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Geerts WH, Jeong E, Robinson LR, Khosravani H. Venous Thromboembolism Prevention in Rehabilitation: A Review and Practice Suggestions. Am J Phys Med Rehabil 2024; 103:934-948. [PMID: 38917440 DOI: 10.1097/phm.0000000000002570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
ABSTRACT Venous thromboembolism is a frequent complication of acute hospital care, and this extends to inpatient rehabilitation. The timely use of appropriate thromboprophylaxis in patients who are at risk is a strong, evidence-based patient safety priority that has reduced clinically important venous thromboembolism, associated mortality and costs of care. While there has been extensive research on optimal approaches to venous thromboembolism prophylaxis in acute care, there is a paucity of high-quality evidence specific to patients in the rehabilitation setting, and there are no clinical practice guidelines that make recommendations for (or against) thromboprophylaxis across the broad spectrum of rehabilitation patients. Herein, we provide an evidence-informed review of the topic with practice suggestions. We conducted a series of literature searches to assess the risks of venous thromboembolism and its prevention related to inpatient rehabilitation as well as in major rehabilitation subgroups. Mobilization alone does not eliminate the risk of venous thromboembolism after another thrombotic insult. Low molecular weight heparins and direct oral anticoagulants are the principal current modalities of thromboprophylaxis. Based on the literature, we make suggestions for venous thromboembolism prevention and include an approach for consideration by rehabilitation units that can be aligned with local practice.
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Affiliation(s)
- William H Geerts
- From the Thromboembolism Program, Sunnybrook Health Sciences Centre (WHG); Department of Medicine, University of Toronto, Toronto, ON, Canada (WHG); Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada (EJ); Sunnybrook Health Sciences Centre, Toronto, ON, Canada (LRR, HK); Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada (LRR); and Division of Neurology, University of Toronto, Toronto, ON, Canada (HK)
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2
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Wiles MD, Benson I, Edwards L, Miller R, Tait F, Wynn-Hebden A. Management of acute cervical spinal cord injury in the non-specialist intensive care unit: a narrative review of current evidence. Anaesthesia 2024; 79:193-202. [PMID: 38088443 DOI: 10.1111/anae.16198] [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] [Accepted: 11/23/2023] [Indexed: 01/11/2024]
Abstract
Each year approximately one million people suffer spinal cord injury, which has significant physical, psychosocial and economic impacts on patients and their families. Spinal cord rehabilitation centres are a well-established part of the care pathway for patients with spinal cord injury and facilitate improvements in functional independence and reductions in healthcare costs. Within the UK, however, there are a limited number of spinal cord injury centres, which delays admission. Patients and their families often perceive that they are not receiving specialist care while being treated in non-specialist units. This review aimed to provide clinicians who work in non-specialist spinal injury centres with a summary of contemporary studies relevant to the critical care management of patients with cervical spinal cord injury. We undertook a targeted literature review including guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials published in English between 1 June 2017 and 1 June 2023. Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also included. We then summarised the key management themes: acute critical care management approaches (including ventilation strategies, blood pressure management and tracheostomy insertion); respiratory weaning techniques; management of pain and autonomic dysreflexia; and rehabilitation.
