reviewed for thrombo-embolic complications by reference to the Scottish Morbidity Record form SMR1. To ensure that all patients were compliant with the policy, data for the whole of 1995 was omitted and the period 1 January 1996 to 31 December 2003 was taken to assess its effectiveness. Surgery was done with the patient in the kneeling, seated prone position which leaves the abdomen free and avoids venous kinking in the legs. Records of a total of 1,111 lumbar spine operations were performed from 1 January 1985 to 31 December 2004 were reviewed. The overall incidence of thrombo-embolic complications was 0.29%. A total of 697 operations were performed from 1 January 1985 to 31 December 1994 with two cases of DVT and no cases of PE giving thromboembolic complication rate of 0.29%. During the period 1 January 1996 to 31 December 2003, 414 operations resulted in one case of DVT and no cases of PE, a rate of 0.24%. The incidence of symptomatic thromboembolic complications in lumbar spinal surgery is low in the kneeling, seated prone operating position, whether or not anticoagulation is used.
EFFICACY OF EARLY LOW-MOLECULAR-WEIGHT HEPARIN PROPHYLAXIS IN ELDERLY PATIENTS AFTER DEGENERATIVE SPINAL SURGERY: A BRIEF RETROSPECTIVE REVIEW, 2019
Many orthopaedic surgical procedures are potentially affected by deep vein thrombosis (DVT) and Pulmonary Embolism (PE). DVT and PE are a clinical expression of the same pathological process called venous thromboembolism (VTE). Low-molecular-weight heparin (LMWH) is approved/ recognized to be a pharmacological solution to prevent VTE. The objective of the current study is twofold: (i) to assess the effect of a therapeutic protocol with LWMH started 24 hours after surgery on systemic bleeding and ii) to assess its effect on thrombosis and pulmonary embolism risk in patients undergoing early prophylaxis after spine surgery. A consecutive cohort of 110 patients undergoing spinal surgery was tested. Fifty six cases were spinal stenosis and 54 were degenerative thoracolumbar kypho-scoliosis. None of the patients withdrew from the study. 2 patients manifested PE signs and a prophylactic protocol therapy with LMWH which was started 24 hours after spine surgery resulted in a very low haemorrhage risk and low rate of PE and DVT.
Study Design Retrospective analysis of prospectively collected cohort data. Objective Anterior lumbar interbody fusion (ALIF) is a commonly performed procedure for the treatment of degenerative diseases of the lumbar spine. Detailed and comprehensive descriptions of intra- and postoperative complications of ALIF are surprisingly limited in the literature. In this report, we describe our experience with a team model for ALIF and report all complications occurring in our patient series. Methods Patients were prospectively enrolled between January 2009 and January 2013 by a combined spine surgeon and vascular surgeon team. All patients underwent an open ALIF using an anterior approach to the lumbosacral spine. Results From the 227 ALIF cases, mean operative blood loss was 103mL, ranging from 30 to 900 mL. Mean operative time was 78 minutes. The average length of stay was 5.2 days. Intraoperative vascular injury requiring primary repair with suturing occurred in 15 patients (6.6%). There were 2 cases of postoperative retroperitoneal hematoma. Three patients (1.3%) had incisional hernia requiring revision surgery; 7 (3.1%) patients had prolonged ileus (>7 days) managed conservatively. Four patients described retrograde ejaculation. Sympathetic dysfunction occurred in 15 (6.6%) patients. There were 5 (2.2%) cases of superficial wound infection treated with oral antibiotics, with no deep wound infections requiring reoperation or intravenous therapy. There were no mortalities in this series. Conclusions ALIF is a safe procedure when performed by a combined vascular surgeon and spine surgeon team with acceptably low complication rates. Our series confirms that the team approach results in short operative times and length of stay, with rapid control of intraoperative vessel injury and low overall blood loss. received February 2, 2015 accepted after revision May 11, 2015 DOI http://dx.doi.org/ 10.1055/s-0035-1557141. ISSN 2192-5682. © Georg Thieme Verlag KG Stuttgart · New York THIEME GLOBAL SPINE JOURNAL Original Article
Global Spine Journal, 2015
Study Design Retrospective analysis of prospectively collected cohort data. Objective Anterior lumbar interbody fusion (ALIF) is a commonly performed procedure for the treatment of degenerative diseases of the lumbar spine. Detailed and comprehensive descriptions of intra- and postoperative complications of ALIF are surprisingly limited in the literature. In this report, we describe our experience with a team model for ALIF and report all complications occurring in our patient series. Methods Patients were prospectively enrolled between January 2009 and January 2013 by a combined spine surgeon and vascular surgeon team. All patients underwent an open ALIF using an anterior approach to the lumbosacral spine. Results From the 227 ALIF cases, mean operative blood loss was 103 mL, ranging from 30 to 900 mL. Mean operative time was 78 minutes. The average length of stay was 5.2 days. Intraoperative vascular injury requiring primary repair with suturing occurred in 15 patients (6.6%). The...
