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Wadhwa H, Rohde MS, Xiao M, Maschhoff C, Bishop JA, Gardner MJ, Goodnough LH. Preoperative and Postoperative Therapeutic Anticoagulation in Orthopaedic Surgery Increases the Risk of Bleeding: A Systematic Review and Meta-Analysis. J Am Acad Orthop Surg 2024:00124635-990000000-01095. [PMID: 39254989 DOI: 10.5435/jaaos-d-24-00161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 07/21/2024] [Indexed: 09/11/2024] Open
Abstract
INTRODUCTION Patients requiring postoperative therapeutic anticoagulation may have increased risk of bleeding complications, infection, and poor wound healing. The purpose of this study was to perform a systematic review and meta-analysis assessing bleeding complication rates among orthopaedic surgery patients receiving perioperative therapeutic anticoagulation. METHODS A systematic review and meta-analysis was performed in concordance with the Preferred Reporting Items for Systematic Review and Meta Analysis 2020 guidelines. PubMed was queried for articles related to therapeutic anticoagulation in orthopaedic surgery and complications using keywords and medical subject headings. Inclusion/exclusion criteria were any study reporting bleeding complications after orthopaedic surgery among patients on perioperative therapeutic anticoagulation with a minimum 1-year follow-up. Studies were reviewed for heterogeneity and risk of bias. Pooled analysis was done to determine postoperative complication rates among patients on therapeutic anticoagulation. RESULTS Thirty-seven studies with 3,990 patients were included. Studies were grouped by their surgical subspecialty with 16 from arthroplasty, one foot and ankle, two spine, one sports, 13 trauma, and four upper extremity. Among patients on therapeutic anticoagulation, the pooled rate and 95% confidence intervals of bleeding complications was 8% (5 to 11%) overall, 10% (5 to 15%) in arthroplasty, 6% (3 to 11%) in trauma, and 5% (1 to 30%) in upper extremity. The overall rates (95% CI) of venous thromboembolism (VTE) were 2% (2 to 4%), infection 5% (3 to 10%), and revision surgery 4% (3 to 6%). Upper extremity VTE rates were 0% (0 to 15%), infection 4% (3 to 6%), and revision surgery 4% (3 to 6%). Trauma VTE rates were 4% (2 to 5%), infection 2% (1 to 6%), and revision surgery 3% (2 to 4%). Arthroplasty VTE rates were 2% (1 to 5%), infection 9% (4 to 18%), and revision surgery 4% (2 to 7%). CONCLUSIONS Therapeutic postoperative anticoagulation may increase the risk of bleeding complications when compared with the general population. Incidence of VTE was similar when compared with historical data.
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Affiliation(s)
- Harsh Wadhwa
- From the Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA
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Ikeda N, Yokoyama K, Ito Y, Tanaka H, Yamada M, Sugie A, Takami T, Wanibuchi M, Kawanishi M. The safety of perioperative antiplatelet continuation without selection biases in microsurgical decompression surgery for single level lumbar spinal stenosis and lumbar disc herniotomy. Acta Neurochir (Wien) 2024; 166:262. [PMID: 38864938 DOI: 10.1007/s00701-024-06156-1] [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: 02/13/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE Each institution or physician has to decide on an individual basis whether to continue or discontinue antiplatelet (AP) therapy before spinal surgery. The purpose of this study was to determine if perioperative AP continuation is safe during single-level microsurgical decompression (MSD) for treating lumbar spinal stenosis (LSS) and lumbar disc hernia (LDH) without selection bias. METHODS Patients who underwent single-level MSD for LSS and LDH between April 2018 to December 2022 at our institute were included in this retrospective study. We collected data regarding baseline characteristics, medical history/comorbidities, epidural hematoma (EDH) volume, reoperation for EDH, differences between preoperative and one-day postoperative blood cell counts (ΔRBC), hemoglobin (ΔHGB), and hematocrits (ΔHCT), and perioperative thromboembolic complications. Patients were divided into two groups: the AP continuation group received AP treatment before surgery and the control group did not receive antiplatelet medication before surgery. Propensity scores for receiving AP agents were calculated, with one-to-one matching of estimated propensity scores to adjust for patient baseline characteristics and past histories. Reoperation for EDH, EDH volume, ΔRBC, ΔHGB, ΔHCT, and perioperative thromboembolic complications were compared between the groups. RESULTS The 303 enrolled patients included 41 patients in the AP continuation group. After propensity score matching, the rate of reoperation for EDH, the EDH volume, ΔRBC, ΔHGB, ΔHCT, and perioperative thromboembolic complication rates were not significantly different between the groups. CONCLUSION Perioperative AP continuation is safe for single-level lumbar MSD, even without biases.
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Affiliation(s)
- Naokado Ikeda
- Department of Neurosurgery, Neuroendoscope center, Ijinkai Takeda General Hospital, 28-1 Ishidamoriminamichou, Fushimi, Kyoto, 601-1495, Japan.
| | - Kunio Yokoyama
- Department of Neurosurgery, Neuroendoscope center, Ijinkai Takeda General Hospital, 28-1 Ishidamoriminamichou, Fushimi, Kyoto, 601-1495, Japan
| | - Yutaka Ito
- Department of Neurosurgery, Neuroendoscope center, Ijinkai Takeda General Hospital, 28-1 Ishidamoriminamichou, Fushimi, Kyoto, 601-1495, Japan
| | - Hidekazu Tanaka
- Department of Neurosurgery, Neuroendoscope center, Ijinkai Takeda General Hospital, 28-1 Ishidamoriminamichou, Fushimi, Kyoto, 601-1495, Japan
| | - Makoto Yamada
- Department of Neurosurgery, Neuroendoscope center, Ijinkai Takeda General Hospital, 28-1 Ishidamoriminamichou, Fushimi, Kyoto, 601-1495, Japan
| | - Akira Sugie
- Department of Neurosurgery, Neuroendoscope center, Ijinkai Takeda General Hospital, 28-1 Ishidamoriminamichou, Fushimi, Kyoto, 601-1495, Japan
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, 569-8686, Osaka, Japan
| | - Masahiko Wanibuchi
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, 569-8686, Osaka, Japan
| | - Masahiro Kawanishi
- Department of Neurosurgery, Neuroendoscope center, Ijinkai Takeda General Hospital, 28-1 Ishidamoriminamichou, Fushimi, Kyoto, 601-1495, Japan
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Orban C, Abramovic A, Gmeiner R, Lener S, Demetz M, Thomé C. The Influence of Preoperative Anticoagulant and Antiplatelet Therapy on Rebleeding Rates in Patients Suffering from Spinal Metastatic Cancer: A Retrospective Cohort Study. Cancers (Basel) 2024; 16:2052. [PMID: 38893171 PMCID: PMC11171320 DOI: 10.3390/cancers16112052] [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: 04/15/2024] [Revised: 05/25/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION The age of patients requiring surgery for spinal metastasis, primarily those over 65, has risen due to improved cancer treatments. Surgical intervention targets acute neurological deficits and instability. Anticoagulants are increasingly used, especially in the elderly, but pose challenges in managing bleeding complications. The study examines the correlation between preoperative anticoagulant/antiplatelet use and bleeding risks in spinal metastasis surgery, which is crucial for optimizing patient outcomes. MATERIAL AND METHODS In a retrospective study at our department from 2010 to 2023, spinal tumor surgery patients were analyzed. Data included demographics, neurological status, surgical procedure, preoperative anticoagulant/antiplatelet use, intra-/postoperative coagulation management, and the incidence of rebleeding. Coagulation management involved blood loss assessment, coagulation factor administration, and fluid balance monitoring post-surgery. Lab parameters were documented at admission, preop, postop, and discharge. RESULTS A cohort of 290 patients underwent surgical treatment for spinal metastases, predominantly males (63.8%, n = 185) with a median age of 65 years. Preoperatively, 24.1% (n = 70) were on oral anticoagulants or antiplatelet therapy. Within 30 days, a rebleeding rate of 4.5% (n = 9) occurred, unrelated to preoperative anticoagulation status (p > 0.05). A correlation was found between preoperative neurologic deficits (p = 0.004) and rebleeding risk and the number of levels treated surgically, with fewer levels associated with a higher incidence of postoperative bleeding (p < 0.01). CONCLUSIONS Surgical intervention for spinal metastatic cancer appears to be safe regardless of the patient's preoperative anticoagulation status. However, it remains imperative to customize preoperative planning and preparation for each patient, emphasizing meticulous risk-benefit analysis and optimizing perioperative care.
