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.
References: Systematic Review of Safety and Efficacy of Venous Thromboembolic Prophylaxis After Neurosurgical Procedures
1. Agnelli G, Piovella F, Buoncristiani P, et al. Enoxaparin plus Compression Stockings Compared with Compression Stockings Alone in the Prevention of Venous Thromboembolism after Elective Neurosurgery. New England Journal of Medicine. 1998;339(2):80-85.
2. Akeda K, Matsunaga H, Imanishi T, et al. Prevalence and countermeasures for venous thromboembolic diseases associated with spinal surgery: A follow-up study of an institutional protocol in 209 patients. Spine (Phila Pa 1976). 2014;39(10):791-797.
3. Al-Dujaili TM, Majer CN, Madhoun TE, Kassis SZ, Saleh AA. Deep venous thrombosis in spine surgery patients: Incidence and hematoma formation. International Surgery. 2012;97(2):150-154.
4. Boström S, Holmgren E, Jonsson O, et al. Post-operative thromboembolism in neurosurgery - A study on the prophylactic effect of calf muscle stimulation plus dextran compared to low-dose heparin. Acta Neurochirurgica (Wien). 1986;80(3-4):83-89.
5. Du W, Zhao C, Wang J, Liu J, Shen B, Zheng Y. Comparison of rivaroxaban and parnaparin for preventing venous thromboembolism after lumbar spine surgery. J Orthopedic Surgery and Research. 2015;10(1):1-8.
6. Epstein NE. Intermittent pneumatic compression stocking prophylaxis against deep venous thrombosis in anterior cervical spinal surgery: a prospective efficacy study in 200 patients and literature review. Spine (Phila Pa 1976). 2005;30(22):2538-2543.
7. Ferree B a, Wright a M. Deep venous thrombosis following posterior lumbar spinal surgery. Spine (Phila Pa 1976). 1993;18(8):1079-1082.
8. Frim DM, Barker FG, Poletti CE, Hamilton AJ. Postoperative low-dose heparin decreases thromboembolic complications in neurosurgical patients. Neurosurgery. 1992;30(6):830-833.
9. Gerlach R, Scheuer T, Beck J, et al. Risk of Postoperative Hemorrhage after Intracranial Surgery after Early Nadroparin Administration: Results of a Prospective Study. Neurosurgery. 2003;53(5):1028-1035.
10. Gruber UF, Rem J, Meisner C, Gratzl O. Prevention of thromboembolic complications with miniheparin-dihydroergotamine in patients undergoing lumbar disc operations. European Archives of Psychiatry and Neurological Sciences. 1984;234(3):157-161.
11. Nurmohamed MT, van Riel AM, Henkens CM, et al. Low molecular weight heparin and compression stockings in the prevention of venous thromboembolism in neurosurgery. Thrombosis and Haemostasis. 1996;75(2):233-238.
12. Otero-Fernandez R, Gomez-Outes A, Martinez-Gonzalez J, Rocha E, Fontcuberta J, Patients BCSG in O. Evaluation of the effectiveness and safety of bemiparin in a large population of orthopedic patients in a normal clinical practice. Clinical and applied thrombosis/hemostasis : official journal of the International Academy of Clinical and Applied Thrombosis/Hemostasis. 2008;14(1):75-83.
13. Ozturk C, Ganiyusufoglu K, Alanay A, Aydogan M, Onat L, Hamzaoglu A. Efficacy of prophylactic placement of inferior vena cava filter in patients undergoing spinal surgery. Spine (Phila Pa 1976). 2010;35(20):1893-1896.
14. Bucci MN, Papadopoulos SM, Chen JC, Campbell JA, Hoff JT. Mechanical prophylaxis of venous thrombosis in patients undergoing craniotomy: a randomized trial. Surgical Neurology. 1989;32(4):285-288.
15. Schizas C, Neumayer F, Kosmopoulos V. Incidence and management of pulmonary embolism following spinal surgery occurring while under chemical thromboprophylaxis. Eur Spine J. 2008;17(7):970-974. doi:10.1007/s00586-008-0668-z
16. Smith MD, Bressler EL, Lonstein JE, Winter R, Pinto MR, Denis F. Deep venous thrombosis and pulmonary embolism after major reconstructive operations on the spine. A prospective analysis of three hundred and seventeen patients. Journal of Bone and Joint Surgery - Series A. 1994;76(7):980-985.
17. Strom RG, Frempong-Boadu AK. Low-molecular-weight heparin prophylaxis 24 to 36 hours after degenerative spine surgery: Risk of hemorrhage and venous thromboembolism. Spine (Phila Pa 1976). 2013;38(23).
18. Turpie a G, Hirsh J, Gent M, Julian D, Johnson J. Prevention of deep vein thrombosis in potential neurosurgical patients. A randomized trial comparing graduated compression stockings alone or graduated compression stockings plus intermittent pneumatic compression with control. Archives of Internal Medicine. 1989;149(3):679-681.
19. Voth D, Schwarz M, Hahn K, Dei-Anang K, Butmeh SA, Wolf H. Prevention of deep vein thrombosis in neurosurgical patients: a prospective double-blind comparison of two prophylactic regimen. Neurosurgery Rev. 1992;15:289-294.
20. Weber B, Seal A, McGirr J, Fielding K. Case series of elective instrumented posterior lumbar spinal fusions demonstrating a low incidence of venous thromboembolism. ANZ Journal of Surgery. 2016;86(10):796-800.
21. Wen DY, Hall WA. Complications of subcutaneous low-dose heparin therapy in neurosurgical patients. Surgical Neurology. 1998;50(6):521-525.
22. Wood KB, Kos PB, Abnet JK, Ista C. Prevention of deep-vein thrombosis after major spinal surgery: a comparison study of external devices. J Spinal Disorders. 1997;10(3):209-214.