Recommendations from the ICM-VTE: Spine

Abstract

1 - Is routine screening for DVT required in the pre-operative and/or post-operative period for patients undergoing spine procedures? Response/Recommendation: There is no role for routine screening for deep venous thrombosis (DVT) in patients undergoing spine procedures. Doppler ultrasonography surveillance may be considered in high-risk surgical patients including those who are older, with spine injury, personal history of VTE, malignancy, cervical spondylotic myelopathy (CSM), and/or non-ambulatory. Strength of Recommendation: Limited. Delegates vote: Agree 96.43% Disagree 3.57% Abstain 0.00% (Strong Consensus). Rationale: Venous thromboembolism (VTE) is a well-known complication of major orthopaedic and spine surgeries. The reported incidence of VTE in patients undergoing spine surgery range from 0.29% – 31%1-3. Moreover, the overall rates of pulmonary (PE) and associated fatality after spinal surgery are 1.38% and 0.34%, respectively2-5. Although contrast venography has been used for diagnosis of DVT, it is not suitable for the routine screening of asymptomatic patients due to potential complications, technical issues, expense, and invasiveness6. Similarly, the use of D-dimer, a byproduct of fibrinolysis7, as a screening tool lacked sensitivity and specificity in detecting VTE after hip arthroplasty8-12. Ultrasonography, on the other hand, has become the primary non-invasive method for investigating suspected DVT of the femoral and popliteal veins9. Standard ultrasound showed relatively high sensitivity (> 90%) for proximal or (around 60%) for below-the-knee DVT in a systematic review of diagnostic cohort studies13. Duplex ultrasonography (DUS) has also improved precision and efficiency in diagnosing DVT compared to most non-invasive techniques14. Furthermore, combined D-dimer and ultrasound screening in patients with acute spinal cord injury have improved the detection of VTE compared to D-dimer screening alone15. However, controversy remains regarding the use of routine screening for DVT in the perioperative period for patients undergoing spine procedures. We performed an extensive systematic review of all publications. A total of 26 articles that satisfied all inclusion criteria were selected for data extraction after full review. Information about these studies with respect to year of publication, level of evidence, number of patients, methods of screening, timing of screening, methods of prophylaxis, and incidence of VTE are summarized in Table I. Studies suggest against screening for patients undergoing spine surgery while others recognize that only patients at high risk may benefit. Based on the available literature, the risk factors for an increased risk of VTE in patients undergoing spine surgery may be seen in older patients, long periods of bedrest from paralysis and pain, high D-dimer level, longer duration of operation, intraoperative blood loss and transfusion, previous history of VTE, fracture, comorbid disease burden and tumor surgery16-44. Studies reporting DVT and/or PE rates vary in the type of surgery included and the methods used to detect DVT ranging from to screening screening D-dimer combined with and/or and - of the 26 articles selected for inclusion in the of of screening of VTE after surgery DVT DVT and after surgery VTE and after surgery asymptomatic DVT venography after surgery DVT 26 and after surgery DVT in high-risk patients PE after surgery DVT and PE - VTE and of PE and PE after surgery Standard in the and in the surgery and after surgery and 1 to after surgery PE combined with and and after surgery and DVT PE PE and DVT, DVT only or after surgery DVT and/or 1 after surgery or PE in and PE in and/or VTE PE and and or not VTE and and or or after surgery VTE DVT and surgery DVT in patients with combined with and after surgery and DVT combined with and after and and after surgery asymptomatic PE and asymptomatic DVT combined with after surgery DVT in the and DVT in the and after surgery DVT DVT is with venous contrast spondylotic articles and/or routine screening for routine DVT screening in a patients with that screening be considered for patients with and in those who are older, have longer duration of have and have a disease DVT after spinal methods were used for against VTE in venography performed after There were no patients with of DVT and However, patients showed of DVT, of and only a proximal that the of DVT after spinal surgery is factors of DVT after spine DVT of of and of D-dimer were compared the DVT and to for of the level of D-dimer that perioperative of for detecting DVT in the be performed in patients undergoing spine surgery who are and with D-dimer in blood with PE or DVT after spine cervical or D-dimer at and to be a for the diagnosis of PE after spine A reported an incidence of asymptomatic DVT screening of of in older patients, those with major of injury and with spinal The surveillance in patients with these risk There are other that against routine screening for DVT in patients undergoing spine asymptomatic DVT and in undergoing The for screening of DVT on the surgery and on the and of included and and total of VTE in Doppler and ultrasound were in