Tranexamic Acid in Spinal Surgery: a stratified protocol from the surgeon´s point of view

Intraoperative bleeding in spinal surgery remains a major concern, given its association with increased morbidity, prolonged hospitalization, and greater transfusion requirements. Tranexamic acid (TXA), a synthetic antifibrinolytic, has shown consistent efficacy in minimizing blood loss across diverse surgical contexts. Nevertheless, its application in spinal surgery must be individualized, taking into account bleeding risk, surgical complexity, and patient comorbidities. Following the creation of a dedicated Spine Unit, our objective was to design and validate a protocol for TXA administration and blood transfusion (BT) specific to spinal procedures. We retrospectively reviewed 1,223 spinal surgeries in 1,059 patients aged over 13 years, conducted from April 2018 to April 2023. TXA use was guided by a stratified bleeding risk model incorporating surgical approach, use of minimally invasive spinal surgery (MISS), number of treated levels, instrumentation, reoperations, and diagnosis of complex spine surgery (CSS). Preoperative variables included hemoglobin level, anticoagulant/antiplatelet therapy, and coagulopathy. Outcomes assessed were transfusion needs, hemoglobin drop, estimated blood loss (EBL), complications, infections, length of stay, and mortality. Propensity scores (c-statistic = 0.756) and standardized morbidity ratio weighting addressed treatment selection bias. TXA was significantly associated with non-MISS procedures involving instrumentation or high-bleeding-risk conditions such as metastatic tumors or deformities. EBL >500 mL increased the odds of TXA use 6.5-fold. TXA was not linked to thromboembolic or renal complications. Transfusion was associated with high-risk diagnoses, infections, prolonged aPTT, multilevel surgery, and EBL >500 mL, and predicted worse outcomes, including longer stays and higher mortality. TXA significantly reduced mortality (OR=0.25). Our findings support a stratified TXA protocol incorporating patient- and procedure-related risk factors. Such an approach enhances perioperative safety, reduces transfusion requirements, and improves survival in high-risk spinal surgeries. • Stratified protocol for tranexamic acid tailored to spinal surgery risk. • TXA usage independently reduced mortality without added complications in our study population. • The model integrates patient and procedure factors to guide TXA indication. • TXA particularly beneficial in deformity, metastasis, and multilevel ( > 3) cases. • Protocol will enhance perioperative safety and reduce transfusion needs.