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Yamanouchi K, Funao H, Fujita N, Ebata S, Yagi M. Safety and Efficacy of Tranexamic Acid in Spinal Surgery: A Systematic Review and Meta-Analysis. Spine Surg Relat Res 2024; 8:253-266. [PMID: 38868794 PMCID: PMC11165496 DOI: 10.22603/ssrr.2023-0244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/14/2023] [Indexed: 06/14/2024] Open
Abstract
Background Tranexamic acid (TXA) has gained popularity in spinal surgery because of its potential to reduce blood loss. However, concerns regarding its safety and efficacy remain. This systematic review and meta-analysis aimed to evaluate the efficacy of TXA in reducing blood loss and its safety profile in spinal surgeries. Methods A comprehensive search was conducted in electronic databases for randomized controlled trials and prospective studies evaluating the use of TXA in spinal surgery. The primary outcomes were intraoperative and total estimated blood loss (EBL), and the secondary outcomes included the incidence and types of complications associated with TXA use. Meta-analyses were performed using random-effects models. Results Thirteen studies involving 1,213 participants were included in the meta-analysis. The use of TXA was associated with significant reductions in both intraoperative (mean difference: -46.56 mL [-73.85, -19.26], p<0.01]) and total EBL (mean difference: -210.17 mL [-284.93, -135.40], p<0.01) while also decreasing the need for blood transfusions (risk ratio: 0.68 [0.51, 0.90], p<0.01). No significant difference was found in the incidence and types of thrombotic complications when TXA was used in spinal surgery. Subgroup analysis showed consistent results in instrumentation and fusion surgery and different doses of TXA. Conclusions TXA is effective in reducing intraoperative and overall blood loss in spinal surgery without increasing the risk of complications. These findings support the use of TXA to improve patient outcomes. However, caution should be exercised because of the heterogeneity among the included studies. Further research is needed to confirm these findings and explore potential long-term complications.
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Affiliation(s)
- Kento Yamanouchi
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Haruki Funao
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Naruhito Fujita
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Shigeto Ebata
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, Narita, Japan
- Department of Orthopaedic Surgery, International University of Health and Welfare (IUHW) Narita Hospital, Narita, Japan
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Zheng H, Han Y, Zhao G, Wang R, Wu J, Chen X, Zhao Q, Ren F, Huang J. Topical Use of Low-dose Tranexamic Acid Has no Effect on Drainage Volume after Medial Open Wedge High Tibial Osteotomy: A Case Control Study. Orthop Surg 2024; 16:894-901. [PMID: 38444379 PMCID: PMC10984820 DOI: 10.1111/os.14014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVE Many studies reported that tranexamic acid (TXA) was effective in reducing surgical blood loss in the perioperative period of medial open wedge high tibial osteotomy (MOWHTO). However, few studies focused on the simple topical use of TXA in MOWHTO, and the modality and dosage of topical use of TXA varied. The purpose of this study was to observe the effect of topical use of low-dose TXA on drainage volume after MOWHTO, and to analyze the related influencing factors. METHODS Data of patients who underwent MOWHTO combined with arthroscopic knee surgery in our department from January 2019 to September 2021 were retrospectively analyzed. A total of 105 patients (38 males and 67 females, aged 57.7 ± 7.5 years) were included in this study who received topical TXA or no TXA. The patients were divided into three groups: control group (39 cases), 0.5 g TXA group (40 cases), 1 g TXA group (26 cases). Postoperative drainage volume, wound healing, incidence of hematoma and deep venous thrombosis (DVT) were observed and analyzed in the three groups. The effects of gender, hypertension and diabetes on postoperative drainage volume were analyzed using a t-test. The correlation between age, body mass index (BMI), osteotomy gap and postoperative drainage volume were analyzed using the Pearson correlation coefficient. RESULTS The average postoperative drainage volume of the control group was 259.54 ± 226.33 mL, that of the 0.5 g TXA group was 277.18 ± 177.68 mL, and that of the 1 g TXA group was 229.15 ± 219.93 mL. There was no statistically significant difference in postoperative drainage volume among the three groups (F = 0.423, p = 0.656). There was no local hematoma and wound infection in the three groups. The wound fat liquefaction was found in one patient of the control group. The incidence of DVT was 38.9% (7/18) and 57.1% (8/14) in the control group and 0.5 TXA group, respectively. There was no significant difference in the incidence of DVT between the above two groups (p = 0.476). The average postoperative drainage volume of male patients in the three groups was higher than that of female patients, and the differences were statistically significant (p < 0.05). There was no correlation between age, BMI, osteotomy gap and postoperative drainage volume in the three groups (p > 0.05). CONCLUSION Topical use of low-dose TXA has no significant effect on drainage volume after MOWHTO. The drainage volume after MOWHTO in male patients was more than that in female patients. Topical administration of low-dose TXA does not increase postoperative complications, such as DVT and hematoma.