Venous thromboembolism in adult elective spinal surgery
Bone & Joint Journal, 2017
Aims To evaluate the incidence of primary venous thromboembolism (VTE), epidural haematoma, surgical site infection (SSI), and 90-day mortality after elective spinal surgery, and the effect of two protocols for prophylaxis. Patients and Methods A total of 2181 adults underwent 2366 elective spinal procedures between January 2007 and January 2012. All patients wore anti-embolic stockings, mobilised early and were kept adequately hydrated. In addition, 29% (689) of these were given low molecular weight heparin (LMWH) while in hospital. SSI surveillance was undertaken using the Centers for Disease Control and Prevention criteria. Results In patients who only received mechanical prophylaxis, the incidence of VTE was 0.59% and that of SSI 2.1%. In patients who were additionally given LMWH, the incidence of VTE was 0% and that of SSI 0.7%. The unadjusted p-value was 0.04 for VTE and 0.01 for SSI. There were no cases of epidural haematoma or 90-day mortality in either group. When adjusted ...
SPINE, 2019
To evaluate peri-operative morbidity in patients undergoing minimally invasive spine surgery (MISS) of the lumbar spine while continuing the anti-platelet drug (APD) peri-operatively as compared to those not continuing these drugs and those not on these drugs. Summary of Background Data: While discontinuation of anti-platelet drugs carries with it the risk of thrombosis of the cardiac stents, myocardial infarction, peripheral vascular occlusion, cerebrovascular events and other thrombotic complications, continuation of these drugs has the risk of intra spinal bleeding and the serious consequences of subsequent epidural hematoma with associated spinal cord compression. Methods: This institutional review board approved study included 1587 patients from 2011 to 2018. Peri-operative parameters were analyzed for 216 patients who underwent spinal surgery after the discontinuation of anticoagulation therapy, 240 patients who continued to take APD daily through the peri-operative period and 1131 patients who were never exposed to APD therapy. The operative time, intra-operative estimated blood loss, length of hospital stay, incidence of clinically evident hematoma and transfusion of blood products were also recorded and compared in 3 cohorts. Results: The patients who continued taking APD in the peri-operative period had a longer length of hospital stay on average (2.5±0.67 VS 1.59±0.76 and 1.67±0.83, P <0.05), whereas there was no significant difference in the operative time, estimated blood loss, the amount of blood products transfused and overall intra and post-operative complication rate. There were no instances of postoperative wound soakage or neurological deficit suggestive of possible spinal epidural hematomas in either of the study groups. Conclusion: The current study has observed no appreciable increase in peri-operative morbidities including bleeding related complication rates in patients undergoing lumbar MISS while continuing to take APD compared with patients who either discontinued APD prior to surgery or those not taking APD.
Hidden Blood Loss in Transforaminal Lumbar Interbody Fusion: An Analysis of Underlying Factors
Cureus
Background In the management of lumbar spine diseases, various techniques have been described for minimizing intraoperative blood loss. Soft tissue extravasation and hemolysis have been referred to as hidden blood loss (HBL). By acknowledging HBL and accounting for it in our postoperative care, strategies of fluid infusion and blood transfusion may be altered. Our study aims to estimate HBL in transforaminal lumbar interbody fusion (TLIF) surgeries and to analyze associated factors. Methods This is a retrospective cohort study. Records of patients who underwent TLIF between January 2016 and December 2020 were reviewed. Patients with both minimally invasive (MIS) and open TLIF were included. Patients with infection, tumors, or fractures being the indication for surgery were excluded. Moreover, patients with known blood-related diseases, aged younger than 18 years, patients requiring blood transfusion, or patients with estimated intra-operative blood loss greater than 1.5 L were excluded. HBL was calculated according to the formulae depending on patients' weight, height, and hematocrit. Statistical analyses were performed to determine associations between HBL and other factors. Results A total of 95 patients were included. The mean estimated blood loss (EBL) was 231 mL, whereas the mean HBL was 265 mL, and the mean total blood loss is 629.7 ml with HBL accounting for 42% of it. Significant associated factors with HBL were the type of surgery, patient's total blood volume, preoperative hemoglobin and hematocrit, and decrease in hemoglobin and hematocrit. Conclusion Significant HBL may occur after TLIF, which was shown to be more than EBL. Although MIS had less EBL, it was associated with more HBL. Patients' preoperative hemoglobin and hematocrit, and a decrease in them, have been shown to be associated with HBL. All these factors should be considered for postoperative management of blood loss.