Prevalence and risk factors for the development of venous thromboembolism after spinal tumor surgery

Screening for Deep Vein Thrombosis Using D-dimer Levels Based on Surgical Patients' Characteristics

Purpose Owing to the shortage of surgeons and the decrease in medical staff in regional medical care, reducing unnecessary tests can limit the burden on the staff. In this study, we aimed to examine the predictors of deep vein thrombosis (DVT), such as D-dimer levels in patients who underwent surgery at our hospital, and determine the feasibility of screening in these patients. Knowledge of D-dimer levels can indicate the risk of DVT in patients about to undergo surgery. Methods We retrospectively analyzed 310 of 1,059 surgical cases in which preoperative lower extremity ultrasonography was performed in our department between April 2021 and June 2024. We compared 46 patients with thrombi and 264 patients without thrombi. Results Patients with low body mass indices (<18.5 kg/m2) and high D-dimer levels (> 2 μg/mL) had a significantly higher risk of DVT, whereas patients taking oral antiplatelet drugs or anticoagulants had a significantly lower risk of DVT. The area under the curve for D-dimer levels in predicting DVT was 0.779. D-dimer levels of 2 μg/mL had high sensitivity - (1 - specificity). However, there were three false-negative cases, and the highest D-dimer level that resulted in 100% sensitivity was 1.4 μg/mL. Conclusion Predicting DVT using D-dimer levels may be effective, and considering additional testing based on D-dimer levels and patient background may reduce excessive preoperative testing.

Short-Term Bed Rest is not a Risk Factor for Venous Thromboembolism After Endoscopic Skull Base Surgery

BACKGROUND

Venous thromboembolism (VTE) increases morbidity in postoperative patients. No current guidelines identify which patients undergoing endoscopic endonasal approach (EEA) to the skull base may be at increased risk. Postoperative care for these patients often includes a period of inactivity to prevent transient intracranial pressure shifts that may impact skull base reconstruction. We sought to characterize if postoperative bed rest puts patients undergoing EEA at increased risk of developing thromboembolic complications.

METHODS

Retrospective chart review of patients undergoing intradural surgery with primary skull base reconstruction for intraoperative cerebrospinal fluid leak via EEA for any skull base pathology between July 2018 and May 2024 yielded 221 patients who met inclusion criteria. Univariate and multivariable regressions were performed with patient demographics, extent of approach, intraoperative leak flow rate, bed rest duration, presence and length of postoperative lumbar drainage, and use of postoperative mechanical VTE prophylaxis.

RESULTS

Mean age of included patients was 52.6 ± 16.8 years, 48% of patients were male, and 3.6% of patients had DVTs. Age (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.96-1.06, P = 0.83), sex (OR 0.40, 95% CI 0.05-2.19, P = 0.31), body mass index (OR 0.98, 95% CI 0.87-1.07, P = 0.74), extended approach (OR 0.80, 95% CI 0.13-4.36, P = 0.80), cerebrospinal fluid leak flow rate (OR 5.71, 95% CI 0.77-118.90, P = 0.14), bed rest duration (OR 1.06, 95% CI 0.77-1.27, P = 0.60), and presence of lumbar drainage (OR 1.10, 95% CI 0.55-2.02, P = 0.76) were not significant predictors of postoperative VTE incidence on multivariable analysis.

CONCLUSIONS

Short-term bed rest after EEA is not a risk factor for development of VTE in the immediate postoperative period.

A retrospective cohort study on enhanced recovery after surgery (ERAS) in patients with diabetic foot ulcer