all that VTE are after and routine screening is not the incidence of thromboembolism in patients who after spine and the diagnostic of as a screening incidence of VTE in the and and that not as a screening of DVT of high Based on the available literature, not to be a role for routine screening for DVT in patients undergoing spine be for patients at high-risk of VTE, as studies on the and - VTE be considered and be considered in spine Response/Recommendation: venous thromboembolism (VTE) risk in spine high-risk those performed for or as as those or combined including or an as as cervical also be considered the other hand, most cervical and or cervical may be considered procedures. Strength of Recommendation: Delegates vote: Agree Disagree 0.00% Abstain 0.00% Consensus). Rationale: personal history of VTE, factors of and are associated with increased risk of is no regarding the VTE risk it to surgical and of spine for spinal surgery has been to the risk of VTE with a reported incidence a of patients, a diagnosis of tumor in an of for VTE a diagnosis of an of has also been for cervical and with studies reporting of or Furthermore, surgery for or an be considered has been to VTE risk in with an of in a cohort of VTE, and an incidence of in a of Similarly, a of patients with reported a VTE incidence of in the and in the an increased use of in the or as an for spinal surgery has also been to the risk of VTE, and these be considered a of patients, a diagnosis of associated with an increased risk of VTE an increased use of in of of patients, the of VTE patients compared to in the has also been to be an of pulmonary (PE) in a of and combined surgical have also been to the risk of A cohort of VTE surgery and combined to the risk of studies have that have an increased risk of VTE compared to cervical However, an to the spine and a to the cervical spine have been to VTE risk compared to and A of cervical a VTE incidence of in cervical compared to in cervical and The number of surgical is that the risk of A cohort of VTE or surgical as a risk and other studies reported an increased risk for number of Furthermore, a for with a increased risk of VTE for 1 - for - and for spine most are considered VTE patients undergoing surgery for and the or have a relatively increased VTE risk compared to those undergoing surgery for and or cervical and have a risk of VTE, with rates for studies have that may the risk of However, has been and of patients that the risk of for VTE Furthermore, no increased risk has been in the VTE risk of spinal and surgery not be and the surgical and number of VTE risk The for these is these it is to the blood injury, and may the increased risk in combined and while may the increased risk in and including surgical and VTE risk be to and spine - the for the for VTE after spine Response/Recommendation: is a complication after spinal with rates ranging from to Although is no to the of it that in be an increased risk of spinal studies are required to the and of regarding spinal and Venous thromboembolism Strength of Recommendation: Limited. Delegates vote: Agree Disagree 0.00% Abstain (Strong Consensus). Rationale: The used in of and were and Studies were included spinal and of Studies were not not VTE or the method of VTE and were of included studies were data from the included studies including method of VTE screening, and rates of VTE and studies were included for data extraction after full review - of included studies year of of surgery of screening VTE on routine DVT after DVT PE after DVT PE DVT PE DVT DVT DVT PE DVT PE DVT PE with and DVT PE PE PE as or or from 1 to as the 1 and after of of or of or of as of the and with patients that a who not to a who VTE rates are venous the of and as spinal against the of Studies a VTE of - and spinal of - rates are that to a and timing for spinal surgery is compared in a level the use of to for and spinal cord procedures. patients a spinal and VTE to spinal the that combined with in VTE and not the risk for and spinal procedures. a patients who were to patients no in spine surgeries. in VTE for were for those who – compared VTE and after and after a with the VTE in the and no in included spinal on patients of surgery and 1 a DVT, and patients of patients were with The that is and is not associated with an increased risk of spinal as after in patients that from surgery used and VTE were not patients a spinal of compared patients who with patients who The risk of in The that of of or of or of of surgery for patients undergoing spinal procedures. studies no in rates and no for in a of patients undergoing spinal patients with an were with patients with the surgical and use and were associated with an increased risk of - However, the VTE not and for factors not use of not associated with an increased risk for and a that patients with and spinal and to is the from that not the of on VTE and spinal patients a VTE of patients a spinal of The that not the of VTE and spinal studies risk factors for of spinal including perioperative high intraoperative blood loss (> 1 intraoperative use of for increased and Although no studies have use in these high-risk patients, may to from from the included studies are the of methods of