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Affiliation(s)
| | - Anto Abramovic
- Department of Neurosurgery, Medical University Innsbruck, 6020 Innsbruck, Austria; (C.O.); (C.T.)
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Lucke-Wold N, Hey G, Rivera A, Sarathy D, Rezk R, MacNeil A, Albright A, Lucke-Wold B. Optimizing Dual Antiplatelet Therapy in the Perioperative Period for Spine Surgery After Recent Percutaneous Coronary Intervention: A Comprehensive Review, Synthesis, and Catalyst for Protocol Formulation. World Neurosurg 2024; 185:267-278. [PMID: 38460814 DOI: 10.1016/j.wneu.2024.03.005] [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: 02/29/2024] [Accepted: 03/03/2024] [Indexed: 03/11/2024]
Abstract
The increased incidence of spine surgery within the past decade has highlighted the importance of robust perioperative management to improve patient outcomes overall. Coronary artery disease is a common medical comorbidity present in the population of individuals who receive surgery for spinal pathology that is often treated with dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. Discontinuation of DAPT before surgical intervention is typically indicated; however, contradictory evidence exists in the literature regarding the timing of DAPT use and discontinuation in the perioperative period. We review the most recent cardiac and spine literature on the intricacies of percutaneous coronary intervention and its associated risks in the postoperative period. We further propose protocols for DAPT use after both elective and urgent spine surgery to optimize perioperative care.
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Affiliation(s)
- Noelle Lucke-Wold
- Malcom Randall Veteran Affairs Medical Center, Gainesville, Florida, USA
| | - Grace Hey
- University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Angela Rivera
- Malcom Randall Veteran Affairs Medical Center, Gainesville, Florida, USA
| | - Danyas Sarathy
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Rogina Rezk
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Andrew MacNeil
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ashley Albright
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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Song MG, Kim CW, Song SY, Kim HG, Kim DH. Management of Patients with Ischemic Heart Disease in Spine Surgery. Asian Spine J 2023; 17:1168-1175. [PMID: 38105637 PMCID: PMC10764142 DOI: 10.31616/asj.2023.0161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 12/19/2023] Open
Abstract
In ischemic heart disease (IHD), the myocardium does not receive enough blood and oxygen. Although the IHD-related mortality rate is decreasing, the risk remains and is a major predictor of cardiac complications following noncardiac surgery. Given the increase in the older population, the number of patients with spinal diseases requiring surgery is increasing. Among these patients, those with underlying IHD or a high risk of cardiac complications before and after surgery are also increasing. Given that cardiac complications following spinal surgery are associated with delayed patient recovery and even death, spinal surgeons should be knowledgeable about overall patient management, including medication therapy in those at high risk of developing perioperative cardiac complications for successful patient care. Before surgery, the underlying medical conditions of patients should be evaluated. Patients with a history of myocardial infarction should be checked for a history of surgical treatments, and the anticoagulant dose should be controlled depending on the surgery type. In addition, the functional status of patients must be examined before surgery. Functional status can be assessed according to the metabolic equivalent of task (MET). More preoperative cardiac examinations are needed for patients who are unable to perform four METs in daily because of the high risk of postoperative cardiac complications. Patients with a history of IHD require appropriate preoperative management and further postoperative evaluation. When considering surgery, spinal surgeons should be knowledgeable about patient care before and after surgery.
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Affiliation(s)
- Myung-Geun Song
- Department of Orthopaedic Surgery, Inha University Hospital, Incheon,
Korea
| | - Chang-Won Kim
- Department of Orthopaedic Surgery, Institute of Health Sciences, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju,
Korea
| | - Sang-Youn Song
- Department of Orthopaedic Surgery, Institute of Health Sciences, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju,
Korea
| | - Han-Gyul Kim
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju,
Korea
| | - Dong-Hee Kim
- Department of Orthopaedic Surgery, Institute of Health Sciences, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju,
Korea
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Tezuka F, Sakai T, Imagama S, Takahashi H, Takaso M, Aizawa T, Otani K, Okuda S, Kato S, Kanemura T, Kawaguchi Y, Konishi H, Suda K, Terai H, Nakanishi K, Nishida K, Machino M, Miyakoshi N, Murakami H, Yamato Y, Yukawa Y. Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan. Spine Surg Relat Res 2023; 7:428-435. [PMID: 37841038 PMCID: PMC10569803 DOI: 10.22603/ssrr.2023-0015] [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: 01/30/2023] [Accepted: 03/13/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction The number of patients on antithrombotic drugs for coronary heart disease or cerebrovascular disease has been increasing with the aging of society. We occasionally need to decide whether to continue or discontinue antithrombotic drugs before spine surgery. The purpose of this study is to understand the current perioperative management of antithrombotic drugs before elective spine surgery in Japan. Methods In 2021, members of the Japanese Society for Spine Surgery and Related Research (JSSR) were asked to complete a web-based questionnaire survey that included items concerning the respondents' surgical experience, their policy regarding discontinuation or continuation of antithrombotic drugs, their reasons for decisions concerning the management of antithrombotic drugs, and their experience of perioperative complications related to the continuation or discontinuation of these drugs. Results A total of 1,181 spine surgeons returned completed questionnaires, giving a response rate of 32.0%. JSSR board-certified spine surgeons comprised 75.1% of the respondents. Depending on the management policy regarding antithrombotic drugs for each comorbidity, approximately 73% of respondents discontinued these drugs before elective spine surgery, and about 80% also discontinued anticoagulants. Only 4%-5% of respondents reported continuing antiplatelet drugs, and 2.5% reported continuing anticoagulants. Among the respondents who discontinued antiplatelet drugs, 20.4% reported having encountered cerebral infarction and 3.7% reported encountering myocardial infarction; among those who discontinued anticoagulants, 13.6% reported encountering cerebral embolism and 5.4% reported encountering pulmonary embolism. However, among the respondents who continued antiplatelet drugs and those who continued anticoagulants, 26.3% and 27.2%, respectively, encountered an unexpected increase in intraoperative bleeding, and 10.3% and 8.7%, respectively, encountered postoperative spinal epidural hematoma requiring emergency surgery. Conclusions Our findings indicate that, in principle, >70% of JSSR members discontinue antithrombotic drugs before elective spine surgery. However, those with a discontinuation policy have encountered thrombotic complications, while those with a continuation policy have encountered hemorrhagic complications.
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Affiliation(s)
- Fumitake Tezuka
- Department of Orthopedics, Tokushima University, Tokushima, Japan
| | - Toshinori Sakai
- Department of Orthopedics, Tokushima University, Tokushima, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Takahashi
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University, School of Medicine, Kanagawa, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Koji Otani
- Department of Orthopedic Surgery, Fukushima Medical University, Fukushima, Japan
| | - Shinya Okuda
- Department of Orthopedics, Hoshigaoka Medical Center, Hirakata, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Tokumi Kanemura
- Department of Orthopaedic Surgery, Konan Kosei Hospital, Aichi, Japan
| | | | - Hiroaki Konishi
- Department of Orthopedics, Nagasaki Rosai Hospital, Sasebo, Japan
| | - Kota Suda
- Hokkaido Spinal Cord Injury Center, Bibai, Japan
| | - Hidetomi Terai
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Kazuo Nakanishi
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Kotaro Nishida
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Masaaki Machino
- Department of Orthopaedic Surgery/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Nagoya City University, Nagoya, Japan
| | - Yu Yamato
- Division of Geriatric Musculoskeletal Health, Hamamatsu University School of Medicine, Shizuoka, Japan
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Tarukado K, Ono T, Doi T, Harimaya K, Nakashima Y. Safety and Clinical Results of Continuous Low-Dose Aspirin in Microendoscopic Laminectomy. Spine Surg Relat Res 2023; 7:350-355. [PMID: 37636142 PMCID: PMC10447200 DOI: 10.22603/ssrr.2022-0224] [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: 11/10/2022] [Accepted: 12/07/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction It remains controversial whether it is better to continue oral low-dose aspirin (LDA) during the perioperative period in spinal surgery. This study aims to evaluate the safety of continued LDA administration in the perioperative periods of microendoscopic laminectomy (MEL) by assessing perioperative complications and clinical outcomes. Methods We ultimately included 88 patients (35 males, 53 females) who underwent one level of MEL for lumbar spinal canal stenosis from April 2016 to March 2022. Patients who did not undergo anticoagulation therapy were classified into Group A (65 patients), those who stopped anticoagulation therapy at the perioperative periods were classified into Group B (9 patients), and those who continued oral administration of LDA throughout the perioperative periods were classified into Group C (14 patients). Surgery time, intraoperative estimate blood loss (EBL), differences between hemoglobin (Hb) and platelet (Plt) before and after surgery, perioperative complications, and cross-sectional area of hematoma and dural sac on MRI taken within 1 week and at 6 months or more after surgery were assessed between three groups. The EuroQol-5 dimensions (EQ-5D), Oswestry Disability Index (ODI), and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) were also evaluated as the clinical outcomes. Results There was no statistically significant difference between the three groups in operation time, intraoperative EBL, differences between Hb and Plt before and after surgery, and cross-sectional area of hematoma and dural sac on MRI. A case of hematoma removal was confirmed in Group A. There was also no statistically significant difference between the three groups in EQ-5D, ODI, and each domain of JOABPEQ. Conclusions The continuation of LDA throughout the perioperative periods did not affect perioperative complications and clinical outcomes of one-level MEL. In MEL, it might be possible to continue oral administration of LDA throughout the perioperative periods.
