Short-term safety of tranexamic acid use in posterior cervical decompression and fusion surgery

A Retrospective Comparative Analysis on the Effect of Tranexamic Acid to Reduce Perioperative Blood Loss in Patients Undergoing Cervical Spine Surgery

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

The purpose of this study is to assess the impact of intravenous TXA on blood loss outcomes in anterior, posterior, and combined approaches for elective cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Tranexamic acid (TXA) has been shown to reduce blood loss in a variety of operations, such as lumbar spine surgery. However, limited studies have evaluated the efficacy of TXA in cervical spine surgery.

METHODS

We performed a retrospective review of a single surgeon's elective cervical spine operations between September 2011 and March 2017. Patients were divided into 3 groups: anterior approach, posterior approach, or combined approach. Patients were then further subdivided into TXA versus control groups based on whether they received TXA treatment. We performed multiple linear regressions to assess the relationship between the use of TXA and other dependent variables (number of vertebral levels treated, need for a vertebral corpectomy) on total perioperative blood loss, intraoperative estimated blood loss, postoperative drain output, total operative time, postoperative change in hemoglobin, and occurrence of transfusion and/or postoperative deep venous thrombus (DVT).

RESULTS

We found that the use of TXA statistically significantly reduced total perioperative blood loss ( P =0.04) and postoperative drain output ( P =0.004) in posterior surgical approach cervical spine surgery but did not statistically significantly impact any blood loss variables in anterior or combined surgical approaches to elective cervical spine surgery. The use of TXA was a significant predictor for a decrease in intraoperative ( P =0.02) and postoperative ( P <0.01) blood loss.

CONCLUSIONS

This study found that TXA statistically significantly decreased total blood loss and postoperative drain output when controlling for multiple confounding factors.

LEVEL OF EVIDENCE

Level III.

Efficacy and safety of tranexamic acid in cervical spine surgery: a systematic review and meta-analysis

Background

Tranexamic acid (TXA) is an antifibrinolytic drug associated with reduced blood loss in a range of surgical specialties. This meta-analysis aimed to compare the efficacy and safety of TXA in cervical surgery, focusing on its effects on intraoperative blood loss and related outcomes.

Methods

We searched the PubMed, EMBASE, Medline, and Cochrane Library databases to identify all literature related to TXA used in cervical spinal surgery. Intraoperative blood loss, postoperative drainage volume, total blood loss, postoperative hematological variables, and complications were analyzed.

Results

Eight trials met the inclusion criteria. The pooled results showed that intraoperative blood loss, total blood loss, and postoperative drainage volume were significantly lower in the TXA group than in the control group. The hemoglobin and hematocrit on postoperative day 1 was significantly higher in the TXA group than in the control group. There was no significant difference in complications between the two groups.

Conclusion

The available evidence indicates that TXA effectively reduces blood loss in cervical spinal surgery while maintaining a favorable safety profile, without increasing associated risks.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023459652.

Determining the Effect of Intraoperative TXA on Postoperative Blood Loss in ACDF

STUDY DESIGN

Retrospective cohort study using prospectively collected data.

OBJECTIVE

To determine the effectiveness of intraoperative tranexamic acid (TXA) in anterior cervical discectomy and fusion (ACDF) on postoperative blood loss.

SUMMARY OF BACKGROUND DATA

TXA has been proven to be a safe and effective agent in reducing blood loss after cervical surgery; however, its efficacy when used intraoperatively for ACDF surgeries had yet to be researched. Currently, there are few studies examining the effects of intraoperative TXA in cervical spinal fusion, and none specifically examining TXA use in ACDF.

METHODS

A tertiary medical center's prospectively collected spine registry was queried between 1/1/18 and 12/1/21 for all patients who underwent elective ACDF surgery and received a drain postoperatively. Patients were separated into 2 groups; those who had received intraoperative TXA and those who did not. Baseline demographic and operative variables were collected from the registry. The primary outcome was postoperative blood loss over a 24-hour period. Secondary outcomes included total drain output, intraoperative estimated blood loss, operative duration, drain duration, changes in preoperative to postoperative hemoglobin and hematocrit levels, and rate of transfusions, complications, revisions, and reoperations. Univariate and multivariate regression analyses were performed.