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Affiliation(s)
- Huifeng Zheng
- Department of Sports Injury and ArthroscopyTianjin HospitalTianjinChina
| | - Yuqin Han
- Department of Sports Injury and ArthroscopyTianjin HospitalTianjinChina
| | - Guangjuan Zhao
- Department of Sports Injury and ArthroscopyTianjin HospitalTianjinChina
| | - Rui Wang
- Department of Sports Injury and ArthroscopyTianjin HospitalTianjinChina
| | - Jiang Wu
- Department of Sports Injury and ArthroscopyTianjin HospitalTianjinChina
| | - Xiao Chen
- Department of Sports Injury and ArthroscopyTianjin HospitalTianjinChina
| | - Qian Zhao
- Department of Sports Injury and ArthroscopyTianjin HospitalTianjinChina
| | - Fuji Ren
- Department of Sports Injury and ArthroscopyTianjin HospitalTianjinChina
| | - Jingmin Huang
- Department of Sports Injury and ArthroscopyTianjin HospitalTianjinChina
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Linzey JR, Lillard J, LaBagnara M, Park P. Complications and Avoidance in Adult Spinal Deformity Surgery. Neurosurg Clin N Am 2023; 34:665-675. [PMID: 37718113 DOI: 10.1016/j.nec.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Adult spinal deformity (ASD) is a complex disease that can result in significant disability. Although surgical treatment has been shown to be of benefit, the complication rate in the perioperative and postoperative periods can be as high as 70%. Some of the most common complications of ASD surgery include intraoperative cerebrospinal fluid leak, high blood loss, new neurologic deficit, hardware failure, proximal junctional kyphosis/failure, pseudarthrosis, surgical site infection, and medical complications. For each of these complications, one or more strategies can be utilized to avoid and/or minimize the consequences.
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Affiliation(s)
- Joseph R Linzey
- Department of Neurosurgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Jock Lillard
- University of Tennessee & Semmes-Murphey Clinic, Memphis, TN 38120, USA
| | - Michael LaBagnara
- University of Tennessee & Semmes-Murphey Clinic, Memphis, TN 38120, USA
| | - Paul Park
- University of Tennessee & Semmes-Murphey Clinic, Memphis, TN 38120, USA.
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Chen JW, Martini M, Pennington Z, Lakomkin N, Mikula AL, Sebastian AS, Freedman BA, Bydon M, Elder BD, Fogelson JL. Characterizing the Current Clinical Trial Landscape in Spinal Deformity: A Retrospective Analysis of Trends in the ClinicalTrials.gov Registry. World Neurosurg 2023; 174:e92-e102. [PMID: 36906083 DOI: 10.1016/j.wneu.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND The management of adult spinal deformity (ASD) relies upon retrospective data, but there have been calls for prospective trials to improve the evidentiary base. This study sought to define the state of the spinal deformity clinical trials and highlight trends to guide future research. METHODS The ClinicalTrials.gov database was queried for all ASD trials initiated since 2008. ASD was defined as adults (>18 years) and defined by the trial. All identified trials were categorized by enrollment status, study design, funding source, start and completion dates, country, outcomes examined, among many other study characteristics. RESULTS Sixty trials were included, of which 33(55.0%) started within the past 5 years of the query date. Most trials were sponsored by academic centers (60.0%) followed by industry (48.3%). Notably, 16 (27%) trials had multiple funding sources, all included collaboration with an industry entity. Only one trial had funding from a government agency. There were 30 (50%) interventional and 30 (50%) observational studies. The average time to completion was 50.8 ± 49.1 months. A total of 23 (38.3%) studies investigated a new procedural innovation, while 17 (28.3%) studies examined the safety or efficacy of a device. Study publications were associated with 17 (28.3%) trials in the registry. CONCLUSIONS The number of trials has increased significantly over the past 5 years, with the bulk of trials being funded by academic centers and industry and a notably lack by government agencies. Most trials focused on device or procedural investigation. Despite growing interest in ASD clinical trials, there remain many points for improvement in the current evidentiary base.