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Affiliation(s)
- Kiyoshi Tarukado
- Department of Orthopaedic Surgery, Kyushu Rosai Hospital, Fukuoka, Japan
| | - Teruaki Ono
- Department of Orthopedic Surgery, Kyushu University Beppu Hospital, Oita, Japan
| | - Toshio Doi
- Department of Orthopedic Surgery, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Katsumi Harimaya
- Department of Orthopedic Surgery, Kyushu University Beppu Hospital, Oita, Japan
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Chung Wong Y, Kit Lau T, Wang Chau W, On Kwok K, Wai Law S. Safety of Continuing Aspirin Use in Cervical Laminoplasty: A Propensity Score-Matched Analysis. Spine Surg Relat Res 2023; 7:142-148. [PMID: 37041877 PMCID: PMC10083087 DOI: 10.22603/ssrr.2022-0163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/10/2022] [Indexed: 04/03/2023] Open
Abstract
Introduction Aspirin is commonly used for the primary and secondary prevention of cardiovascular disease and stroke. Controversy exists concerning whether and when is the optimal time to stop aspirin before spinal surgery. Previous studies on this topic mainly focused on patients who received thoracolumbar spine surgeries. There are only a few literatures concerning the safety of aspirin use in cervical spine surgery patients. Methods This pilot study recruited patients who received cervical laminoplasty from January 2010 to December 2021. The operation time, intraoperative blood loss, and postoperative complications of the patients who had taken aspirin during the perioperative period were compared with age, sex, and comorbidity-matched control patients. Propensity score matching was utilized in the selection of control to minimize bias. Results Twenty-one patients who have received cervical laminoplasty while taking aspirin during the perioperative period were included. The control group included 21 age, sex, and comorbidity-matched patients who have not taken aspirin. The operation time and intraoperative and postoperative blood loss were higher in patients taking aspirin but were not statistically significant. There was no statistically significant difference in the wound infection rate. No case of epidural hematoma was found. Conclusions In patients undergoing cervical laminoplasty, a continuation of aspirin is safe and does not increase the difficulty of the surgery, wound complication, or hemorrhage.
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Claydon MH, Biddau DT, Laggoune JP, Malham GM. Who bleeds during elective anterior lumbar surgery? NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 12:100180. [PMID: 36568642 PMCID: PMC9768351 DOI: 10.1016/j.xnsj.2022.100180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022]
Abstract
Background Blood loss (BL) during elective anterior lumbar access for interbody fusion or disc replacement is a potentially major complication. This study sought to identify factors other than major vascular injury which contribute to BL and therefore this risk. Factors suggested to effect blood loss include age, increasing body mass index (BMI), sex, prothesis, intraoperative heparinization and continuation of low-dose aspirin (LD-ASA). Methods A Cell Saver was used in all cases with BL measured and recorded by an independent autotransfusionist. Heparin was administered intravenously when one or both of 2ndtoe saturation metre signal/s lost pulsatility indicating lower limb arterial flow was interrupted. Results The mean age of the 364 patients was 47 ± 13.2 yrs. [95% CI: 45 - 48]; and 191 (52%) were male. Age, BMI and heparinization showed a positive correlation with increased BL. There was no significant association with continuation of low-dose ASA with increased BL. Most patients underwent an ALIF - 265 (72%), 52 (14%) had a TDR, and 47 (13%) had a hybrid operation. There was a significant increase in mean BL between single- and two-level procedures in the non-heparinised group (48 vs 83 mls, p = 0.003). Intraoperative heparinization was administered in 102 patients (28%). The total mean BL for the heparin group (104 ml) which was significantly higher than for the non-heparin group (53 ml) (p = 0.001). Heparinisation did not significantly increase the mean BL in single or double level ALIF patients but did significantly increase the BL in single level TDR (57 vs 151 mls, p = 0.039). Conclusions Younger, leaner, non-heparinized, single level ALIF patients represented the lowest bleeding risk in anterior lumbar surgery. Conversely, older, increasing BMI, two operative levels, TDR prosthesis and heparinization represent the highest bleeding risk. Continuation of LD-ASA was not associated with an increase in BL.
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Affiliation(s)
| | - Dean T. Biddau
- Epworth Hospital, Melbourne, VIC, Australia,Spine Surgery Research, Swinburne University of Technology, Melbourne, VIC, Australia
| | | | - Gregory M. Malham
- Epworth Hospital, Melbourne, VIC, Australia,Spine Surgery Research, Swinburne University of Technology, Melbourne, VIC, Australia,Corresponding author at: Epworth Hospital, Melbourne.
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Inoue T, Mizutamari M, Hatake K. Safety of Continuous Low-Dose Aspirin Therapy for Cervical Laminoplasty. Spine Surg Relat Res 2022; 6:240-246. [PMID: 35800625 PMCID: PMC9200418 DOI: 10.22603/ssrr.2021-0081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/25/2021] [Indexed: 01/25/2023] Open
Abstract
Introduction Methods Results Conclusions
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Affiliation(s)
- Tetsuji Inoue
- Department of Orthopedic Surgery, Kumamoto Chuo Hospital
| | | | - Kuniaki Hatake
- Department of Orthopedic Surgery, Kumamoto Chuo Hospital
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Louie PK, Urakawa H, Manzur MK, Craig CM, Qureshi SA. Narrative Review of Antiplatelet and Anticoagulant Medications for Venous Thromboembolism Prevention in Spine Surgery. Clin Spine Surg 2022; 35:63-75. [PMID: 34694260 DOI: 10.1097/bsd.0000000000001260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a narrative review. OBJECTIVE The objective of this study was to identify commonly utilized venous thromboembolism (VTE) prophylactic measures, spine surgeon perspective, and provide pharmacologic recommendations from the literature. SUMMARY OF BACKGROUND DATA Considered a preventable cause of morbidity and mortality, VTE remains an important iatrogenic diagnosis of concern. Reported rates of VTE following spine surgery vary widely (0.3%-31.0%). MATERIALS AND METHODS A MEDLINE query identified literature reporting on VTE prevention and outcomes in the setting of spine surgery. Findings extracted from the included articles were summarized in a narrative review format to identify salient aspects of the current literature. RESULTS Sixty articles were summarized. Many anticoagulation medications that are described in the literature target factors involved in the coagulation cascade common pathway including aspirin and other antiplatelet medications, heparins, and warfarin. Newer direct inhibitors of thrombin and factor Xa are now being utilized for VTE prevention, although with limited use specifically in spine surgery. CONCLUSIONS Perioperative management of antiplatelet and anticoagulation medications in spine surgery requires evidence-based protocols that can account for patient comorbidities and surgery-specific features. Future studies should prospectively focus on establishing stronger recommendations based on pathology, surgical indications, patient comorbidities, region of the spine, and broad surgical intervention to enable effective prophylaxis for VTE. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
| | | | - Mustfa K Manzur
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Chad M Craig
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Sheeraz A Qureshi
- Hospital for Special Surgery, New York, NY
- Weill Cornell Medical College, New York, NY
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Huec JL, AlEissa S, Bowey A, Debono B, El-Shawarbi A, Fernández-Baillo N, Han K, Martin-Benlloch A, Pflugmacher R, Sabatier P, Vanni D, Walker I, Warren T, Litrico S. Hemostats in Spine Surgery: Literature Review and Expert Panel Recommendations. Neurospine 2022; 19:1-12. [PMID: 35378578 PMCID: PMC8987560 DOI: 10.14245/ns.2143196.598] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/10/2022] [Indexed: 01/05/2023] Open
Abstract
Bleeding in spine surgery is a common occurrence but when bleeding is uncontrolled the consequences can be severe due to the potential for spinal cord compression and damage to the central nervous system. There are many factors that influence bleeding during spine surgery including patient factors and those related to the type of surgery and the surgical approach to bleeding. There are a range of methods that can be employed to both reduce the risk of bleeding and achieve hemostasis, one of which is the adjunct use of hemostatic agents. Hemostatic agents are available in a variety of forms and materials and with considerable variation in cost, but specific evidence to support their use in spine surgery is sparse. A literature review was conducted to identify the pre-, peri-, and postsurgical considerations around bleeding in spine surgery. The review generated a set of recommendations that were discussed and ratified by a wider expert group of spine surgeons. The results are intended to provide a practical guide to the selection of hemostats for specific bleeding situations that may be encountered in spine surgery.
