Introduction: Venous thromboembolism (VTE) is a potentially life-threatening complication after neurosurgery. Current recommendations suggest chemoprophylactic, mechanical or combination therapy to reduce the risk of VTEs; however, the literature has been inconclusive as to which strategy is the most efficacious in reducing the incidence of VTE while being safe. In this systematic review, the aim was to compare the efficacy and safety of chemoprophylaxis, compression devices, and combination therapies for VTE prophylaxis after a variety of neurosurgical procedures.

Methods: A search was performed of Pubmed, MedlinePlus, JAMA and the National Library of Medicine (NLM) for the following key words: venous thromboembolism, prevention, prophylaxis, unfractionated heparin, mechanical, neurosurgery, spinal surgery. Twenty-two qualifying studies were identified. The following cohorts were evaluated: control (no prophylaxis), chemoprophylaxis, mechanical prophylaxis, and combination therapy. Incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), adverse bleeding events, and intracranial hemorrhage (ICH) were the primary outcomes evaluated. Adverse bleeding events included incidence of hematomas.

Results: Twenty-two studies met inclusion criteria and reported on 7368 patients undergoing common neurosurgical procedures. Qualifying studies had quality scores of 2 or greater. The control cohort reported a VTE incidence of 19.8%. The pooled mechanical prophylaxis cohort reported a 4.0% incidence of VTEs. The chemoprophylaxis cohort had a VTE incidence of 2.2% and the combination prophylaxis cohort had a VTE incidence of 1.6%. Incidence of adverse bleeding events was 0%, 0.3%, 4.6%, 1.5% for the control, mechanical prophylaxis, chemoprophylaxis, and combination therapy cohorts, respectively. Incidence for ICH in all groups was less than 0.03%.

Conclusions: All VTE prophylactic interventions are effective in reducing the incidence of VTE as compared to no prophylaxis. The incidence of VTEs was lowest with combination prophylaxis, particularly with Xa inhibitors. However, the hematoma incidence rate was highest with Xa inhibitors. Literature is limited on the most appropriate chemoprophylaxis after neurosurgical procedures.

Patient Care: This study provides evidence-based guidance on the use of thromboprophylaxis in post-operative neurosurgical patients.

Learning Objectives: By the conclusion of this session, participants should be able to 1) Discuss options for thromboprophylaxis in neurosurgical patients, 2) Discuss risk of thromboembolism with various methods of thromboprophylaxis, 3) Discuss risk of hemorrhage with various methods of thromboprophylaxis, 4) Offer evidence-based recommendations for thromboprophylaxis in neurosurgical patients.

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