and VTE screening, surgical and the timing and of vary studies or are not Furthermore, of the studies is and the level of is The that spinal are relatively and of in a a patients or patients for of these data on and timing of and and the of studies are also to the use of after surgery as as timing and - VTE to be be spine procedures? Response/Recommendation: Venous (VTE) be - and patients considered to be risk with be against the of and Strength of Recommendation: Limited. Delegates vote: Agree Disagree 0.00% Abstain (Strong Consensus). Rationale: VTE is a after spine surgery that be with the use of However, the use of to be the associated with as issues, spine is about the of of the spinal and the potential of The of VTE are on the incidence of as as the associated of these factors are reported with in the are for VTE that be considered spine screening is and are that the is to the regarding VTE be spine it is to be of the VTE is most the of of the that deep venous thrombosis (DVT) a of after cervical surgery and after The were not high be a from to it is to to from A of the in on the regarding timing of spine spine most are on 1 and with a range of – who were in of of orthopaedic and spine for timing of after high-risk spinal The most after surgery of However, and others use The most for to be personal of patients who or spinal at a the of a VTE in those who of surgery with no in a of of VTE in those who 1 to after surgery to be the to in who were not no in the rates of studies have also no in with at the of to be these studies not the of the There are for on the risk to of patients undergoing spine a of VTE and is to studies to suggest that VTE be or studies were on the of the are to suggest VTE after spine However, to be on and of at of increased risk of - VTE is to be the number of and/or the and/or surgical the of VTE for patients undergoing spinal Recommendation: There is that be considered in patients undergoing spine performed an Strength of Recommendation: Limited. Delegates vote: Agree Disagree 0.00% Abstain (Strong Consensus). Rationale: There are methods used in spinal including and However, the of of has to a in compared to those for other orthopaedic as or the is The of against routine for spinal in patients with no risk and a of and in patients with risk is that have a longer is a risk for venous thromboembolism in a the of on patients undergoing level cervical and to patients undergoing VTE in the and in the in a that with patients undergoing surgery a of pulmonary at high risk of VTE, those undergoing surgery on combined and have been to have a of PE and post-operative with A other studies have that of in high-risk patients against of in a of patients a incidence of deep venous thrombosis (DVT) surgery compared to cervical and surgeries. is to that no patients in cohort VTE prophylaxis, of the patients of all VTE were routine a investigating the use of and in a of patients undergoing major spinal in the and/or There no to and that were for most of spinal level The reported of DVT after spine ranging from - is and combined are of the high-risk factors for VTE to the venous thrombosis to associated to these risk factors from other high-risk is that the risk associated with and is to intraoperative of the and a incidence of asymptomatic DVT venography after spinal surgery in cohort a PE incidence in spine patients undergoing and compared to a in the patients only a with the of or to and a PE incidence of with and combined and with The in incidence compared to to the after injury to the is the incidence of to a may not from the also that of the a of PE compared to of the to the compared the to a cohort and for the of prophylaxis, no associated increased risk of VTE with or due to a surgical also not a in VTE with risk an in the of with compared to a of VTE in in a on patients compared of The risk associated with VTE is due to the potential for the risk of VTE to be against the risk of of VTE to patients undergoing spine procedures. - Is a for VTE in patients undergoing spine Response/Recommendation: may venous thromboembolism (VTE) after orthopaedic are no studies in patients undergoing spine We the potential of with of increased Strength of Recommendation: Delegates vote: Agree 96.43% Disagree 0.00% Abstain 3.57% (Strong Consensus). Rationale: VTE orthopaedic is a complication as it may to pulmonary The incidence of VTE spine surgery is not with rates from - no for VTE in patients undergoing spine surgery due to the of performed spine is that VTE in spine surgery may the risk of and in cord and Although the of hip and is in spine surgery is studies are to regarding the use of for VTE The only deep venous thrombosis (DVT) in spine surgery no incidence of acute DVT in patients who spine and were with a in of no for VTE in patients undergoing spine The no of of these were as or and the were spinal has of DVT and no PE for an overall VTE of The of of these were as and the were of DVT and no of PE for a VTE of no in the rates of VTE A of patients who surgery for spinal were VTE after surgery including and VTE in of the patients that used and in who no A review of a data on patients who were and the surgery and for to while and for on an VTE or in