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Affiliation(s)
- J.C. Le Huec
- Spine Unit, Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France,Corresponding Author J.C. Le Huec https://orcid.org/0000-0002-0463-6706 Spine Unit, Polyclinique Bordeaux Nord Aquitaine, Université Bordeaux, 33000, Bordeaux, France
| | - S. AlEissa
- King Saud bin Abdulaziz University for Health Sciences Riyadh, Riyadh, Saudi Arabia
| | - A.J. Bowey
- Department of Orthopaedic Spinal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - B. Debono
- Paris-Versailles Spine Center (Centre Francilien du Dos), Ramsay Santé - Hôpital Privé de Versailles, Versailles, France
| | | | - N. Fernández-Baillo
- Spine Unit, Department of Orthopedic Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - K.S. Han
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A. Martin-Benlloch
- Department of Orthopaedic Surgery, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - R. Pflugmacher
- Department of Orthopaedics and Trauma Surgery, University Hospital Bonn, Germany
| | - P. Sabatier
- Department of Neurosurgery, Clinique des Cèdres, Cornebarrieu, France
| | - D. Vanni
- G-spine 4, Spine Surgery Division, I.R.C.C.S. Istituto Ortopedico Galeazzi, Milan, Italy
| | - I. Walker
- Triducive Partners Limited, Hertfordshire, UK
| | - T. Warren
- Triducive Partners Limited, Hertfordshire, UK
| | - S. Litrico
- Department of Spine Surgery, Pasteur II Hospital, Centre Hospitalo-Universitaire de Nice, Nice, France
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15
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Okamoto N, Kato S, Doi T, Nakamoto H, Matsubayashi Y, Taniguchi Y, Inanami H, Higashikawa A, Kawamura N, Hara N, Azuma S, Takeshita Y, Ono T, Fukushima M, Tanaka S, Oshima Y. Influence of Perioperative Antithrombic Agent Discontinuation in Elective Posterior Spinal Surgery: A Propensity-Score-Matched Analysis. World Neurosurg 2021; 158:e362-e368. [PMID: 34743017 DOI: 10.1016/j.wneu.2021.10.182] [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: 09/18/2021] [Revised: 10/28/2021] [Accepted: 10/28/2021] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Naoki Okamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan; University of Tokyo Spine Group (UTSG), Tokyo, Japan
| | - So Kato
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan; University of Tokyo Spine Group (UTSG), Tokyo, Japan
| | - Toru Doi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan; University of Tokyo Spine Group (UTSG), Tokyo, Japan
| | - Hideki Nakamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan; University of Tokyo Spine Group (UTSG), Tokyo, Japan
| | - Yoshitaka Matsubayashi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan; University of Tokyo Spine Group (UTSG), Tokyo, Japan
| | - Yuki Taniguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan; University of Tokyo Spine Group (UTSG), Tokyo, Japan
| | - Hirohiko Inanami
- University of Tokyo Spine Group (UTSG), Tokyo, Japan; Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, Tokyo, Japan
| | - Akiro Higashikawa
- University of Tokyo Spine Group (UTSG), Tokyo, Japan; Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kawasaki City, Japan
| | - Naohiro Kawamura
- University of Tokyo Spine Group (UTSG), Tokyo, Japan; Department of Spine and Orthopedic Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Nobuhiro Hara
- University of Tokyo Spine Group (UTSG), Tokyo, Japan; Department of Orthopaedic Surgery, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Seiichi Azuma
- University of Tokyo Spine Group (UTSG), Tokyo, Japan; Department of Orthopaedic Surgery, Japanese Red Cross Saitama Hospital, Saitama City, Japan
| | - Yujiro Takeshita
- University of Tokyo Spine Group (UTSG), Tokyo, Japan; Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety Yokohama Rosai Hospital, Yokohama City, Japan
| | - Takashi Ono
- University of Tokyo Spine Group (UTSG), Tokyo, Japan; Department of Spinal Surgery, Japan Community Health-care Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Masayoshi Fukushima
- University of Tokyo Spine Group (UTSG), Tokyo, Japan; Spine Center, Toranomon Hospital, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan; University of Tokyo Spine Group (UTSG), Tokyo, Japan.
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16
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Impact of acetylsalicylic acid (ASA) on postoperative hemorrhage in spinal lumbar surgery: Should preoperative ASA be discontinued for elective surgery? J Neurol Sci 2021; 427:117508. [PMID: 34087567 DOI: 10.1016/j.jns.2021.117508] [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: 03/25/2021] [Revised: 05/17/2021] [Accepted: 05/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The application of acetylsalicylic acid (ASA) represents high evidence in the aging society due to primary and secondary prevention in cardiovascular disease and stroke. However, this presents a challenge for neurosurgeons in terms of preoperative and postoperative management of care. This study aimed to analyze the risk of bleeding by applying ASA before lumbar spinal surgery. METHODS Retrospective analysis of medical records of 3051 patients was performed from 2008 to 2018 who underwent lumbar surgery at our institution. The risk of postoperative hemorrhage was compared in patients treated with ASA versus patients without ASA treatment. Additionally, the relationship between discontinuation of ASA preoperatively (≥7 days) or no previous history of ASA versus continuation with ASA (<7 days) on postoperative hemorrhage was analyzed. RESULTS Postoperative hemorrhagic were observed in 2.1% (n = 63) of all lumbar operations. In 421 patients, the effect of ASA (<7 days) was still persistent at the time of surgery (ASA impact group). Of these, 12 (2.85%) patients had a hemorrhage. No significant differences were found in comparison to the No ASA impact group (p = 0.272). Sex (p = 0.003), hypertension (p = 0.015), recurrent surgery (p = 0.001) and use of hemostatic agents (p = 0.023) had a significant impact on postoperative hemorrhage. CONCLUSION The continuation of ASA medication is not associated with increased risk of postoperative hemorrhage after spinal surgery. However, sex, hypertension, recurrent surgery and the use of hemostatic agents under continued ASA treatment were found to be associated with an increased risk of hemorrhage.