Enhanced recovery after surgery (ERAS) has been successfully integrated into a diverse array of surgical fields to improve the quality and efficacy of treatment intervention. Nonetheless, the application of the ERAS protocol for patients with diabetic foot ulcer (DFU) subsequent to undergoing surgical procedures has not been previously explored. Therefore, this study aimed to investigate the effect of an enhanced recovery protocol on perioperative outcomes in patients with DFU following surgical procedures. A retrospective analysis was conducted on 112 patients with DFU who underwent surgery between January 2020 and December 2021 at a tertiary referral care center. In total, 57 patients received standard perioperative care (the non-ERAS group), and 55 patients received ERAS care (the ERAS group). The primary outcomes included the length of stay (LOS), wound healing time, patient satisfaction, and costs, serving as the basis for assessing the effectiveness of the two approaches. Secondary outcomes included preoperative anxiety (APAIS score), nutritional status (PG-SGA), pain (NRS score), the incidence of lower-extremity deep vein thrombosis (DVT), the reduction in lower-limb circumference, and the activity of daily living scale (Barthel Index). The ERAS group exhibited significantly shorter LOS (11.36 vs. 26.74 days; P < 0.001) and lower hospital costs (CNY 62,165.27 vs. CNY 118,326.84; P < 0.001), as well as a higher patient satisfaction score and Barthel Index score (P < 0.05). Additionally, we found a lower APAIS score, incidence of DVT, and circumference reduction in lower limbs in the ERAS group compared to the non-ERAS group (P < 0.05). In comparison, the wound healing time, nutritional status, and pain levels of participants in both groups showed no significant difference (P > 0.05). By reducing the LOS and hospital costs, and by minimizing perioperative complications, the ERAS protocol improves the quality and efficacy of treatment intervention in patients with DFU who underwent surgical procedures.Trial registration number: ChiCTR 2200064223 (Registration Date: 30/09/2022).

Is perioperative blood transfusion associated with postoperative thromboembolism or infection after metastatic spinal tumor surgery?

STUDY DESIGN

Retrospective cohort.

SUMMARY OF BACKGROUND DATA

Patients with metastatic spine disease who undergo surgical intervention have a high risk of requiring red blood cell (RBC) transfusion. Perioperative transfusion has been independently associated with increased risk of venous thromboembolic (VTE) and infectious complications following orthopedic procedures and degenerative spinal intervention; however, literature within spine oncology is limited.

OBJECTIVE

To determine the association between perioperative RBC transfusion and postoperative VTE or infection following spinal tumor surgery.

METHODS

A total of 153 patients who underwent surgery for spinal metastases between April 2012 and April 2022 were included. Medical records were reviewed to identify RBC transfusion administered either intraoperatively or within 96 h following surgery. The primary endpoints were: 1) development of any VTE or 2) development of any infection within 30 days following surgery. Any VTE was defined as deep vein thrombosis or pulmonary embolism, and any infection was defined as pneumonia, meningitis, Clostridium difficile infection, urinary tract infection, surgical site infection, or sepsis. Logistic regression analyses were performed.

RESULTS

Of the 153 patients included in the study, 43 % received a perioperative RBC transfusion. The overall incidence of postoperative VTE and infection was 15 % and 22 %, respectively. In univariate analysis, perioperative transfusion was not associated with postoperative VTE (odds ratio [OR] 2.41; 95 % confidence interval [CI] 0.97-6.00; p = 0.058) but was associated with infection (OR 3.02; 95 % CI 1.36-6.73; p = 0.007). After adjusting for confounders such as performance status, operative time, and surgical extent, transfusion was not associated with both VTE (OR 1.25; 95 % CI 0.36-4.32; p = 0.727) or infection (OR 1.86; 95 % CI 0.70-4.92; p = 0.210). While not statistically significant, sub-analyses demonstrated a trend towards increased VTE incidence in patients requiring transfusion earlier (within 24 h) as opposed to later postoperatively.

CONCLUSIONS

We found that perioperative transfusion was not an independent predictor of 30-day postoperative VTE or infection in patients undergoing metastatic spinal surgery. Further exploration of time-dependent transfusion outcomes is warranted.

The Impact of Frailty on Postoperative Complications in Total En Bloc Spondylectomy for Spinal Tumors

Total en bloc spondylectomy (TES) is an effective treatment for spinal tumors. However, its complication rate is high, and the corresponding risk factors remain unclear. This study aimed to clarify the risk factors for postoperative complications after TES, including the patient's general condition, such as frailty and their levels of inflammatory biomarkers. We included 169 patients who underwent TES at our hospital from January 2011-December 2021. The complication group comprised patients who experienced postoperative complications that required additional intensive treatments. We analyzed the relationship between early complications and the following factors: age, sex, body mass index, type of tumor, location of tumor, American Society of Anesthesiologists score, physical status, frailty (categorized by the 5-factor Modified Frailty Index [mFI-5]), neutrophil-to-lymphocyte ratio, C-reactive protein/albumin ratio, preoperative chemotherapy, preoperative radiotherapy, surgical approach, and the number of resected vertebrae. Of the 169 patients, 86 (50.1%) were included in the complication group. Multivariate analysis showed that high mFI-5 scores (odds ratio [OR] = 2.99, p < 0.001) and an increased number of resected vertebrae (OR = 1.87, p = 0.018) were risk factors for postoperative complications. Frailty and the number of resected vertebrae were independent risk factors for postoperative complications after TES for spinal tumors.