RESULTS

Two hundred eighty-six patients were included. One hundred ninety patients underwent ACDF and did not receive intraoperative TXA, whereas 96 patients underwent ACDF and did receive TXA. There were no differences in any demographic or baseline variables. Multivariate analysis showed intraoperative TXA was associated with shorter drain duration (β=-5.74, 95% CI: -10.9 to -0.53, P =0.031) and reduction in 24-hour drain output (β=-12.2, 95% CI: -19.4 to -4.89, P =0.001) and total drain output (β=-14.0, 95% CI: -22.9 to -5.05, P =0.002).

CONCLUSIONS

TXA use during ACDF procedures leads to a decrease in perioperative blood loss and faster drain removal. TXA is an effective and safe agent for reducing perioperative blood loss in ACDF surgery.

LEVEL OF EVIDENCE

III.

Tranexamic Acid in Combination With Vancomycin or Gentamicin Has a Synergistic Effect Against Staphylococci

Background

Tranexamic acid (TXA) is an antifibrinolytic agent applied in orthopedic surgery and has been proven to reduce post-surgery infection rates. We previously showed that TXA also had an additional direct antimicrobial effect against planktonic bacteria. Therefore, we aimed to evaluate whether it has a synergistic effect if in combination with antibiotics.

Materials and Methods

Three ATCC and seven clinical strains of staphylococci were tested against serial dilutions of vancomycin and gentamicin alone and in combination with TXA at 10 and 50 mg/ml. The standardized microtiter plate method was used. Minimal inhibitory concentrations (MICs) were calculated by standard visualization of well turbidity (the lowest concentration at which complete absence of well bacterial growth was observed by the researcher) and using the automated method (the lowest concentration at which ≥80% reduction in well bacterial growth was measured using a spectrophotometer).

Results

Tranexamic acid-10 mg/ml reduced the MIC of vancomycin and gentamicin with both the standard method (V: 1-fold dilution, G: 4-fold dilutions) and the automated turbidity method (vancomycin: 8-fold dilutions, gentamicin: 8-fold dilutions). TXA-50 mg/ml reduced the MIC of gentamicin with both the standard turbidity method (6-fold dilutions) and the automated turbidity method (1-fold dilutions). In contrast, for vancomycin, the MIC remained the same using the standard method, and only a 1-fold dilution was reduced using the automated method.

Conclusion

Ours was a proof-of-concept study in which we suggest that TXA may have a synergistic effect when combined with both vancomycin and gentamicin, especially at 10 mg/ml, which is the concentration generally used in clinical practice.

The efficacy and safety of intravenous tranexamic acid in patients with posterior operation of multilevel thoracic spine stenosis: a prospective randomized controlled trial

Background

This study was a randomized controlled trial to evaluate efficacy and safety of the usage of intravenous tranexamic acid during posterior operation of multilevel thoracic spine stenosis for controlling perioperative blood loss.

Methods

Sixty eight patients with multilevel thoracic spine stenosis were randomized into the tranexamic acid group receiving 15 mg/kg body weight before the skin incision was made and 1 mg/kg body weight per hour during operation or the control group receiving the same dose of placebo (0.9% sodium chloride solution) intravenously. Pedicle screw fixation, laminectomy and selective discectomy were performed. Intraoperative and perioperative total blood loss were compared. The necessity and amount for blood transfusion, blood coagulation function, durations of postoperative hospital stays were compared. The complications of tranexamic acid were also investigated such as cardiovascular and cerebrovascular events, lower limb venous thrombosis.

Results

There were no statistically significant differences in age, gender, body mass index, ASA status, pathology required surgery, preoperative hemoglobin, operation time, laminectomy segments and discectomy segments between the tranexamic acid and control groups. The intraoperative blood loss (455.9 ± 206.6 ml vs 580.6 ± 224.3 ml, p < 0.05) and total blood loss (675.3 ± 170.3 ml vs 936.8 ± 306.4 ml, p < 0.01) in tranexamic acid group were significant lower than those in control group. The means of blood unit transfused (2.5 ± 1.0 vs 4.7 ± 2.4, p < 0.05) and Hb reduction in 48 h (22.5 ± 3.4 g/L vs 25.3 ± 3.9 g/L, p < 0.01) were significantly lower in tranexamic acid group than that in control group. There were no statistically significant differences in blood coagulation function pre-operation or 48 h post-operation between the tranexamic acid and the control groups. The requirements for patients to receive blood transfusion were fewer and durations of post-operational hospital stays were shorter in the tranexamic acid group, however, the difference did not achieve statistical significance. There was no significant difference in superficial or deep venous thrombosis of lower limbs or deterioration of neurological function between tranexamic acid group and control group.

Conclusions

Application of intravenous tranexamic acid significantly reduces intraoperative and perioperative total blood loss without significant side effects in posterior operation of multilevel thoracic spine stenosis.