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Ricciardi L, Raco A, Sturiale CL. Perioperative interruption of antiplatelet medications for elective extradural non-instrumented spine surgery: it is really necessary? J Neurosurg Sci 2020; 65:541-542. [PMID: 33320472 DOI: 10.23736/s0390-5616.20.05251-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Luca Ricciardi
- UOC di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Dipartimento NESMOS, Sapienza, Rome, Italy -
| | - Antonino Raco
- UOC di Neurochirurgia, Azienda Ospedaliera Sant'Andrea, Dipartimento NESMOS, Sapienza, Rome, Italy
| | - Carmelo L Sturiale
- UOC di Neurochirurgia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Louie P, Harada G, Harrop J, Mroz T, Al-Saleh K, Brodano GB, Chapman J, Fehlings M, Hu S, Kawaguchi Y, Mayer M, Menon V, Park JB, Qureshi S, Rajasekaran S, Valacco M, Vialle L, Wang JC, Wiechert K, Riew KD, Samartzis D. Perioperative Anticoagulation Management in Spine Surgery: Initial Findings From the AO Spine Anticoagulation Global Survey. Global Spine J 2020; 10:512-527. [PMID: 32677576 PMCID: PMC7359688 DOI: 10.1177/2192568219897598] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Cross-sectional, international survey. OBJECTIVES This study addressed the global perspectives concerning perioperative use of pharmacologic thromboprophylaxis during spine surgery along with its risks and benefits. METHODS A questionnaire was designed and implemented by expert members in the AO Spine community. The survey was distributed to AO Spine's spine surgeon members (N = 3805). Data included surgeon demographic information, type and region of practice, anticoagulation principles, different patient scenarios, and comorbidities. RESULTS A total of 316 (8.3% response rate) spine surgeons completed the survey, representing 64 different countries. Completed surveys were primarily from Europe (31.7%), South/Latin America (19.9%), and Asia (18.4%). Surgeons tended to be 35 to 44 years old (42.1%), fellowship-trained (74.7%), and orthopedic surgeons (65.5%) from academic institutions (39.6%). Most surgeons (70.3%) used routine anticoagulation risk stratification, irrespective of geographic location. However, significant differences were seen between continents with anticoagulation initiation and cessation methodology. Specifically, the length of a procedure (P = .036) and patient body mass index (P = .008) were perceived differently when deciding to begin anticoagulation, while the importance of medical clearance (P < .001) and reference to literature (P = .035) differed during cessation. For specific techniques, most providers noted use of mobilization, low-molecular-weight heparin, and mechanical prophylaxis beginning on postoperative 0 to 1 days. Conversely, bridging regimens were bimodal in distribution, with providers electing anticoagulant initiation on postoperative 0 to 1 days or days 5-6. CONCLUSION This survey highlights the heterogeneity of spine care and accentuates geographical variations. Furthermore, it identifies the difficulty in providing consistent perioperative anticoagulation recommendations to patients, as there remains no widely accepted, definitive literature of evidence or guidelines.
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Affiliation(s)
- Philip Louie
- Rush University Medical Center, Chicago, IL, USA
| | | | - James Harrop
- Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | | | - Jens Chapman
- Swedish Neuroscience Institute, Seattle, WA, USA
| | | | - Serena Hu
- Stanford University, Stanford, CA, USA
| | | | - Michael Mayer
- Salzburg Paracelsus Medical School, Salzburg, Austria
| | | | | | | | | | | | - Luiz Vialle
- Pontifical Catholic University, Curitiba, Brazil
| | | | | | | | - Dino Samartzis
- Rush University Medical Center, Chicago, IL, USA,Dino Samartzis, Department of Orthopaedic Surgery, Rush University Medical Center, Orthopaedic Building, Suite 204-G, 1611W Harrison Street, Chicago, IL 60612, USA.
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19
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The Practice of Continuation of Anti-platelet Therapy During the Perioperative Period in Lumbar Minimally Invasive Spine Surgery (MISS): How Different Is the Morbidity in This Scenario? Spine (Phila Pa 1976) 2020; 45:673-678. [PMID: 32358305 DOI: 10.1097/brs.0000000000003357] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cohort. OBJECTIVE To evaluate perioperative morbidity in patients undergoing minimally invasive spine surgery of the lumbar spine while continuing the antiplatelet drug (APD) perioperatively as compared with those not continuing these drugs and those not on these drugs. SUMMARY OF BACKGROUND DATA While discontinuation of antiplatelet drugs carries with it the risk of thrombosis of the cardiac stents, myocardial infarction, peripheral vascular occlusion, cerebro-vascular 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. Perioperative 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 perioperative period and 1131 patients who were never exposed to APD therapy. The operative time, intraoperative estimated blood loss, length of hospital stay, incidence of clinically evident hematoma, and transfusion of blood products were also recorded and compared in three cohorts. RESULTS The patients who continued taking APD in the perioperative 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 postoperative 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 perioperative morbidities including bleeding related complication rates in patients undergoing lumbar minimally invasive spine surgery while continuing to take APD compared with patients who either discontinued APD prior to surgery or those not taking APD. LEVEL OF EVIDENCE 4.
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20
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Mikhail C, Pennington Z, Arnold PM, Brodke DS, Chapman JR, Chutkan N, Daubs MD, DeVine JG, Fehlings MG, Gelb DE, Ghobrial GM, Harrop JS, Hoelscher C, Jiang F, Knightly JJ, Kwon BK, Mroz TE, Nassr A, Riew KD, Sekhon LH, Smith JS, Traynelis VC, Wang JC, Weber MH, Wilson JR, Witiw CD, Sciubba DM, Cho SK. Minimizing Blood Loss in Spine Surgery. Global Spine J 2020; 10:71S-83S. [PMID: 31934525 PMCID: PMC6947684 DOI: 10.1177/2192568219868475] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVE To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery. METHODS A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery. RESULTS There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements. CONCLUSION As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.
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Affiliation(s)
| | | | - Paul M. Arnold
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Norman Chutkan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John G. DeVine
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Daniel E. Gelb
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Fan Jiang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Brian K. Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas E. Mroz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmad Nassr
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K. Daniel Riew
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lali H. Sekhon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | | | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, USA.
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21
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Abstract
STUDY DESIGN Literature review. OBJECTIVE Preoperative management of therapeutic anticoagulation in spine surgery is critical to minimize risk of thromboembolic events yet prevent postsurgical complications. Limited research is available, and most guidelines are based on drug half-lives. We aim to clarify current guidelines and available evidence for safe practice of spine surgery in this patient population. METHODS A literature search in PubMed was done encompassing comprehensive search terms to locate published literature on anticoagulation and spine surgery. Predefined inclusion and exclusion criteria were applied and data extraction was performed. RESULTS A total of 17 articles met the final inclusion criteria. Of these, 12 articles were retrospective chart reviews, 3 were prospective observational studies, and 2 were systematic reviews. Current practice suggests holding warfarin until international normalized ratio <1.4, anti-Xa drugs for 48 to 72 hours, 12 to 24 hours for low-molecular-weight heparin, and 4 to 24 hours for heparin, before surgery. Antiplatelet agents can be stopped for 1 to 3 days prior to operation (81-500 mg) but must be stopped for 1 week for doses >1 g/d. For Plavix, 5 to 7 days of discontinuation advised to prevent complications. CONCLUSIONS This review provides an overview of main anticoagulation agents seen in preoperative setting for spine patients. Although data is mixed and no true randomized control trials are available, there is growing evidence suggesting the aforementioned guidelines are needed to optimize anticoagulation in setting of spine surgery. Further studies are needed to elucidate risk of complications while operating under therapeutic levels of anticoagulation for a variety of comorbid conditions.
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Affiliation(s)
| | | | | | - Paul M. Arnold
- Carle Illinois College of Medicine and Carle Foundation Hospital, Urbana, IL, USA
| | - Avery L. Buchholz
- University of Virginia, Charlottesville, VA, USA,Avery L. Buchholz, Department of Neurosurgery, University of Virginia, Hospital West Complex, Barringer Wing Room 3453, Charlottesville, VA 22903, USA.
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22
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Risk of bleeding in patients with continued dual antiplatelet therapy during orthopedic surgery. Chin Med J (Engl) 2019; 132:943-947. [PMID: 30958436 PMCID: PMC6595756 DOI: 10.1097/cm9.0000000000000186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: To prevent risk of life-threatening stent thrombosis, all patients need to undergo dual antiplatelet therapy (DAPT) for at least 6 weeks to 12 months after stent implantation. If DAPT is continued during noncardiac surgery, there is a risk of severe bleeding at the surgical site. Our study was to assess the risk of bleeding in patients with continued DAPT during orthopedic surgery. Methods: The clinical data of 78 patients with coronary heart disease who underwent orthopedic surgery from February 2006 to July 2018 were retrospectively analyzed. Prior to orthopedic surgery, DAPT was continued in 16 patients (group I), 24 patients were treated with single antiplatelet therapy (group II), and 26 patients received low-molecular-weight heparin therapy for more than 5 days after the discontinuation of all antiplatelet therapies (group III). Twelve patients were excluded, as they had undergone minimally invasive surgery such as transforaminal endoscopy and vertebroplasty. The perioperative blood loss of each patient was calculated using Nadler's formula and Gross’ formula. The intraoperative bleeding volume, total volume of intraoperative bleeding in addition to postoperative drainage, and total blood loss were compared between groups. The level of significance was set at P < 0.05. Results: There were no significant differences between the three groups in age, intraoperative bleeding volume, total volume of intraoperative bleeding in addition to postoperative drainage, and total perioperative blood loss calculated by Nadler's formula and Gross’ formula (all P > 0.05). Six patients experienced postoperative cardiovascular complications due to the delayed restart of antiplatelet therapy; one of these patients in group III died from myocardial infarction. Conclusions: Continued DAPT or single antiplatelet treatment during orthopedic surgery does not increase the total intraoperative and perioperative bleeding compared with switching from antiplatelet therapy to low-molecular-weight heparin. However, the discontinuation of antiplatelet therapy increases the risk of serious cardiac complications.
