Antithrombotic effects of aspirin on 1- or 2-level lumbar spinal fusion surgery: a comparison between 2 groups discontinuing aspirin use before and after 7 days prior to surgery

The safety of perioperative antiplatelet continuation without selection biases in microsurgical decompression surgery for single level lumbar spinal stenosis and lumbar disc herniotomy

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.

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

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.

Management of Antithrombotic Drugs before Elective Spine Surgery: A Nationwide Web-Based Questionnaire Survey in Japan

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.

Safety and Clinical Results of Continuous Low-Dose Aspirin in Microendoscopic Laminectomy

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.

Nonsteroidal anti-inflammatory drugs (NSAID) do not increase blood loss or the incidence of postoperative epidural hematomas when using minimally invasive fusion techniques in the degenerative lumbar spine

Objective

Nonsteroidal anti-inflammatory drugs (NSAID) are essential in surgeons' armamentarium for pain relief and antiphlogistic effects. However, spine surgeons are concerned about the drugs' impact on coagulation, fearing hemodynamic instability due to blood loss and neurological complications due to postoperative hematoma. Furthermore, there are no clear guidelines for the use of these drugs.

Materials and methods

In this retrospective subgroup analysis of a prospective observational study, we investigated 181 patients who underwent minimally invasive spinal fusions in degenerative lumbar spine pathologies. 83 patients were given NSAID perioperatively, 54 of which were female and 29 male. Of these patients who took NSAID, 39 were on NSAID until at least one day before surgery or perioperatively, whilst the others discontinued their NSAID medication at least three days before surgery. Differences in perioperative blood loss, as well as complication rates between patients with and without NSAID treatment, were investigated.

Results

A significantly higher amount of blood loss during surgery and the monitoring period was encountered in patients whose spine was fused in more than one level, regardless of whether NSAID medication was taken or not and up until what point. Furthermore, it was found that taking NSAID medication had no effect on the incidence of postoperative epidural hematomas.

Conclusion

Perioperatively taking NSAID medication does not increase blood loss or the incidence of postoperative hematoma in patients undergoing minimally invasive lumbar spinal fusion surgery.

Safety of Continuous Low-Dose Aspirin Therapy for Cervical Laminoplasty

Introduction

Methods

Results

Conclusions

Narrative Review of Antiplatelet and Anticoagulant Medications for Venous Thromboembolism Prevention in Spine Surgery

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.

Antithrombotic Therapy in Spinal Surgery Does Not Impact Patient Safety–A Single Center Cohort Study

Objective

Antithrombotic therapy is common in older patients to avoid thromboembolic events. Careful planning is required, particularly in the perioperative environment. There are no clearly date guidelines on the best timing for interrupting the use of anticoagulation in the case of spinal surgery. This study evaluates early per procedural clinical outcomes in patients whose antithrombotic therapy was interrupted for spinal surgery.

Methods

This is a retrospective cohort study. All patients who underwent dorsal instrumentation from January 1, 2019 to December 31, 2020 were included. In group A, vitamin K antagonists (VKA) were suspended for 5 days and direct oral anticoagulants (DOAC) for 3 days. In group B, antiplatelet agents (APA) were paused for at least 7 days before surgery to prevent perioperative bleeding. Patients not taking anticoagulation medication were gathered into control group C. We analyzed demographic data, ASA status, blood loss, comorbidities, duration of surgery, blood transfusion, length of hospital stay, complications, thromboembolism, and 30 day in-hospital mortality. Multivariate analyses from the three groups were further analyzed and conducted.

Results

A total of 217 patients were operated and included. Twenty-eight patients taking VKA/DOAC (group A), 37 patients using APA (group B), and 152 patients without anticoagulation (group C) underwent spinal surgery. Those using anticoagulants were significantly older and often with multimorbidity, but did not differ significantly in procedural bleeding, time of surgery, length of hospital stay, complication rate, thromboembolism, or 30 day in-hospital mortality (p > 0.05).

Conclusion

Our data show that dorsal instrumentation safely took place in patients whose antithrombotic therapy was interrupted.

