Elective spine surgery with continuation of clopidogrel anti-platelet therapy: Experiences from the community

The influence of antiplatelet drugs on outcomes of spinal surgery: a systematic review and meta-analysis

INTRODUCTION

The management of antiplatelet therapy (APT) in patients undergoing spinal surgery is complex, requiring balancing the risks of thromboembolic events against those of potential perioperative bleeding. This review evaluates the effects of continuing versus discontinuing APT on the surgical outcomes of spinal surgery.

HYPOTHESIS

The hypothesis is that continuing antiplatelet therapy (APT) in patients undergoing spinal surgery will not significantly increase intraoperative blood loss, operative time, or postoperative complications compared to discontinuing APT, but may lead to a higher need for postoperative transfusions.

MATERIAL AND METHODS

Systematic search was done in EMBASE, Scopus, PubMed Central, Google Scholar, and ScienceDirect databases for studies comparing the continuation of APT to its discontinuation in terms of estimated blood loss, operative time, hospital stay length, postoperative transfusion units, postoperative complications, postoperative hematoma, readmission rate, cardiovascular events amongst patients undergoing spinal surgery. Risk of bias was assessed with the Newcastle Ottawa scale and synthesized the data using random-effects meta-analyses, summarizing outcome results as either standardized mean differences (SMDs) or odds ratios (ORs) as appropriate.

RESULTS

13 studies were included in meta-analysis. Similar estimated blood losses (SMD = 0.125; 95%CI, -0.087 to 0.337) and operative times (SMD = 0.231; 95%CI, -0.225 to 0.687) were found between the patients who continued and those who discontinued the APT. However, patients who continued APT had a slightly higher chance of requiring postoperative transfusions (SMD = 0.244; 95%CI, 0.030 to 0.458). Similar hospital stay lengths, and postoperative complication or cardiovascular event rates were found.

DISCUSSION

Continuing APT during spinal surgery does not significantly increase the risks of intraoperative blood loss or increase the operative time, however; it may increase the need for postoperative transfusions. These findings suggest that for patients at risk of thromboembolic events, the benefits of continuing APT outweigh the risks.

LEVEL OF EVIDENCE

III; Systematic Review and Meta-analysis.

Influence of Perioperative Antithrombic Agent Discontinuation in Elective Posterior Spinal Surgery: A Propensity-Score-Matched Analysis

OBJECTIVE

To investigate the influence of perioperative antithrombotic agent (antiplatelet agents and anticoagulants) discontinuation in elective posterior spinal surgery in terms of bleeding complications, such as epidural hematoma and postoperative thromboembolism.

METHODS

We enrolled patients undergoing elective posterior spinal surgery at 9 hospitals between April 2017 and August 2020. We collected data regarding patient baseline characteristics, surgical details, intraoperative estimated blood loss, and postoperative complication rates, including epidural hematoma and thromboembolism. We divided the patients into a discontinuation group, in which antithrombic agents were discontinued perioperatively, and a control group without antithrombic agents. Propensity scores for taking any antithrombic agents were calculated, with 1-to-1 matching based on the estimated propensity scores to adjust for patient baseline characteristics and surgical details. Intraoperative estimated blood loss and 30-day postoperative complication rates were compared between the groups.

RESULTS

We enrolled 9853 patients, including 1123 patients (11.4%) who discontinued antithrombic agents perioperatively. One-to-one propensity score matching yielded 1111 pairs with and without antithrombic agents. Intraoperative estimated blood loss per 10 minutes (8.2 mL vs. 8.9 mL) and the incidence of epidural hematoma requiring revision (0.97% vs. 0.72%) were similar between the groups. Although postoperative cardiac events and stroke were observed only in the discontinuation group (0.27% and 0.09%, respectively), these incidences were not significantly different between the groups.

CONCLUSIONS

Perioperative antithrombic agent discontinuation in elective posterior spinal surgery normalized the intraoperative bleeding tendency and the incidence of postoperative epidural hematoma and did not influence in a significative way the incidence of postoperative thromboembolism.