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23
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Du YQ, Duan WR, Chen Z, Wu H, Jian FZ. Carotid Artery-Related Perioperative Stroke Following Anterior Cervical Spine Surgery: A Series of 3 Cases and Literature Review. J Stroke Cerebrovasc Dis 2019; 28:458-463. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/06/2018] [Accepted: 10/16/2018] [Indexed: 12/22/2022] Open
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Sierra P, Gómez-Luque A, Llau JV, Ferrandis R, Cassinello C, Hidalgo F. Recommendations for perioperative antiplatelet treatment in non-cardiac surgery. Working Group of the Spanish Society of Anaesthesiology-Resuscitation and Pain Therapy, Division of Haemostasis, Transfusion Medicine, and Perioperative Fluid Therapy. Update of the Clinical practice guide 2018. ACTA ACUST UNITED AC 2018; 66:18-36. [PMID: 30166124 DOI: 10.1016/j.redar.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 12/24/2022]
Affiliation(s)
- P Sierra
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Fundación Puigvert (IUNA), Barcelona, España.
| | - A Gómez-Luque
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, España
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Dr. Peset, Universitat de València, Valencia, España
| | - R Ferrandis
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hopital Clínic i Universitari La Fe, Universitat de València, Valencia, España
| | - C Cassinello
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - F Hidalgo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Clínica Universidad de Navarra, Pamplona, España
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25
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Shin WS, Ahn DK, Lee JS, Yoo IS, Lee HY. The Influence of Antiplatelet Drug Medication on Spine Surgery. Clin Orthop Surg 2018; 10:380-384. [PMID: 30174816 PMCID: PMC6107813 DOI: 10.4055/cios.2018.10.3.380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/07/2018] [Indexed: 11/17/2022] Open
Abstract
Background The incidence of cardiovascular and neurovascular diseases has been increasing with the aging of the population, and antiplatelet drugs (APDs) are more frequently used than in the past. With the average age of spinal surgery patients also increasing, there has been a great concern on the adverse effects of APD on spine surgery. To our knowledge, though there have been many studies on this issue, their results are conflicting. In this study, we aimed to determine the influence of APDs on spine surgery in terms of intraoperative bleeding and postoperative spinal epidural hematoma complication. Methods Patients who underwent posterior thoracolumbar decompression and instrumentation at our institution were reviewed. There were 34 APD takers (APDT group). Seventy-nine non-APD takers (NAPDT group) were selected as a control group in consideration of demographic and surgical factors. There were two primary endpoints of this study: the amount of bleeding per 10 minutes and cauda equina compression by epidural hematoma measured at the cross-sectional area of the thecal sac in the maximal compression site on the axial T2 magnetic resonance imaging scans taken on day 7. Results Both groups were homogeneous regarding age and sex (demographic factors), the number of fused segments, operation time, and primary/revision operation (surgical factors), and the number of platelets, prothrombin time, and activated partial thromboplastin time (coagulation-related factors). However, the platelet function analysis-epinephrine was delayed in the APDT group than in the NAPDT group (203.6 seconds vs. 170.0 seconds, p = 0.050). Intraoperative bleeding per 10 minutes was 40.6 ± 12.8 mL in the APDT group and 43.9 ± 9.9 mL in the NAPDT group, showing no significant difference between the two groups (p = 0.154). The cross-sectional area of the thecal sac at the maximal compression site by epidural hematoma was 120.2 ± 48.2 mm2 in the APDT group and 123.2 ± 50.4 mm2 in the NAPDT group, showing no significant difference between the two groups (p = 0.766). Conclusions APD medication did not increase intraoperative bleeding and postoperative spinal epidural hematoma. Therefore, it would be safer to perform spinal surgery without discontinuation of APD therapy in patients who are vulnerable to cardiovascular and neurovascular complications.
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Affiliation(s)
- Won Shik Shin
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Dong Ki Ahn
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Jung Soo Lee
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - In Sun Yoo
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Ho Young Lee
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
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Epstein NE. When and if to stop low-dose aspirin before spine surgery? Surg Neurol Int 2018; 9:154. [PMID: 30159198 PMCID: PMC6094494 DOI: 10.4103/sni.sni_196_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/18/2018] [Indexed: 11/23/2022] Open
Abstract
Background: Prior to spine surgery (SS), we ask whether and when to stop low-dose aspirin (LD-ASA), particularly in patients with significant cardiovascular disease (CAD). Although platelets typically regenerate in 10 days, it can take longer in older patients. Methods: Here we reviewed several studies regarding the perioperative risks/complications [e.g. hemorrhagic complications, estimated blood loss (EBL), continued postoperative drainage] for continuing vs. stopping LD-ASA at various intervals prior to lumbar SS. Results: Multiple studies confirmed the increased perioperative risks for continuing LD-ASA throughout SS, or when stopping it for just 3–7 preoperative days; however, there were no increased risks if stopped between 7 to 10 days postoperatively. Other studies documented no increased perioperative risk for continuing LD-ASA throughout SS, although some indicated increased morbidity (e.g., one patient developed a postoperative hematoma resulting in irreversible paralysis). Conclusions: Several studies demonstrated more hemorrhagic complications if LD-ASA was continued throughout or stopped just 3 to up to 7 days prior to SS. However, there were no adverse bleeding events if stopped from 7–10 days preoperatively. As a spine surgeon who wishes to avoid a postoperative epidural hematoma/paralysis, I would recommend stopping LD-ASA 10 days or longer prior to SS. Nevertheless, each spine surgeon must determine what is in the “best interest” of their individual patient. Certainly, we need future randomized controlled trials to better answer: when and if to stop LD-ASA before spine surgery.
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Affiliation(s)
- Nancy E Epstein
- Professor of Clinical Neurosurgery, School of Medicine, State University of N.Y. at Stony Brook, New York, USA.,Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital, NYU Winthrop Neuro Science, Mineola, New York, USA
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Abstract
Venous thromboembolism (VTE) is a source of morbidity and mortality in patients undergoing orthopaedic surgery. A substantial body of literature supports the use of VTE prophylactic agents in patients undergoing lower extremity surgery. Treatment options include early mobilization, mechanical prophylaxis via pneumatic compression devices, pharmacologic agents, and venous filters. No consensus has been established regarding utilization or timing of VTE prophylaxis measures after spine surgery. The risk of VTE in patients undergoing spine surgery is not well characterized and varies substantially by the procedure and degree of neurologic compromise. In addition, the risk of clinically notable VTE must be weighed against the risk of postoperative bleeding and epidural hematoma after spine surgery. A standardized approach to VTE prophylaxis in patients undergoing spine surgery must take into account the available studies of risk factors, choice of prophylactic agents, and timing of prophylaxis.