of these a of patients who cervical and or were or on the of patients in the incidence of VTE these However, patients increased of a blood - There is a of studies investigating the use of as a VTE in patients undergoing spine The studies that are in and are not Although has been to be for of VTE other orthopaedic as a VTE in patients undergoing spine surgery remains - is the for of patients who are on for a to spine Response/Recommendation: to spine - used for primary and be for to 1 be for at to However, in patients with extensive it is to spine Strength of the Recommendation: Delegates vote: Agree Disagree Abstain 0.00% (Strong Consensus). Rationale: is used for patients with with to to to surgery has been associated with a and a to in the to acute the timing of to or to to to patients patients who to patients who to who to to surgery surgical and longer of surgical compared to the other also that spine no in risk compared to the other the other hand, compared of patients undergoing spinal patients patients who at to The increased rates of and at to patients who or level patients who to surgery patients who surgery that increased for and compared to Furthermore, the of a that increased perioperative blood loss in all it is also to in the perioperative the other hand, patients with who were to a that spine surgery while or or a that to spine surgery that patients who not of blood and overall complication and rates to the patients who no major in the of in patients who Similarly, a of patients undergoing compared perioperative of and of patients on a who that and not to risk of perioperative blood surgical or of on an in complication the of perioperative in spine the of on in patients undergoing spine and procedures. The that surgery be performed after as after 1 is used for and after is used for primary is to for 1 The also that be in patients with extensive history with potential the risk of major surgical other the of spine the and - be for to to spine for the is 1 patients with extensive it is to spine - is the for of patients who are with for a to spine Response/Recommendation: be at spine and the be or Strength of the Recommendation: Delegates vote: Agree Disagree 3.57% Abstain 3.57% (Strong Consensus). Rationale: a - the of factors and the is a used for of deep venous thrombosis (DVT) and pulmonary and of in patients with or of be associated with increased risk of reported that in patients undergoing major spinal the perioperative use of be associated with major blood loss (> while no in DVT compared to the use of and the of after the of patients the to considered for A number of patients of or However, the of range for considered and the of to spine and with a of or most available data suggest for a of to be in patients undergoing spinal is for increased blood loss after of patients undergoing spine surgery including with and patients on to that patients on in intraoperative blood loss and blood compared to patients not on the data on and spinal is for a of while a of or is a range of or is for spinal surgeries. - patients on for a is perioperative of to spine Response/Recommendation: is not to in of to spine be associated with risk of major a is in high-risk patients, and at the of the and are Strength of the Recommendation: Limited. Delegates vote: Agree Disagree 3.57% Abstain (Strong Consensus). Rationale: of is the of and the of However, may in high-risk patients with or venous thromboembolism The of to the risk of in the perioperative period after of a reported risk of with or the use of perioperative of in patients with against the use of due to a of in and the associated risk of major not to spine and patients with a history of or VTE to reported a of or perioperative of a against the use of routine also not to patients undergoing spine the for the use of in spine and the not an perioperative The also that the to to surgery is to a is in high-risk patients, the evidence, the that or is a that is and A be - on a of 1 - to surgery and be be on a of - to surgery and be - the to spine perioperative is not to in of to be associated with risk of major a is in high-risk patients, and are - patients with spine routine VTE and after Response/Recommendation: from spine injury are at an increased risk for venous thromboembolism for VTE and after surgery in spine on factors as of spinal cord injury of the spine and Strength of Recommendation: Delegates vote: Agree Disagree 0.00% Abstain 0.00% Consensus). Rationale: the use VTE in surgical spinal is in as it in surgical and The is in of a of and is VTE deep venous thrombosis and pulmonary (PE) is the most major with an incidence and has been a on the incidence of VTE in other major orthopaedic as hip and total a in the in the incidence of VTE after spinal The range of VTE in spinal surgery from to on the and diagnostic is no or of with to VTE in spinal a major in orthopaedic and spine with and in spine surgery to on that included the risk of DVT, the for of and use of The that is in regarding in spinal due to the of in the VTE in spinal surgery be on the or of patients is of with of the and venous blood The reported incidence of VTE in patients with has a range of to a of a total of patients with the a