Global guidelines needed for perioperative anticoagulation management in spine surgery
Findings from an AO Spine anticoagulation global survey were published in the August 2020 issue of Global Spine Journal (GSJ).
17 August 2020
The need for comprehensive guidelines is evident: 91.8% of survey respondents indicated that they would likely adopt anticoagulation guidelines if established.
The survey participants included 316 spine surgeons from 64 different countries, making this the largest and most geographically diverse survey on perioperative anticoagulation practices in spine surgery to date. Lead author Philip K. Louie explains that clinically, the rationale for specific perioperative anticoagulation and antiplatelet management requires multidisciplinary decision making. "However, widely accepted global guidelines are still lacking regarding venous thromboembolism (VTE) prevention.”
VTE is a preventable cause of perioperative morbidity and mortality. The incidence ranges from 0.3% to 31% after spine surgery, with differences attributed to medical comorbidities, spinal pathology, and surgical techniques. While multiple groups have published guidelines for preventing VTE after spine surgery, none have been widely adopted. Only 14% of survey respondents report following hospital, national, or other guidelines.
Louie notes that recommendations are often individualized per patient with hospital-specific criteria for different prophylaxis algorithms and the need for comprehensive guidelines is evident.
Balancing opposing goals
Perioperative anticoagulation management must balance two opposing goals: reducing the risk of blood clots and reducing the risk of bleeding. Most surgeons who participated in the survey (70.3%) use routine anticoagulation risk stratification to identify patients most at-risk for VTE. The most common reason for not using risk stratification was indiscriminate anticoagulation use (23.1%). Nonpharmacological approaches to reduce risk include patient mobilization and compression devices. Pharmacologic agents used include heparin, low-molecular-weight heparin, and warfarin.
In deciding when to begin anticoagulation, surgeons from different global regions placed different emphasis on the length of the procedure (P = .036) and body mass index (P = .008). When deciding on cessation, there were statistically significant differences in the use of medical clearance (P < .001) and reference to literature (P =.035). These and other differences point to areas that are ripe for further study to establish best practices.
Louie notes the study group's goal was to share global perspectives. "We wanted to share views provided by spine surgeons around the world to gauge their knowledge, attitudes, and practices on this topic."
Of particular interest may be the survey responses for hypothetical scenarios involving patients with and without baseline anticoagulation use, and a history of deep vein thrombosis, coronary artery disease, artificial heart valve, stent, etc. Bridging regimens were bimodal in distribution, with anticoagulation commonly initiated on postoperative days 0 to 1, or 5 to 6. Again, these differences provide research opportunities to establish best practices.
The survey questions were developed by the GSJ Editorial Board and the Regional Research Chairs of AO Spine. The 21 authors serve at 19 institutions in 11 different countries on 4 continents. Corresponding author and Deputy Editor of GSJ, Dino Samartzis, emphasizes that the impetus for these collaborative projects is to develop improved recommendations and guidelines for spine surgeons to address such issues.
"This study is a further example of the global outreach of the society and the journal working in concert towards ultimately making an impact upon patient care,” Samartzis concludes.