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Affiliation(s)
- M D Wiles
- Academic Department of Anaesthesia and Peri-operative Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Centre for Applied Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - I Benson
- National Spinal Injuries Centre, Buckinghamshire Hospitals NHS Trust, Stoke Mandeville, UK
| | - L Edwards
- University of Nottingham, Nottingham, UK
| | - R Miller
- Critical Care Department, Northampton General Hospital, Northampton, UK
| | - F Tait
- Critical Care Department, Northampton General Hospital, Northampton, UK
| | - A Wynn-Hebden
- Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust, Leicester, UK
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3
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Wei B, Zhou H, Liu G, Zheng Y, Zhang Y, Hao C, Wang Y, Kang H, Lu X, Yuan Y, Meng Q. Risk factors for venous thromboembolism in patients with spinal cord injury: A systematic review and meta-analysis. J Spinal Cord Med 2023; 46:181-193. [PMID: 33890837 PMCID: PMC9987783 DOI: 10.1080/10790268.2021.1913561] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
CONTEXT Patients with spinal cord injury (SCI) are at high risk for venous thromboembolism (VTE). The risk factors for VTE in patients with SCI are complex. OBJECTIVE This meta-analysis was conducted to clarify the risk factors for VTE in patients with SCI. METHODS The Cochrane Library, PubMed, EBSCO, Web of Science, China National Knowledge Infrastructure (CNKI), China Biomedical Literature Database (CBM), Wanfang Med Data Database, and VIP Database were searched to identify studies reporting on risk factors for VTE in patients with SCI. RESULTS The meta-analysis included 25 studies. Findings showed that risk of VTE in patients with SCI was significantly associated with middle- and old-age (OR = 2.08, 95%CI, 1.47, 2.95), male sex (OR = 1.41, 95%CI, 1.26, 1.59), complete paralysis (OR = 3.69, 95%CI, 2.60, 5.24), personal/family history of venous thrombosis (OR = 1.95, 95%CI, 1.35, 2.81), history of smoking (OR = 2.67, 95%CI, 1.79, 3.98), lack of compression therapy (OR = 2.44, 95%CI, 1.59, 3.73), presence of lower limb/pelvic fracture (OR = 3.47, 95%CI, 1.79, 6.75), paraplegia (OR = 1.81, 95%CI, 1.49, 2.19), and diabetes (OR = 4.24, 95%CI, 2.75, 6.52). CONCLUSION The meta-analysis identified 9 risk factors for VTE in patients with SCI. Healthcare providers should be aware of the risk factors for VTE when rehabilitating patients with SCI.
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Affiliation(s)
- Bo Wei
- Department of Spinal Cord Injury Rehabilitation, China Rehabilitation Research Center, Beijing, People's Republic of China.,China Rehabilitation Research Center, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Hongjun Zhou
- Department of Spinal Cord Injury Rehabilitation, China Rehabilitation Research Center, Beijing, People's Republic of China.,China Rehabilitation Research Center, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Genlin Liu
- Department of Spinal Cord Injury Rehabilitation, China Rehabilitation Research Center, Beijing, People's Republic of China.,China Rehabilitation Research Center, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Ying Zheng
- Department of Spinal Cord Injury Rehabilitation, China Rehabilitation Research Center, Beijing, People's Republic of China.,China Rehabilitation Research Center, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Ying Zhang
- Department of Spinal Cord Injury Rehabilitation, China Rehabilitation Research Center, Beijing, People's Republic of China.,China Rehabilitation Research Center, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Chunxia Hao
- Department of Spinal Cord Injury Rehabilitation, China Rehabilitation Research Center, Beijing, People's Republic of China.,China Rehabilitation Research Center, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Yiji Wang
- Department of Spinal Cord Injury Rehabilitation, China Rehabilitation Research Center, Beijing, People's Republic of China.,China Rehabilitation Research Center, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Haiqiong Kang
- Department of Spinal Cord Injury Rehabilitation, China Rehabilitation Research Center, Beijing, People's Republic of China.,China Rehabilitation Research Center, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Xiaolei Lu
- Department of Spinal Cord Injury Rehabilitation, China Rehabilitation Research Center, Beijing, People's Republic of China.,China Rehabilitation Research Center, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Yuan Yuan
- Department of Spinal Cord Injury Rehabilitation, China Rehabilitation Research Center, Beijing, People's Republic of China.,China Rehabilitation Research Center, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
| | - Qianru Meng
- Department of Spinal Cord Injury Rehabilitation, China Rehabilitation Research Center, Beijing, People's Republic of China.,China Rehabilitation Research Center, School of Rehabilitation Medicine, Capital Medical University, Beijing, People's Republic of China
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Bluvshtein V, Catz A, Mahamid A, Elkayam K, Michaeli D, Front L, Kfir A, Gelernter I, Aidinoff E. Venous thromboembolism and anticoagulation in spinal cord lesion rehabilitation inpatients: A 10-year retrospective study. NeuroRehabilitation 2023; 53:143-153. [PMID: 37424485 PMCID: PMC10473086 DOI: 10.3233/nre-230063] [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: 04/05/2023] [Accepted: 06/08/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a concern following the onset of spinal cord lesions (SCL). OBJECTIVES To assess the current efficacy and risks of anticoagulation after SCL and consider changes in thromboprophylaxis. METHODS This retrospective cohort study included individuals admitted to inpatient rehabilitation within 3 months of SCL onset. Main outcome measures were the incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, thrombocytopenia, or death, which occurred within 1 year of the SCL onset. RESULTS VTE occurred in 37 of the 685 patients included in the study (5.4%, 95% CI 3.7-7.1%, 2.8% PE), and in 16 of 526 patients who received prophylactic anticoagulation at rehabilitation (3%, 95% CI 1.6-4.5%, 1.1% PE, with at least 1 fatality). Of these 526, 1.3% developed clinically significant bleeding and 0.8% thrombocytopenia. Prophylactic anticoagulation, most commonly 40 mg/day, continued until a median period of 6.4 weeks after SCL onset (25% -75% percentiles 5.8-9.7), but in 29.7%, VTE occurred more than 3 months after SCL onset. CONCLUSION The VTE prophylaxis used for the present cohort contributed to a considerable but limited reduction of VTE incidence. The authors recommend conducting a prospective study to assess the efficacy and safety of an updated preventive anticoagulation regimen.