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Aspirin therapy discontinuation and intraoperative blood loss in spinal surgery: a systematic review. Neurosurg Rev 2018; 41:1029-1036. [PMID: 29362950 DOI: 10.1007/s10143-018-0945-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/10/2018] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to determine the effect of aspirin therapy discontinuation on intraoperative blood loss in spinal surgery. We searched Medline and Google Scholar 1946 to January 2017 inclusive for case-control studies, cohort studies, and controlled trials reporting intraoperative blood loss during spinal surgery in patients on pre-operative aspirin. Other outcome measures reported in the eligible studies were collected as secondary outcomes. Two reviewers independently screened and extracted data from each study. Five retrospective cohort and two case-control studies were eligible for inclusion. Of the 1173 patients identified, 587 patients were never on aspirin (Ax), 416 patients had aspirin discontinued before surgery (Ad), ranging from 3 to 10 days, and 170 patients had aspirin continued until surgery (Ac). Six out of seven studies reported no statistically significant difference in intraoperative blood loss irrespective of aspirin discontinuation. Meta-analysis was not possible due to high risk of bias. Of the secondary outcome measures, operative time and postoperative complications were most commonly reported. One of six studies evaluating operative time reported a significantly longer operative time in the Ad group compared with the Ac group. The overall risk of postoperative haematoma in Ax, Ad, and Ac groups is 0.2% (n/N = 1/587), 0.2% (n/N = 1/416), and 1.2% (n/N = 2/170), respectively. No study reported a statistically significant difference in postoperative complications. There is no strong evidence demonstrating a difference in intraoperative blood loss, operation time, and postoperative complications, irrespective of aspirin discontinuation. This is, however, based on a limited number of studies and higher-quality research is required to answer this question with a higher degree of confidence.
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Abstract
Substantial blood loss during spine surgery can result in increased patient morbidity and mortality. Proper preoperative planning and communication with the patient, anesthesia team, and operating room staff can lessen perioperative blood loss. Advances in intraoperative antifibrinolytic agents and modified anesthesia techniques have shown promising results in safely reducing blood loss. The surgeon's attention to intraoperative hemostasis and the concurrent use of local hemostatic agents also can lessen intraoperative bleeding. Conversely, the use of intraoperative blood salvage has come into question, both for its potential inability to reduce the need for allogeneic transfusions as well as its cost-effectiveness. Allogeneic blood transfusion is associated with elevated risks, including surgical site infection. Thus, desirable transfusion thresholds should remain restrictive.
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Postoperative Spinal Epidural Hematoma: The Danger Caused by the Misuse of Thrombin-Containing Local Hemostatics. Asian Spine J 2017; 11:898-902. [PMID: 29279744 PMCID: PMC5738310 DOI: 10.4184/asj.2017.11.6.898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 03/16/2017] [Accepted: 04/10/2017] [Indexed: 11/08/2022] Open
Abstract
Study Design Retrospective case-control study. Purpose To examine the hypothesis that the misuse of thrombin-containing local hemostatics (TCLH) increases the risk of postoperative spinal epidural hematoma (POSEH). Overview of Literature Many studies have focused on hypocoagulability as a risk factor for POSEH. However, there are no prior reports on the increased risk of POSEH in hypercoagulable states. Methods Posterior instrumented lumbar spine surgery cases over 2 consecutive years were divided into two groups: a study group (98 patients in whom TCLH was used) and a control group (176 patients in whom TCLH was not used). The excess TCLH matrix that was not associated with blood clot was not removed from the patients in the study group. The senior author decided whether to use TCLH or not. Suction drains were used in all patients. The demographics, coagulation-related factors, and intraoperative factors of the patients in the two groups were analyzed. The development of POSEH was compared between the two groups. Results The two groups were homogenous in demographics (age and sex), coagulation-related factors (platelet count, prothrombin time, activated partial thromboplastin time, and platelet function analysis), and surgical factors (total blood loss, operation time, blood loss/10 minutes, number of fusion segments, posterolateral fusion/posterior lumbar interbody fusion, and virgin or revision surgery). POSEH developed more frequently in the patients in the study group than in those in the control group (14/98 patients, 14.3% vs. 3/176 patients, 1.7%, respectively; p=0.001; odds ratio, 17.1). Conclusions TCLH causes blood clot not only at the edge of damaged vessels but also at the site of extravascular blood. Excess TCLH matrix not associated with blood clot at the epidural space can enhance POSEH development because early clotted hematomas do not drain through suction drains.
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Goes R, Muskens IS, Smith TR, Mekary RA, Broekman MLD, Moojen WA. Risk of aspirin continuation in spinal surgery: a systematic review and meta-analysis. Spine J 2017; 17:1939-1946. [PMID: 28823937 DOI: 10.1016/j.spinee.2017.08.238] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 07/25/2017] [Accepted: 08/09/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Aspirin is typically discontinued in spinal surgery because of increased risk of hemorrhagic complications. The risk of perioperative continuation of aspirin in neurosurgery needed to be evaluated. PURPOSE This study aimed to evaluate all available evidence about continuation of aspirin and to compare peri- and postoperative blood loss and complication rates between patients that continued aspirin and those who discontinued aspirin perioperatively in spinal surgery. STUDY SETTING Systematic review and meta-analysis were carried out. METHOD A meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing aspirin continuation with discontinuation were included. Studies using a combination of anticlotting agents or non-spinal procedures were excluded. Operative outcomes (blood loss and operative length) and different complications (surgical site infection [SSI]), stroke, myocardial infarction within 30 days postoperatively) were extracted. Overall prevalence and means were calculated for the reported outcomes in fixed-effects models with heterogeneity (I-squared [I2]) and effect modification (P-interaction) assessment. RESULTS Out of 1,339 studies, three case series were included in the meta-analysis. No significant differences in mean operating time were seen between the aspirin-continuing group (mean=201.8 minutes, 95% confidence interval [CI]=193.3; 210.3; I2=95.4%; 170 patients) and the aspirin-discontinuing group (mean=178.4 minutes, 95% CI=119.1; 237.6; I2=93.5%; 200 patients); (P-interaction=0.78). No significant differences in mean perioperative blood loss were seen between the aspirin-continuing group (mean=553.9 milliliters, 95% CI=468.0; 639.9; I2=83.4%; 170 patients) and the aspirin-discontinuing group (mean=538.7 milliliters, 95% CI=427.6; 649.8; I2=985.5%; 200 patients); (P-interaction=0.96). Similar non-significant differences between the two groups were found for cardiac events, stroke, and surgical site infections. CONCLUSIONS This meta-analysis showed an absence of significant differences in perioperative complications between aspirin continuation and discontinuation. Because of the paucity of included studies, further well-designed prospective trials are imperative to demonstrate potential benefit and safety.
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Affiliation(s)
- Rik Goes
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, The Netherlands.
| | - Ivo S Muskens
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands; Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Woman's Hospital, 60 Fenwood Road, 1st Floor, Boston, MA, USA
| | - Timothy R Smith
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Woman's Hospital, 60 Fenwood Road, 1st Floor, Boston, MA, USA
| | - Rania A Mekary
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Woman's Hospital, 60 Fenwood Road, 1st Floor, Boston, MA, USA; Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, 179 Longwood Ave, Boston, MA, 02115, USA
| | - Marike L D Broekman
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands; Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Woman's Hospital, 60 Fenwood Road, 1st Floor, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, 15 Parkman Street 835, Boston, MA, 02114, USA
| | - Wouter A Moojen
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, The Netherlands; Department of Neurosurgery, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545AA, The Hague, The Netherlands; Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
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Zhang C, Wang G, Liu X, Li Y, Sun J. Safety of continuing aspirin therapy during spinal surgery: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e8603. [PMID: 29145278 PMCID: PMC5704823 DOI: 10.1097/md.0000000000008603] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Questions whether to continue or discontinue aspirin administration in the perioperative period of spinal surgery has not been systematically evaluated. OBJECTIVE The present systematic review is carried out to assess the impact of continuing aspirin administration on the bleeding and cardiovascular events in perispinal surgery period. METHODS Studies were retrieved through MEDLINE, EMBASE, and Springer Link Databases (search terms, aspirin, continue or discontinue, and spinal fusion), bibliographies of the articles retrieved, and the authors' reference files. We included studies that enrolled patients who underwent spinal surgery who were anticoagulated with aspirin alone and that reported bleeding or cardiovascular events as an outcome. Study quality was assessed using a validated form. 95% confidence interval (95% CI) was pooled to give summary estimates of bleeding and cardiovascular risk. RESULTS We identified 4 studies assessing bleeding risk associated with aspirin continuation or cardiovascular risk with aspirin discontinuation during spinal surgery. The continuation of aspirin will not increase the risk of blood loss during the spinal surgery (95% CI, -111.72 to -0.59; P = .05). Also, there was no observed increase in the operative time (95% CI, -33.29 to -3.89; P = .01) and postoperative blood transfusion (95% CI, 0.00-0.27; P = .05). But as for the cardiovascular risk without aspirin continuation and mean hospital length of stay with aspirin continuation, we did not get enough samples to make an accurate decision about their relations with aspirin. CONCLUSION Patients undergoing spinal surgery with continued aspirin administration do not have an increased risk for bleeding. In addition, there is no observed increase in the operation time and postoperative blood transfusion.