Chemoprophylactic Anticoagulation Following Lumbar Surgery Significantly Reduces Thromboembolic Events After Instrumented Fusions, Not Decompressions

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To quantify any reduction in venous thromboembolic events (VTEs) caused by chemoprophylaxis among lumbar surgery patients.

SUMMARY OF BACKGROUND DATA

Chemoprophylactic anticoagulation (chemoprophylaxis) is used to prevent VTE after lumbar surgery. However, the treatment effect of chemoprophylaxis has not been reported among spine surgery patients, as conventional statistical methods preclude such inferences.

MATERIALS AND METHODS

A total of 1243 consecutive lumbar fusions and 1433 noninstrumented lumbar decompressions performed at our institution over a six-year period were identified, and clinical and demographic data were collected, including on VTE events within 30 days postoperatively. Instrumented lumbar fusions and noninstrumented lumbar surgeries were analyzed separately. Patients who were given chemoprophylaxis (treatment) and controls were matched according to known VTE risk factors, including age, body mass index, sex, diabetes, chronic kidney disease, history of VTE, estimated blood loss, length of surgery, transfusion, whether surgery was staged, and whether surgery used an anterior approach. K-nearest neighbor propensity score matching was performed, and the treatment effect of chemoprophylaxis was calculated.

RESULTS

Unadjusted, there was no difference in the rate of VTE between treatment and controls in either population. Baseline clinical and demographic characteristics differed significantly between treatment and control groups. In all, 575 lumbar fusion patients and 435 noninstrumented lumbar decompression patients were successfully propensity score matched, yielding balanced models (Rubin B <25, 0.5<Rubin R <2.0) and >60% reduction in known bias for both populations. The treatment effect of chemoprophylaxis after lumbar fusion in our patient population was a reduction in VTE incidence from 9.4% to 4.2% ( P <0.05), and propensity score adjusted regression confirmed a reduced odds of VTE with chemoprophylaxis (odds ratio=0.37, P =0.035). The treatment effect was not significant for noninstrumented lumbar decompression patients.

CONCLUSION

Among patients undergoing instrumented lumbar fusions, chemoprophylactic anticoagulation causes a significant reduction in VTE, but causes no significant reduction among patients undergoing noninstrumented lumbar decompression.

Impact of Prolonged Operative Duration on Postoperative Symptomatic Venous Thromboembolic Events After Thoracolumbar Spine Surgery

OBJECTIVE

To determine the effect of operative duration on the rate of postoperative symptomatic venous thromboembolic (VTE) events in patients undergoing thoracolumbar spine fusion.

METHODS

We identified all thoracolumbar spine fusion patients between 2012 and 2021. Operative duration was defined as time from skin incision to skin closure. A 1:1 propensity match was conducted incorporating patient and surgical characteristics. Logistic regression was performed to assess predictors of postoperative symptomatic VTE events. A receiver operating characteristic curve was created to determine a cutoff time for increased likelihood of VTE.

RESULTS

We identified 101 patients with VTE and 1108 patients without VTE. Seventy-five patients with VTE were matched to 75 patients without VTE. Operative duration (339 vs. 262 minutes, P = 0.010) and length of stay (5.00 vs. 3.54 days, P = 0.008) were significantly longer in patients with a VTE event. Operative duration was an independent predictor of VTE on multivariate regression (odds ratio: 1.003, 95% confidence interval: 1.001-1.01, P = 0.021). For each additional hour of operative duration, the risk of VTE increased by 18%. A cutoff time of 218 minutes was identified (area under the curve [95% confidence interval] = 0.622 [0.533-0.712]) as an optimal predictor of increased risk for a VTE event.

CONCLUSIONS

Operative duration significantly predicted symptomatic VTE, especially after surgical time cutoff of 218 minutes. Each additional hour of operative duration was found to increase VTE risk by 18%. We also identify the impact of VTE on 90-day readmission rates, suggesting significantly higher costs and opportunity for hospital acquired conditions, in line with prior literature.