Trial registration

At Chinese Clinal Trial Registry. http://www.chictr.org.cn/, ChiCTR2100054221. Registered on 11/12/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05361-2.

Effect of Tranexamic Acid against Staphylococcus spp. and Cutibacterium acnes Associated with Peri-Implant Infection: Results from an In Vitro Study

Tranexamic acid (TXA) is extensively used in orthopedic surgery and traumatology as an antifibrinolytic agent to control intra- and postoperative bleeding and, therefore, indirectly, to reduce postsurgery infection rates. The hypothesis of an additional antibiotic effect against microorganisms associated with periprosthetic joint infection needs to be further evaluated. We aimed to assess whether TXA could reduce bacterial growth using an in vitro model. ATCC and clinical strains of staphylococci and Cutibacterium acnes were tested against TXA in both planktonic and sessile forms. We recorded the percent reduction in the following variables: log CFU/mL by microbiological culture, percentage of live cells by confocal laser scanning microscopy, and, additionally in sessile cells, metabolic activity by the 2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide salt (XTT) assay. Variables were compared between groups using the Kruskal-Wallis test, and the results were reported as median (interquartile range [IQR]). Statistical significance was set at a P value of <0.05. Clinical significance was defined as a reduction of ≥25%. TXA at 50 mg/mL led to a slight reduction in CFU counts (4.5%). However, it was at 10 mg/mL that the reduction reached 27.2% and 33.0% for log CFU/mL counts and percentage of live cells, respectively. TXA was not efficacious for reducing preformed 24-h mature staphylococci and 48-h mature C. acnes biofilms, regardless of its concentration. TXA did not exert an antimicrobial effect against bacterial biofilms. However, when bacteria were in the planktonic form, it led to a clinically and statistically significant reduction in bacterial growth at 10 mg/mL.

IMPORTANCE The possible use of TXA as an antibiotic agent in addition to its antifibrinolytic effect may play an important role in the prevention of prosthetic joint infection.

Tranexamic acid dosing strategies and blood loss reduction in multilevel spine surgery: A systematic review and network meta-analysis

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Tranexamic acid (TXA) is used to reduce blood loss during spine surgery

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It is unclear whether there is an optimal TXA dosing regimen (e.g., how many mg/hour?)

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In this network meta-analysis, 7 studies used 4 different TXA dosing regimens in 441 patients

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TXA was associated with reduced blood loss volume, but no dosing regimen was clearly superior

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Additional trials comparing TXA dosing regimens and administration routes are needed

Background

For adults undergoing complex, multilevel spinal surgery, tranexamic acid (TXA) is an antifibrinolytic agent used to reduce blood loss. The optimal dosing of intravenous TXA remains unclear. This systematic review and meta-analysis compare various dosing regimens of intravenous TXA used in patients undergoing multilevel spine surgery (≥2 levels).

Methods

PubMed, Cochrane, and EMBASE databases were searched for English language studies published January 2001 through May 2021 reporting use of TXA versus placebo for multilevel spine surgery. Primary outcomes of interest were intraoperative blood loss volume (BLV) and total BLV. A separate random effects model was fit for each outcome measure. Effect sizes were calculated as pooled mean differences (Diff) with corresponding 95% confidence intervals (CIs). Random effects network meta-analyses assessed whether the specific TXA dosing regimen influenced BLV.

Results

Seven studies with 441 patients were included for meta-analysis. Four different TXA dosing regimens were found: 1) 10 mg/kg + 1 mg/kg/h, 2) 10 mg/kg + 2 mg/kg/h, 3) 15 mg/kg, 4) 15 mg/kg + 1 mg/kg/h. Compared to placebo, patients treated with TXA had reduced intraoperative BLV (Diff = -185.0 ml; 95% CI: -302.1, -67.9) and reduced total BLV (Diff = -439.0 ml; 95% CI: -838.5, -39.6). No significant differences in intraoperative BLV among any of the TXA treatment groups was found. Patients given a TXA dose of 15 mg/kg + 1 mg/kg/h had significantly reduced total BLV in comparison to both placebo (Diff = -823.1 ml; 95% CI: -1249.8, -396.4) and a dose of 15 mg/kg (Diff = -581.2; 95% CI: -1106.8, -55.7).

Conclusions

This study found that intravenous TXA is associated with reduced intraoperative and total BLV, but it remains unclear whether there is an optimal TXA dose. Additional trials directly comparing different TXA regimens and administration routes are needed.