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Affiliation(s)
- Chenggui Zhang
- Department of Spine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province
| | - Guodong Wang
- Department of Spine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province
| | - Xiaoyang Liu
- Department of Spine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province
| | - Yang Li
- Anatomical Institute of Minimally Invasive Surgery, Southern Medical University, Guangzhou, China
| | - Jianmin Sun
- Department of Spine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province
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Zhang ZM, Liu Z, Liu LM, Zhang C, Yu HW, Wan BJ, Deng H, Zhu MW, Liu ZX, Wei WP, Song MM, Zhao Y. Therapeutic experience of 289 elderly patients with biliary diseases. World J Gastroenterol 2017; 23:2424-2434. [PMID: 28428722 PMCID: PMC5385409 DOI: 10.3748/wjg.v23.i13.2424] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/14/2017] [Accepted: 02/17/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To present clinical characteristics, diagnosis and treatment strategies in elderly patients with biliary diseases.
METHODS A total of 289 elderly patients with biliary diseases were enrolled in this study. The clinical data relating to these patients were collected in our hospital from June 2013 to May 2016. Patient age, disease type, coexisting diseases, laboratory examinations, surgical methods, postoperative complications and therapeutic outcomes were analyzed.
RESULTS The average age of the 289 patients with biliary diseases was 73.9 ± 8.5 years (range, 60-102 years). One hundred and thirty-one patients (45.3%) had one of 10 different biliary diseases, such as gallbladder stones, common bile duct stones, and cholangiocarcinoma. The remaining patients (54.7%) had two types of biliary diseases. One hundred and seventy-nine patients underwent 9 different surgical treatments, including pancreaticoduodenectomy, radical resection of hilar cholangiocarcinoma and laparoscopic cholecystectomy. Ten postoperative complications occurred with an incidence of 39.3% (68/173), and hypopotassemia showed the highest incidence (33.8%, 23/68). One hundred and sixteen patients underwent non-surgical treatments, including anti-infection, symptomatic and supportive treatments. The cure rate was 97.1% (168/173) in the surgical group and 87.1% (101/116) in the non-surgical group. The difference between these two groups was statistically significant (χ2 = 17.227, P < 0.05).
CONCLUSION Active treatment of coexisting diseases, management of indications and surgical opportunities, appropriate selection of surgical procedures, improvements in perioperative therapy, and timely management of postoperative complications are key factors in enhancing therapeutic efficacy in elderly patients with biliary diseases.
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Handbook of Bleeding and Coagulation for Neurosurgery. J Neurosurg Anesthesiol 2017. [DOI: 10.1097/ana.0000000000000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Handbook of Bleeding and Coagulation in Neurosurgery. J Neurosurg Anesthesiol 2017. [DOI: 10.1097/ana.0000000000000256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ahn DK, Shin WS, Kim JW, Yi SM. Why Cannot Suction Drains Prevent Postoperative Spinal Epidural Hematoma? Clin Orthop Surg 2016; 8:407-411. [PMID: 27904723 PMCID: PMC5114253 DOI: 10.4055/cios.2016.8.4.407] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 06/30/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Postoperative spinal epidural hematoma (POSEH) is different from spontaneous or post-spinal procedure hematoma because of the application of suction drains. However, it appeared that suction drains were not effective for prevention of POSEH in previous studies. The purpose of this study was to test our hypothesis that POSEH can be caused by hypercoagulability. METHODS This was an experimental study. One hundred fifty milliliters of blood was donated from each of the 12 consecutive patients who underwent spine surgery and infused into 3 saline bags of 50 mL each. One of the 3 bags in each set contained 5,000 units of thrombin. All of them were connected to 120 ± 30 mmHg vacuum suctions: drainage was started 8 minutes after connection to the vacuum system for 12 normal blood bags (BV8) and 12 thrombin-containing blood bags (TBV8) and 15 minutes after connection for the remaining 12 normal blood bags (BV15). The amount of initial and remaining hematoma at 20 minutes, 120 minutes, and 24 hours after vacuum application were measured by their weight (g). The primary endpoint was the difference between BV8 and TBV8. The secondary end point was the difference between BV8 and BV15. RESULTS The remaining hematoma in TBV8 was significantly greater than that in BV8 at all measurement points: 46.3 ± 12.4 vs. 17.0 ± 1.3 (p = 0.000) at 20 minutes; 33.0 ± 8.2 vs. 16.3 ± 1.2 (p = 0.000) at 120 minutes; and 26.1 ± 4.0 vs. 15.8 ± 1.6 (p = 0.000) at 24 hours after vacuum application. The remaining hematoma of BV15 was significantly greater than that of BV8 at all measurement points: 30.0 ± 12.0 vs. 17.0 ± 1.3 (p = 0.002) at 20 minutes; 24.2 ± 7.6 vs. 16.3 ± 1.2 at 120 minutes (p = 0.002); and 22.2 ± 6.6 vs. 15.8 ± 1.6 (p = 0.004) at 24 hours after vacuum application. CONCLUSIONS With a suction drain in place, the amount of remaining hematoma could be affected by coagulability. Thrombin-containing local hemostatics and the length of time elapsed before the commencement of suction resulted in hypercoagulability, indicating these two factors could be causes of POSEH.
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Affiliation(s)
- Dong Ki Ahn
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Won Shik Shin
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Jin Woo Kim
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Seong Min Yi
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
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Smilowitz NR, Oberweis BS, Nukala S, Rosenberg A, Stuchin S, Iorio R, Errico T, Radford MJ, Berger JS. Perioperative antiplatelet therapy and cardiovascular outcomes in patients undergoing joint and spine surgery. J Clin Anesth 2016; 35:163-169. [PMID: 27871515 DOI: 10.1016/j.jclinane.2016.07.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 05/13/2016] [Accepted: 07/11/2016] [Indexed: 01/01/2023]
Abstract
STUDY OBJECTIVE Perioperative thrombotic complications after orthopedic surgery are associated with significant morbidity and mortality. The use of aspirin to reduce perioperative cardiovascular complications in certain high-risk cohorts remains controversial. Few studies have addressed aspirin use, bleeding, and cardiovascular outcomes among high-risk patients undergoing joint and spine surgery. DESIGN/SETTING/PATIENTS We performed a retrospective comparison of adults undergoing knee, hip, or spine surgery at a tertiary care center during 2 periods between November 2008 and December 2009 (reference period) and between April 2013 and December 2013 (contemporary period). MEASUREMENTS Patient demographics, comorbidities, management, and outcomes were ascertained using hospital datasets. MAIN RESULTS A total of 5690 participants underwent 3075 joint and spine surgeries in the reference period and 2791 surgeries in the contemporary period. Mean age was 61±13 years, and 59% were female. In the overall population, incidence of myocardial injury (3.1% vs 5.8%, P<.0001), hemorrhage (0.2% vs 0.8%, P=.0009), and red blood cell transfusion (17.2% vs 24.8%, P<.001) were lower in the contemporary period. Among 614 participants with a preoperative diagnosis of coronary artery disease (CAD), in-hospital aspirin use was significantly higher in the contemporary period (66% vs 30.7%, P<.0001); numerically, fewer participants developed myocardial injury (13.5% vs 19.3%, P=.05), had hemorrhage (0.3% vs 2.1%, P=.0009), and had red blood cell transfusion (37.2% vs 44.2%, P<.001) in the contemporary vs reference period. CONCLUSIONS In a large tertiary care center, the incidence of perioperative bleeding and cardiovascular events decreased over time. In participants with CAD, perioperative aspirin use increased and appears to be safe.
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Affiliation(s)
- Nathaniel R Smilowitz
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, New York, USA
| | - Brandon S Oberweis
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Swetha Nukala
- Department of Clinical Quality and Clinical Effectiveness, New York University School of Medicine, New York, New York, USA
| | - Andrew Rosenberg
- Department of Anesthesiology, New York University School of Medicine, New York, New York, USA
| | - Steven Stuchin
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, USA
| | - Richard Iorio
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, USA
| | - Thomas Errico
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, USA
| | - Martha J Radford
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, New York, USA; Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, New York, USA; Department of Surgery, Division of Vascular Surgery, New York University School of Medicine, New York, New York, USA.
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