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Affiliation(s)
- Jeffrey W Chen
- Vanderbilt University, School of Medicine, Nashville, Tennessee, USA.
| | - Michael Martini
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zach Pennington
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nikita Lakomkin
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anthony L Mikula
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arjun S Sebastian
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Benjamin D Elder
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy L Fogelson
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Helgeson MD, Pisano AJ, Fredericks DR, Wagner SC. What's New in Spine Surgery. J Bone Joint Surg Am 2023:00004623-990000000-00792. [PMID: 37141447 DOI: 10.2106/jbjs.23.00125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Affiliation(s)
- Melvin D Helgeson
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Alfred J Pisano
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Donald R Fredericks
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Scott C Wagner
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Hindman BJ, Gold CJ, Ray E, Wendt LH, Ten Eyck P, Berger JI, Olinger CR, Banks MI, Sanders RD, Howard MA, Woodroffe RW. Surgeon-Specific Treatment Selection Bias and Heterogeneous Perioperative Practices in an Observational Spine Surgery Study. A Statistical Tutorial with Implications for Analysis of Observational Studies of Perioperative Interventions. World Neurosurg 2023; 173:e168-e179. [PMID: 36773808 DOI: 10.1016/j.wneu.2023.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND It is essential that treatment effects reported from retrospective observational studies are as reliable as possible. In a retrospective analysis of spine surgery patients, we obtained a spurious result: tranexamic acid (TXA) had no effect on intraoperative blood loss. This statistical tutorial explains how this result occurred and why statistical analyses of observational studies must consider the effects of individual surgeons. METHODS We used an observational database of 580 elective adult spine surgery patients, supplemented with a review of perioperative medication records. We tested whether common statistical methods (multivariable regression or propensity score-based methods) could adjust for surgeons' selection bias in TXA administration. RESULTS Because TXA administration (frequency, timing, and dose) and surgeon were linked (collinear), estimating and testing the independent effect of TXA on outcome using multivariable regression without including surgeon as a variable would provide biased (spurious) results. Likewise, because of surgeon/TXA linkage, assumptions of propensity score-based analysis were violated, statistical methods to improve comparability between groups failed, and spurious blood loss results were worsened. Others numerous differences among surgeons existed in intraoperative and postoperative practices and outcomes. CONCLUSIONS In observational studies in which individual surgeons determine whether their patients receive the treatment of interest, consideration must be given to inclusion of surgeon as an independent variable in all analyses. Failure to include the surgeon in an analysis of observational data carries a substantial risk of obtaining spurious results, either creating a spurious treatment effect or failing to detect a true treatment effect.
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Affiliation(s)
- Bradley J Hindman
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
| | - Colin J Gold
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Emanuel Ray
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Linder H Wendt
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa, USA
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa, USA
| | - Joel I Berger
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Catherine R Olinger
- Department of Orthopedics and Rehabilitation, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Matthew I Banks
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Robert D Sanders
- Central Clinical School and National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Royce W Woodroffe
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Hmidan Simsam M, Delorme L, Grimm D, Priestap F, Bohnert S, Descoteaux M, Hilsden R, Laverty C, Mickler J, Parry N, Rochwerg B, Sherman C, Smith S, Toole J, Vogt K, Wilson S, Ball I. Efficacy of high dose tranexamic acid (TXA) for hemorrhage: A systematic review and meta-analysis. Injury 2023; 54:857-870. [PMID: 36746710 DOI: 10.1016/j.injury.2022.12.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Standard dose (≤ 1 g) tranexamic acid (TXA) has established mortality benefit in trauma patients. The role of high dose IV TXA (≥2 g or ≥30 mg/kg as a single bolus) has been evaluated in the surgical setting, however, it has not been studied in trauma. We reviewed the available evidence of high dose IV TXA in any setting with the goal of informing its use in the adult trauma population. METHODS We searched MEDLINE, EMBASE and unpublished sources from inception until July 27, 2022 for studies that compared standard dose with high dose IV TXA in adults (≥ 16 years of age) with hemorrhage. Screening and data abstraction was done independently and in duplicate. We pooled trial data using a random effects model and considered randomized controlled trials (RCTs) and observational cohort studies separately. We assessed the individual study risk of bias using the Cochrane Risk of Bias for RCTs and the Newcastle-Ottawa Scale for observational cohort studies. The overall certainty of evidence was assessed using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). RESULTS We included 20 studies with a combined total of 12,523 patients. Based on pooled RCT data, and as compared to standard dose TXA, high dose IV TXA probably decreases transfusion requirements (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.76 to 0.97, moderate certainty) but with possibly no effect on blood loss (mean difference [MD] 43.31 ml less, 95% CI 135.53 to 48.90 ml less, low certainty), and an uncertain effect on thromboembolic events (OR 1.33, 95% CI 0.86 to 2.04, very low certainty) and mortality (OR 0.70, 95% CI 0.37 to 1.32, very low certainty). CONCLUSION When compared to standard dose, high dose IV TXA probably reduces transfusion requirements with an uncertain effect on thromboembolic events and mortality. LEVEL OF EVIDENCE Systematic review and meta-analysis, level IV.