increased risk of DVT and a increased risk of PE compared with in an the that the of DVT in patients as compared to patients with - Furthermore, patients with an acute who were of PE to those who were not the after the injury in DVT to spine patients with associated the is to VTE as as and it is factors for VTE in patients with increased and as a risk is studies have that patients with older patients are to a with a total of patients, the that patients with a risk of a The risk is in the patients, VTE be and to the or of the of the spine also an role in DVT be and after the spine to the of VTE in patients with spine and that in most surgical of cervical spine with associated and spine with or VTE is However, VTE after cervical spine not to be VTE is to be as as in or with surgical The is that VTE to be for at patients with spinal are to VTE and it has been in the that these patients have a high of VTE compared to patients undergoing spine of the major spine may be to VTE in the of injury or after surgery is the increased risk of and that may in a the patients who for spine patients VTE prophylaxis, and patients (> VTE no in or the of the patients in a the A total of patients were VTE who VTE rates of DVT those who not in spinal the risk of and the a in VTE for patients with spine on the of spine spinal patients with is in DVT with of also in Furthermore, to the of selected as of for with and as the and most in the post-operative may be due to of or may be used in a is no of regarding the of VTE to patients from spine There is a of regarding in spinal the of VTE in spinal surgery and the of is - the of a the for VTE after spine Response/Recommendation: spine the of venous thromboembolism (VTE) is in patients with compared to patients in patients with spine VTE be Strength of Recommendation: Limited. Delegates vote: Agree Disagree Abstain (Strong Consensus). Rationale: in spine surgery to in as spinal to of spine surgery are associated with increased complications, and a that VTE in of patients with a in contrast to of patients Similarly, deep venous thrombosis (DVT) and pulmonary (PE) in and of patients with a and only in and of patients for DVT, for seen after and that were associated with VTE cohort patients who spine surgery the from to The or for and patients with rates of surgical and VTE The that of patients to and may to of Although the of VTE in remains the is to be the of factors associated with including and of the after in cervical spine the longer in patients with in those of and PE were in the of and/or to and venous the of a investigating bedrest or for after a in the incidence of in the included rates of DVT However, to DVT to increased rates of VTE in patients with may be to in a cohort of patients undergoing or that intraoperative of an increased duration showed that an surgical duration from to in patients undergoing spinal surgery for of the or and that in to associated with surgical the and has been that and venous also to DVT the of and studies the spine have the of longer on VTE A cohort in patients undergoing spine surgery that duration not in patients that and not However, in cohort and surgical the investigating patients that associated with risk of DVT – and PE – is those in previous studies on the and VTE risk in spine surgery are to a duration of The and VTE is and be to longer and risk for a to VTE in patients undergoing spine surgery these risk factors as as risk factors and to post-operative risk as the and not in intraoperative as the of the in the of a in studies were also to may the of and of these in and intraoperative risk factors in the of a to as and for patients at - patients undergoing major spine routine VTE Response/Recommendation: of venous thromboembolism (VTE) for major spinal in patients is not be to patients with risk on the of Strength of Recommendation: Limited. Delegates vote: Agree Disagree 3.57% Abstain 0.00% (Strong Consensus). Rationale: is no for VTE in orthopaedic patients and a of orthopaedic are of VTE a on of patients the criteria of the of for prophylaxis, of those patients not due to of The incidence of VTE in orthopaedic patients from and the and is reported to be and risk factors for VTE in patients blood transfusion, major venous and longer of The incidence of VTE spinal in is and risk factors and with of spinal or a on a deep venous thrombosis (DVT) of in patients and patients were with pulmonary There is a of data on the of VTE in patients undergoing major spine procedures. However, due to the incidence of VTE in patients, no studies have a a review of patients - undergoing spinal for were no DVT, or PE in patients, of a the incidence of VTE after spine and surgery in with and only used Moreover, only used the be in also has that for spinal cord injury patients the routine use of for spine surgery in is not There is on potential of in spinal A on VTE in patients showed a in post-operative as as the of in patients who post-operative compared to those who of in the The not a and the reported of spine spine and were on in the perioperative of in spinal used for spinal cord injury of compared to for were seen in surgeries. of the with including and the is with the of as a data at

Topics & Concepts