Perioperative myocardial injury after elective neurosurgery: incidence, risk factors, and effects on mortality

Perioperative myocardial injury is an important reason of mortality and morbidity after neurosurgery. It usually is missed due to its asymptomatic character. In the present study, we investigated myocardial injury after noncardiac surgery (MINS) incidence, the risk factor for MINS, and association of MINS with 30-day mortality in neurosurgery patients. Patients with cardiac risk who underwent elective neurosurgery were enrolled to present prospective cohort study. The patients' demographics, comorbidities, medications used, medical history, and type of operation were recorded. The high-sensitivity cardiac troponin (hs-cTn) levels of the patients were measured 12, 24, and 48 h after surgery. The patients were considered MINS-positive if at least one of their postoperative hs-cTn measurement values was ≥ 14 ng/l. All the patients were followed up for 30 days after surgery for evaluation of their outcomes, including total mortality, mortality due to cardiovascular cause, and major cardiac events. A total of 312 patients completed the study and 64 (20.5%) of them was MINS-positive. Long antiplatelet or anticoagulant drug cessation time (OR: 4.9, 95% CI: 2.1-9.4) was found the most prominent risk factor for MINS occurrence. The total mortality rate was 2.4% and 6.2% in patients MINS-negative and MINS-positive, respectively (p = 0.112). The mortality rate due to cardiovascular reasons (0.8% for without MINS, 4.7 for with MINS, and p = 0.026) and incidence of the major cardiac events (4% for without MINS, 10.9 for with MINS, and p = 0.026) were significantly higher in patients with MINS. MINS is a common problem after neurosurgery, and high postoperative hs-cTn level is associated with mortality and morbidity.

Surgical Invasiveness of Single-Segment Posterior Lumbar Interbody Fusion: Comparing Perioperative Blood Loss in Posterior Lumbar Interbody Fusion with Traditional Pedicle Screws, Cortical Bone Trajectory Screws, and Percutaneous Pedicle Screws

Study Design

Single-center retrospective study.

Purpose

This study aims to evaluate the surgical invasiveness of single-segment posterior lumbar interbody fusion (PLIF) by comparing perioperative blood loss in PLIF with traditional pedicle screws (PS), cortical bone trajectory screws (CBT), and percutaneous pedicle screws (PPS).

Overview of Literature

Intraoperative blood loss has often been used to evaluate surgical invasiveness. However, in patients undergoing spinal surgery, more blood loss is observed postoperatively than intraoperatively. Therefore, evaluating surgical invasiveness using only the intraoperative bleeding volume may result in considerable underestimation of the actual surgical invasiveness.

Methods

This study included patients who underwent single-segment PLIF between January 2012 and December 2017. In total, seven patients underwent PLIF with PS (PS-PLIF), nine underwent PLIF with CBT (CBT-PLIF), and 15 underwent PLIF with PPS (PPS-PLIF).

Results

No significant differences were noted in terms of operation time or intraoperative bleeding between the PS-PLIF, CBT-PLIF, and PPS-PLIF groups. However, the postoperative drainage volume in the PPS-PLIF group (210.1 mL; range, 50-367 mL) was determined to be significantly lower than that in the PS-PLIF (416.7 mL; range, 260-760 mL; p=0.002) and CBT-PLIF (421.1 mL; range, 180-890 mL; p=0.006) groups. In addition, the total amount of intraoperative bleeding and postoperative drainage was found to be significantly lower in the PPS-PLIF group (362.8 mL; range, 145-637 mL) than in the PS-PLIF (639.6 mL; range, 285-1,000 mL; p=0.01) and CBT-PLIF (606.7 mL; range, 270-950 mL; p=0.005) groups.

Conclusions

Based on our findings, evaluating surgical invasiveness using only intraoperative bleeding can result in the underestimation of actual surgical invasiveness. Even with single-segment PLIF, the amount of perioperative bleeding can vary depending on the way the posterior instrument is installed.

[Expert consensus on the implementation of enhanced recovery after surgery in percutaneous endoscopic interlaminar lumbar decompression/discectomy (2020)]

In recent years, enhanced recovery after surgery (ERAS) has been widely used in spine surgery and achieved satisfactory results. In order to standardize the ERAS implementation process and application in percutaneous endoscopic interlaminar lumbar decompression/discectomy (PEID), we reviewed the literatures and cited evidence-based medicine data, and had a national comprehensive discussion among experts of the Group of Minimally Invasive Spinal Surgery and Enhanced Recovery, Professional Committee of Orthopedic Surgery and Enhanced Recovery, Association of China Rehabilitation Technology Transformation and Promotion. Altogether, the up-to-date expert consensus have been achieved. The consensus may provide the reference for clinical treatment in aspect of the standardization of surgical operations, the reduction of surgical trauma and complications, the optimization of perioperative pain and sleep management, the prevention of venous thrombosis, and the guidance of patients' functional training and perioperative education.

Perioperative Anticoagulation Management in Spine Surgery: Initial Findings From the AO Spine Anticoagulation Global Survey

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.

Minimizing Blood Loss in Spine Surgery

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.

Anticoagulation and Spine Surgery

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.