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Affiliation(s)
- Mohammad Hmidan Simsam
- Schulich School of Medicine and Dentistry, Western University, 1397 Medway Park Dr, London, Ontario N6G 0Z6, Canada.
| | - Laurence Delorme
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Dylan Grimm
- Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Fran Priestap
- London Health Sciences Centre Trauma Program, London, Ontario, Canada
| | | | | | - Rich Hilsden
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | | | | | - Neil Parry
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | - Bram Rochwerg
- Department of Medicine, MacMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Shane Smith
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Department of Surgery, Western University, London, Ontario, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada
| | | | - Kelly Vogt
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | | | - Ian Ball
- London Health Sciences Centre Trauma Program, London, Ontario, Canada; Royal Canadian Medical Service, Canada; Office of Academic Military Medicine, Western University, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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8
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Kanhere AP, Lambrechts MJ, Issa TZ, Karamian BA, Hendow CJ, Reddy YC, Slota PJ, D'Antonio ND, Kaye ID, Canseco JA, Woods BI, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. The Effect of Tranexamic Acid on Operative and Postoperative Blood Loss in Transforaminal Lumbar Interbody Fusions. World Neurosurg 2022; 166:e443-e450. [PMID: 35840090 DOI: 10.1016/j.wneu.2022.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of this retrospective cohort study was to evaluate the effect of tranexamic acid (TXA) on reducing perioperative blood loss and length of stay after transforaminal lumbar interbody fusion (TLIF). Spine surgery is associated with the potential for significant blood loss, and adequate hemostasis is essential to visualizing crucial structures during the approach and procedure. Although TXA use has been extensively studied in the pediatric and adult spinal deformity literature, there is a dearth of literature on its efficacy in reducing blood loss for patients who undergo 1- to 3-level TLIF. METHODS All patients requiring 1- to 3-level TLIF who received a preoperative loading dose of TXA were grouped and compared with patients who didn't receive TXA. Demographic, surgical, and laboratory values were collected and analyzed. Continuous and categorical variables were analyzed with χ2, Kruskal-Wallis, or analysis of variance tests, depending on normality and data type. Multiple linear regressions were developed to determine independent predictors of the estimated blood loss (EBL), total blood loss, drain output, and length of stay. Statistical significance was set at P < 0.05. RESULTS Patients who received preoperative TXA had more comorbidities (P = 0.006), longer surgery length (P < 0.001), and longer length of stay (P = 0.004). TXA was independently associated with a decreased day 0, 1, 2, and total drain output (P < 0.001, P = 0.001, P = 0.007, P < 0.001, respectively), but was not associated with a change in EBL, total blood loss, or length of stay. CONCLUSIONS The application of preoperative TXA for patients undergoing 1- to 3-level TLIF reduced drain output in the first 2 postoperative days, but it did not affect hospital length of stay, total blood loss, or EBL.
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Affiliation(s)
- Arun P Kanhere
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Tariq Ziad Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chelsea J Hendow
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yashas C Reddy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Paul J Slota
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nicholas D D'Antonio
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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