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Affiliation(s)
- Vadim Bluvshtein
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amiram Catz
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ala Mahamid
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Keren Elkayam
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Dianne Michaeli
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Lilach Front
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Adi Kfir
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Ilana Gelernter
- School of Mathematical Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Elena Aidinoff
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Intensive Care for Consciousness Rehabilitation, Loewenstein Rehabilitation Medical Center, Raanana, Israel
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5
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Robertson K, Ashworth F. Spinal cord injury and pregnancy. Obstet Med 2022; 15:99-103. [PMID: 35845230 PMCID: PMC9277738 DOI: 10.1177/1753495x211011918] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 03/01/2021] [Accepted: 03/29/2021] [Indexed: 09/01/2024] Open
Abstract
Pregnancy in women with spinal cord injury is considered high risk because it may exacerbate many of their existing problems, including autonomic dysreflexia, spasms, decubitus ulcers, urinary tract infections and respiratory infections. Due to the relative rarity of spinal cord injury in the general obstetric population, clinicians often lack familiarity of these specific problems and the women themselves are usually more experienced in their own management than their obstetric team. However, studies have demonstrated that pregnancy outcomes are generally good with appropriate and experienced obstetric care. In this review, we examine the available literature and provide advice on pre-conception counselling and the antenatal, intrapartum and postnatal management of pregnant women with spinal cord injury.
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Affiliation(s)
| | - Felicity Ashworth
- Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust,
Aylesbury, UK
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Lv B, Wang H, Li W, Han G, Liu X, Zhang C, Zhang Z. Admission Prevalence and Risk Factors of Deep Vein Thrombosis in Patients with Spinal Cord Injury Complicated with Cervical Fractures. Clin Appl Thromb Hemost 2022; 28:10760296221108969. [PMID: 35763449 PMCID: PMC9247371 DOI: 10.1177/10760296221108969] [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] [Indexed: 11/17/2022] Open
Abstract
The purpose of this study was to investigate the prevalence of deep vein
thrombosis (DVT) and to clarify the risk factors of DVT in patients with acute
spinal cord injury (SCI) complicated with cervical fractures at admission. From
January 2018 to December 2021, a total of 175 patients with acute SCI
complicated with cervical fractures in our hospital were retrospectively
analyzed. Duplex ultrasound was used to diagnose the DVT. All patients' medical
record data, including demographic variables, medical history, and laboratory
results, were collected. The patients were divided into DVT group and non-DVT
group according to ultrasound results. The prevalence of DVT was determined and
risk factors of DVT were identified. Receiver operating characteristic (ROC)
curve analysis was used to evaluate the diagnostic value of different factors.