Unnecessary Cervical Epidural Injection in An Octogenarian

Background:

Epidural spine injections (ESI) have no documented long-term efficacy. Furthermore, cervical ESI uniquely risk intramedullary injections with resultant neurological deficits (e.g. monoplegia to quadriplegia), and intravascular vertebral injections (e.g. which potentially contribute to stroke, brain stem infarction).

Case Description:

A patient in his mid-eighties presented with 1 year’s duration of neck pain without any accompanying numbness, tingling or weakness in the upper or lower extremities. He had no radiculopathy, myelopathy, or neurological deficit. Two years earlier, the patient sustained a myocardial infarction (MI), requiring over 5 stents and a defibrillator. At the time of presentation, he was still on a baby ASA (81 mg/day), on anti-hypertensives, and cholesterol-lowering medications. His non-contrast cervical CT scan (patient had a pacemaker/defibrillator and could not have an MR) from the summer of 2018 showed no significant spinal cord or nerve root compression at any level. Nevertheless, he was subjected to two cervical epidural injections in the early fall; his baby ASA was stopped 5 days prior to each of these injections. Notably, this placed him at increased risk of MI and/or stroke. When he was seen by neurosurgery, without any neurological deficit or significant cervical radiographic findings, he was referred back to neurology for continued conservative management.

Conclusions:

Patients are increasingly subjected to epidural cervical spinal injections that have no documented long-term efficacy, and expose them to significant risks/complications. This 80+ year-old patient, without a neurological deficit or significant cervical CT-documented pathology, underwent 2 cervical ESI that unnecessarily exposed him to potential cardiac-stent related thrombosis (e.g. stopping ASA for 5 days-a bona-fide requirement for ESI to avoid acute epidural hematomas).

When to stop anticoagulation, anti-platelet aggregates, and non-steroidal anti-inflammatories (NSAIDs) prior to spine surgery

Background

Based upon a select review of the literature, in my opinion, spine surgeons, not just our medical/cardiological colleagues, need to know when to stop anticoagulant, anti-platelet aggregates, and non-steroidal anti-inflammatory (NSAIDs) medications prior to spine surgery to avoid perioperative bleeding complications.

Methods

Typically, medical/cardiological consultants, who "clear our patients" are not as aware as we are of the increased risks of perioperative bleeding if anticoagulant, anti-platelet, and NSAIDs are not stopped in a timely fashion prior to spine surgery (e.g. excessive intraoperative hemorrhage, and postoperative seromas, hematomas, and wound dehiscence).

Results

Different medications need to be discontinued at varying intervals prior to spinal operations. The anticoagulants include; Warfarin (stop at least 5 preoperative days), and Xa inhibitors (Eliquis (Apixaban: stop for 2 days) and Xarelto (Rivaroxaban: stop for 3 days)); note presently data vary. The anti-platelet aggregates include: Aspirin/Clopidogrel (stop >7-10 days preoperatively). The multiple NSAIDs should be stopped for varying intervals ranging from 1-10 days prior to spine surgery, and increase bleeding risks when combined with any of the anticoagulants or anti-platelet aggregates. NSAIDs (generic name/commercial names should be stopped preoperatively for at least; 1 day- Diclofenac (Voltaran), Ibuprofen (Advil, Motrin), Ketorolac (Toradol); 2 days- Etodolac (Lodine), Indomethacin (Indocin); 4-days-Meloxicam (Mobic) and Naproxen (Aleve, Naprosyn, Anaprox); 4 days- Nabumetone (Relafen); 6 days - Oxaprozin (Daypro); and 10 days- Piroxicam (Feldene).

Conclusions

Spine surgeons need to know when anti-platelet, anticoagulant, and NSAIDs therapies should be stopped prior to spine surgery to avoid perioperative bleeding complications.

Avoiding inappropriate spine surgery in a patient with major cardiac comorbidities

Background:

We as spine surgeons increasingly need to carefully screen our own patients for major medical/cardiac comorbidities to determine if they are candidates for spine surgery. Our medical/cardiac colleagues rarely understand how long anti-platelet aggregates and non-steroidal anti-inflammatories (NSAIDs) have to be stopped prior to spine operaeitons, and when it is safe for them to be reinstated.