The prevalence of DVT at admission was 21.71%(38/175), including one (2.63%)
with central DVT, thirty-two (84.21%) with peripheral DVT and five (13.16%) with
mixed DVT. The multivariate analysis revealed that decreased lower extremity
muscle strength, time from injury to admission, and D-dimer were risk factors
for DVT at admission. The diagnostic value of D-dimer was the highest among
these risk factors. In conclusion, in patients with acute SCI complicated with
cervical fractures, the risk of DVT at admission is very high. Decreased lower
extremity muscle strength, time from injury to admission, and D-dimer are risk
factors for DVT. Moreover, D-dimer has the highest diagnostic value among these
risk factors.
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Affiliation(s)
- Bing Lv
- Department of Medical Ultrasonics, 592469Baoding No.1 Central Hospital, Baoding, PR China
| | - Haiying Wang
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, Baoding, PR China
| | - Weifeng Li
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, Baoding, PR China
| | - Gefeng Han
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, Baoding, PR China
| | - Xiangdong Liu
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, Baoding, PR China
| | - Cheng Zhang
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, Baoding, PR China
| | - Zipeng Zhang
- Department of Orthopaedic Surgery, Baoding No.1 Central Hospital, Baoding, PR China
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7
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Risk factors for venous thromboembolism in patients with spinal cord injury: A single-center Turkish study. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.900384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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8
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Lin Z, Sun Y, Xue H, Chen L, Yan C, Panayi AC, Mi B, Liu G. The effectiveness and safety of LMWH for preventing thrombosis in patients with spinal cord injury: a meta-analysis. J Orthop Surg Res 2021; 16:262. [PMID: 33853656 PMCID: PMC8048068 DOI: 10.1186/s13018-021-02412-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/06/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Unfractionated heparin (UFH) and low molecular weight heparin (LMWH) are commonly used for preventing venous thrombosis of the lower extremity in patients with traumatic spinal cord injury. Although, LMWH is the most commonly used drug, it has yet to be established whether it is more effective and safer than UFH. Further, a comparison of the effectiveness of LMWH in preventing thrombosis at different locations and different degrees of spinal cord injury has also not been clearly defined. MATERIALS AND METHODS Cohort studies comparing the use of LMWH and UFH in the prevention of lower limb venous thrombosis in patients with spinal cord injury were identified using PubMed. The risk of bias and clinical relevance of the included studies were assessed using forest plots. The Newcastle-Ottawa quality assessment scale was used to evaluate the quality of the included studies. The main results of the study were analyzed using Review Manager 5.3. RESULTS A total of five studies were included in this meta-analysis. Four studies compared the effectiveness and safety of LMWH and UFH in preventing thrombosis in patients with spinal cord injury. No significant differences were found between the therapeutic effects of the two drugs, and the summary RR was 1.33 (95% CI 0.42-4.16; P = 0.63). There was also no significant difference in the risk of bleeding between the two medications, and the aggregate RR was 0.78 (95% CI 0.55-1.12; P = 0.18). When comparing the efficacy of LMWH in preventing thrombosis in different segments and different degrees of spinal cord injury, no significant differences were found. CONCLUSIONS The results of this analysis show that compared with UFH, LMWH has no obvious advantages in efficacy nor risk prevention, and there is no evident difference in the prevention of thrombosis for patients with injuries at different spinal cord segments.
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Affiliation(s)
- Ze Lin
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Road. 1277#, Wuhan, 430022, Hubei, P. R. China
| | - Yun Sun
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Road. 1277#, Wuhan, 430022, Hubei, P. R. China
| | - Hang Xue
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Road. 1277#, Wuhan, 430022, Hubei, P. R. China
| | - Lang Chen
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Road. 1277#, Wuhan, 430022, Hubei, P. R. China
| | - Chenchen Yan
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Road. 1277#, Wuhan, 430022, Hubei, P. R. China
| | - Adriana C Panayi
- The Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bobin Mi
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Road. 1277#, Wuhan, 430022, Hubei, P. R. China.
| | - Guohui Liu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Road. 1277#, Wuhan, 430022, Hubei, P. R. China.
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9
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Weidner N, Müller OJ, Hach-Wunderle V, Schwerdtfeger K, Krauspe R, Pauschert R, Waydhas C, Baumberger M, Göggelmann C, Wittgruber G, Wildburger R, Marcus O. Prevention of thromboembolism in spinal cord injury -S1 guideline. Neurol Res Pract 2020; 2:43. [PMID: 33324943 PMCID: PMC7727164 DOI: 10.1186/s42466-020-00089-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/09/2020] [Indexed: 11/28/2022] Open
Abstract
Introduction Traumatic and non-traumatic spinal cord injury bears a high risk for thromboembolism in the first few months after injury. So far, there is no consented guideline regarding diagnostic and prophylactic measures to prevent thromboembolic events in spinal cord injury. Based on a Pubmed research of related original papers and review articles, international guidelines and a survey conducted in German-speaking spinal cord injury centers about best practice prophylactic procedures at each site, a consensus process was initiated, which included spinal cord medicine experts and representatives from medical societies involved in the comprehensive care of spinal cord injury patients. The recommendations comply with the German S3 practice guidelines on prevention of venous thromboembolism. Recommendations Specific clinical or instrument-based screening methods are not recommended in asymptomatic SCI patients. Based on the severity of neurological dysfunction (motor completeness, ambulatory function) low dose low molecular weight heparins are recommended to be administered up to 24 weeks after injury. Besides, mechanical methods (compression stockings, intermittent pneumatic compression) can be applied. In chronic SCI patients admitted to the hospital, thromboembolism prophylactic measures need to be based on the reason for admission and the necessity for immobilization. Conclusions Recommendations for thromboembolism diagnostic and prophylactic measures follow best practice in most spinal cord injury centers. More research evidence needs to be generated to administer more individually tailored risk-adapted prophylactic strategies in the future, which may help to further prevent thromboembolic events without causing major side effects. The present article is a translation of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/179-015l_S1_Thromboembolieprophylaxe-bei-Querschnittlaehmung_2020-09.pdf).
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Affiliation(s)
- Norbert Weidner
- Klinik für Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany
| | - Oliver J Müller
- Klinik für Innere Medizin III, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Viola Hach-Wunderle
- Klinik für Gefäßchirurgie und Gefäßmedizin, Krankenhaus Nordwest, Frankfurt/M., Germany
| | - Karsten Schwerdtfeger
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Homburg Saar, Germany
| | - Rüdiger Krauspe
- Klinik und Poliklinik für Orthopädie, Universitätsklinikum, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Rolf Pauschert
- Fachabteilung für Orthopädie/Unfallchirurgie, SRH Gesundheitszentrum Bad Wimpfen, Bad Wimpfen, Germany
| | - Christian Waydhas
- Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Germany
| | | | - Christoph Göggelmann
- Klinik für Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.,Klinik für Innere Medizin III: Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
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10
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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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11
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Ahlquist S, Park HY, Kelley B, Holly L, Shamie AN, Park DY. Venous Thromboembolism Chemoprophylaxis Within 24 Hours of Surgery for Spinal Cord Injury: Is It Safe and Effective? Neurospine 2020; 17:407-416. [PMID: 32615699 PMCID: PMC7338943 DOI: 10.14245/ns.1938420.210] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/10/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Current guidelines recommend initiation of venous thromboembolism (VTE) chemoprophylaxis within 72 hours of spinal cord injury (SCI). This study investigated the safety and efficacy of chemoprophylaxis within 24 hours of surgery for SCI. METHODS A retrospective review of 97 consecutive patients who underwent surgery for acute traumatic SCI at a single level 1 trauma center from 2013-2018 was performed. VTE/postoperative bleeding rates during hospitalization, demographics, medical/surgical complications, drain output, length of stay, and disposition were obtained. Chi-square with odds ratios (ORs), 1-way analysis of variance, and logistic regression were performed to establish significant differences between groups. RESULTS Seventy-nine patients were included, 49 received chemoprophylaxis within 24 hours and 20 within 24-72 hours. Cohort characteristics included an average age of 51.8 years, 77.2% male, 62.0% cervical, and 35.4% thoracic SCIs. Using the American Spinal Injury Association Impairment Scale (AIS), 39.2% were AIS-A injuries, 19.0% AIS-B, 25.3% AIS-C, and 16.5% AIS-D. Unfractionated heparin was administered in 88.6% of patients and 11.4% received low molecular weight heparin. Chemoprophylaxis within 24 hours of surgery was associated with a lower rate of VTE (6.1% vs. 35.0%; OR, 0.121; 95% confidence interval [CI], 0.027-0.535) and deep vein thrombosis (4.1% vs. 30.0%; OR, 0.099; 95% CI, 0.018-0.548) versus 24-72 hours. Pulmonary embolism rates were not significantly different (6.1% vs. 5.0%, p = 1.0). There were no postoperative bleeding complications and no significant difference in drain output between cohorts. CONCLUSION Early VTE chemoprophylaxis is effective with lower VTE rates when initiated within 24 hours of surgery for SCI and is safe with no observed postoperative bleeding complications.