Case Study:

A patient over 65 years of age, presented with 6 months of increased bilateral lower extremity sciatica, and 2-block neurogenic claudication. The MR scan showed moderate to severe lumbar stenosis L2-S1 with grade I L4-L5 spondylolisthesis, and multiple bilateral synovial cysts. Nevertheless, his neurological examination was normal. Further, he had > 5 stents placed within the last five years, and had undergone cardiac surgery two years ago requiring placement of a bovine aortic valve, and resection of a left ventricular wall aneurysm. He was also still on full dose Aspirin (325 mg/day), and Clopidogrel (75 mg po bid). Notably, 3 prior spinal surgeons (neurosurgery/orthopedics) had recommended multilevel lumbar laminectomy with instrumented fusions (e.g. including multilevel transforaminal lumbar interbody fusions (TLIF)).

Conclusions:

Despite multilevel L2-S1 stenosis, Grade I L4-L5 spondylolisthesis, and multilevel bilateral synovial cysts, the patient’s normal neurological examination and multiple cardiac comorbidities (i.e. requiring continued full-dose ASA/Clopidogrel) precluded, in my opinion, offering surgical intervention. Rather, I referred the patient to neurology for conservative management. What would you have done?

Preoperative measures to prevent/minimize risk of surgical site infection in spinal surgery

Background:

Multiple measures prior to spine surgery may reduce the risks of postoperative surgical site infections (SSIs).

Methods:

The incidence of SSI following spinal surgery (including reoperations and readmissions) may be markedly reduced by performing less extensive procedures and avoiding fusion where feasible. Preoperative testing up to 3 weeks postoperatively should include other studies to limit the perioperative SSI risk; cardiac stress tests (e.g., older patients/cardiac comorbidities), starting tamsulosin in males over 60 (e.g. avoid urinary retention due to benign prostatic hypertrophy), albumin/prealbumin levels (e.g., low levels increase SSI risk), and HBA1C levels to identify new/treat known diabetics (normalize/reduce preoperative levels).

Results:

Other measures include the timely administration of preoperative antibiotics (e.g., cefazolin 2 g nonpenicillin allergic), one dose of gentamicin (adjusted dose/weight), nasal cultures for methicillin-resistant Staphylococcus aureus (patients/health-care workers), and bathing 2 weeks preoperatively with chlorhexidine gluconate 4% (not just night before/morning of surgery). Additionally, prior to surgery, the following medications that increase the bleeding risk should be stopped (e.g. for varying periods); anticoagulants, antiplatelet therapies (e.g., aspirin for at least 7–10 days), nonsteroidal anti-inflammatories (NSAIDS: timing depends on the drug), vitamin E, and herbal supplements. Additionally, avoiding elective spinal surgery in morbidly obese patients and recognizing other major medical contraindications to spinal surgery should help reduce infection, morbidity, and mortality rates.

Conclusions:

Appropriate preoperative and intraoperative prophylactic maneuvers may reduce the risk of postoperative spinal SSI. Specific attention to these details may avoid infections and improve outcomes.

The Influence of Antiplatelet Drug Medication on Spine Surgery

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.

When and if to stop low-dose aspirin before spine surgery?

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.

Aspirin therapy discontinuation and intraoperative blood loss in spinal surgery: a systematic review

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.

Blood-loss Management in Spine Surgery

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.

Safety of continuing aspirin therapy during spinal surgery: A systematic review and meta-analysis

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.

Chronic Antiplatelet Use Associated With Increased Blood Loss in Lumbar Spinal Surgery Despite Adherence to Protocols

There are conflicting reports regarding postoperative bleeding risks associated with discontinuation of antiplatelet therapy at least 7 days preoperatively. Most of the studies in the spine literature are based on surveys or anecdotal evidence. The majority of surgeons discontinue therapy 7 days preoperatively, but this varies widely from 5 to 21 days. The purpose of this retrospective study was to assess whether chronic antiplatelet use is associated with increased intraoperative blood loss, need for transfusion, and perioperative complications. Of 454 patients who underwent elective lumbar spinal surgery, 85 were on antiplatelet therapy and 369 were not. All patients stopped antiplatelet therapy at least 7 days preoperatively with approval from their cardiologist or primary care provider. Multiple regression analysis was performed and corrected for age, sex, antiplatelet therapy, number of levels decompressed/fused/instrumented, preoperative hematocrit, and postoperative hematocrit. Results showed that preoperative antiplatelet therapy, despite at least 7 days of discontinuation, is a statistically significant predictor (P=.04) of increased intraoperative blood loss. Blood transfusion was not associated with antiplatelet use but was associated with the number of levels fused, age, and low preoperative hematocrit (all P<.01). There were no recorded complications in either group. The authors conclude that antiplatelet therapy is associated with an increased risk of intraoperative blood loss in spine patients despite discontinuation at least 7 days preoperatively, but the clinical significance of this is unclear given the lack of association with blood transfusions and perioperative complications. [Orthopedics. 2016; 39(4):e695-e700.].