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Affiliation(s)
- Seth Ahlquist
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
| | - Howard Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
| | - Benjamin Kelley
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
| | - Langston Holly
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ayra N Shamie
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
| | - Don Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, CA, USA
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Mirzaeva L, Lobzin S, Tcinzerling N, Sarana A, Gilhus NE, Rekand T. Complications and mortality after acute traumatic spinal cord injury in Saint Petersburg, Russia. Spinal Cord 2020; 58:970-979. [PMID: 32286529 DOI: 10.1038/s41393-020-0458-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES We studied complications during early rehabilitation and their relation to length of stay (LOS) in the hospital as well as to survival in people with traumatic spinal cord injury (TSCI). SETTING All specialized hospitals of Saint Petersburg. METHODS We analysed all charts of patients admitted with acute TSCI to the city hospitals, 2012-2016. Patient characteristics, complications, time and cause of death, and LOS were recorded. Mean values with standard deviations and t-tests were used. We analysed mortality rate using the Kaplan-Meier method and calculated relative risks (RRs). RESULTS A total of 311 patients with TSCI were included. Complications occurred in 34% of patients; most were respiratory complications and pressure ulcers. Complications occurred more often in those with concomitant traumatic brain injury (TBI) (RR = 1.4, 95% CI: 1.2-1.8). All complications prolonged LOS (median, 11 days) and increased mortality in the acute phase (p < 0.001). In the early phase, 15% died, with a median time to death of 13 days. Respiratory complications markedly increased the death rate (RR = 18, 95% CI: 15-22). Mortality rate correlated also with age, TSCI severity and level, and concomitant TBI. Alcohol/drug consumption before TSCI increased the likelihood for complications (RR = 1.7, 95% CI: 1.3-2.1) and mortality (RR = 2.2, 95% CI: 1.6-3.1). CONCLUSION Focus on prevention as well as early and optimal treatment of complications, together with no or low alcohol/drug consumption may reduce mortality in the early phase after TSCI and at the same time shorten LOS.
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Affiliation(s)
- Liudmila Mirzaeva
- Department of Neurology, North-Western State Medical University, Saint Petersburg, Russia
| | - Sergey Lobzin
- Department of Neurology, North-Western State Medical University, Saint Petersburg, Russia
| | - Natalya Tcinzerling
- Department of Neurology, North-Western State Medical University, Saint Petersburg, Russia
| | - Andrey Sarana
- Health Care Committee, Saint Petersburg, Russia.,Saint Petersburg State University, Medical Faculty, Saint Petersburg, Russia
| | - Nils Erik Gilhus
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Tiina Rekand
- Department of Neurology, Haukeland University Hospital, Bergen, Norway. .,Institute for Clinical Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Comparison of two pharmacological prophylaxis strategies for venous thromboembolism in spinal cord injury patients: a retrospective study. Spinal Cord 2019; 57:890-896. [PMID: 31101899 DOI: 10.1038/s41393-019-0293-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 05/01/2019] [Accepted: 05/03/2019] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To compare the cost and incidence of venous thromboembolism (VTE) and bleeding between two different VTE pharmacological prophylaxis strategies in individuals with spinal cord injury: one based on motor impairment (Protocol 1) and the other based on time from the lesion and presence of associated risk factors for VTE (Protocol 2). SETTING A tertiary rehabilitation hospital in Brazil. METHODS We retrospectively reviewed a total of 1475 charts of individual admissions: 814 individuals received pharmacological prophylaxis according to Protocol 1 and 661 according to protocol 2. These cohorts were compared with respect to age, time and level of injury, length of stay, AIS classification, type of injury, and occurrence of VTE and major bleeding. The number of prescribed doses of enoxaparin and expenditures associated with enoxaparin during each period were evaluated. RESULTS The median lesion time was 3 years. The risk-based strategy drastically reduced the average monthly use of enoxaparin by 75% and the 12-month enoxaparin expenditure by $119,930.33, without increasing the risk of VTE. The incidence density of thromboembolic events was 0.55/10,000 patient-days, and all events occurred in individuals receiving prophylaxis according to Protocol 1. CONCLUSIONS Time from injury and risk of VTE-based protocol for indication of pharmacological prophylaxis drastically reduced costs. No difference in occurrence of VTE was observed.
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Wang Y, Wang J, Wang H, Feng X, Tao Y, Yang J, Cai J. Tet1 Overexpression and Decreased DNA Hydroxymethylation Protect Neurons Against Cell Death After Injury by Increasing Expression of Genes Involved in Cell Survival. World Neurosurg 2019; 126:e713-e722. [PMID: 30849555 DOI: 10.1016/j.wneu.2019.02.133] [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: 04/22/2018] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Spinal cord and neuron injury result in loss of muscle function, sensation, or autonomic function in the body. Tet1 produces 5-hydroxymethylcytosin. The conversion was proposed as the initial step of deoxyribonucleic acid demethylation in mammals. However, effects of Tet1 expression and hydroxymethylation status on neuron injury remain unclear. Therefore the current study was designed to explore effects of Tet1 expression and hydroxymethylation status on cell survival and gene expression after neuron injury. METHODS Mouse models of spinal cord injury and cell model of neuron injury were created. Animals were sacrificed, and injured spinal cord tissue was harvested. Neuron-like cells were cultured after scratch injury. Hydroxymethylated deoxyribonucleic acid concentration was detected, and Tet1 expression was examined by qPCR. Neuron-like cells were divided into 3 groups: control, injury, and azacytidine + injury (before injury, cells were pretreated with azacytidine) groups. Culture supernatant was collected, and lactate dehydrogenase concentration was detected. Meanwhile, injured neuron-like cells were divided into 3 groups: negative control, Tet1 overexpression, and Tet1 interference. Relative expression of Tet1, BDNF, NTF3, A20, FLIP, HSP70, HSP90, HSP27, and Bcl2 in neuron-like cells was detected by qPCR. In addition, neuron-like cells were divided into 7 groups. RESULTS Tet1 expression and deoxyribonucleic acid hydroxymethylation increased initially and decreased thereafter after neuron injury in both animal and cell models. Percentages of dead cells increased significantly in neuron-like cells after injury. The percentages of dead cells markedly decreased in injured neuron-like cells that were pretreated with azacytidine. The percentages of dead cells increased markedly in the Tet1 interference group and decreased significantly in the Tet1 overexpression group. Expression of Tet1, BDNF, A20, FLIP, HSP70, HSP90, and Bcl2 decreased significantly after injury. Azacytidine pretreatment in injured neuron-like cells markedly increased expression of Tet1, BDNF, NTF3, A20, FLIP, HSP70, HSP90, HSP27, and Bcl2. Moreover, Tet1 interference significantly decreased the expression of Tet1, BDNF, A20, FLIP, HSP70, and HSP90 in neuron-like cells, whereas Tet1 overexpression markedly increased the expression of Tet1, BDNF, NTF3, A20, FLIP, HSP70, HSP90, HSP27, and Bcl2. BDNF interference significantly increased percentages of dead cells after injury. BDNF interference also markedly decreased the protection of azacytidine and Tet1 overexpression against cell death. CONCLUSIONS Tet1 overexpression and demethylation caused by azacytidine protect neurons against cell death after injury by increasing expression of genes involved in cell survival.
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Affiliation(s)
- Yongxiang Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China; Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, China.
| | - Jingcheng Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China; Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Hua Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China; Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Xinmin Feng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China; Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Yuping Tao
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China; Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Jiandong Yang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China; Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Jun Cai
- Department of Orthopedics, Clinical Medical College of Yangzhou University, Yangzhou, China; Department of Orthopedics, Northern Jiangsu People's Hospital, Yangzhou, China
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