Every hour counts: Venous thromboembolism prophylaxis after spinal trauma

BACKGROUND: Spinal trauma patients are at risk for venous thromboembolism (VTE) due to immobility, endothelial injury, and hypercoagulability. Guidelines recommend initiating VTE prophylaxis (VTEp) 24 to 72 hours after injury, but optimal timing remains uncertain. We investigated the optimal time to administer VTEp in patients with isolated, blunt spinal trauma (IBST) requiring surgery and hypothesized that early VTEp would be associated with fewer VTE events. METHODS: This observational study included patients 16 years old or above with IBST (Abbreviated Injury Scale—Spine ≥3, ≤2 for other regions) who required surgery within the TQIP database (2018-2022). The time from admission to VTEp initiation was evaluated in 4 categories: no VTEp, early VTEp (72 h). Multivariate logistic regression evaluated the relationship between VTEp timing and incidents of VTE or in-hospital mortality, adjusting for age, injury severity score, Abbreviated Injury Scale—Spine, injury type/region, and pharmacologic agent. The primary exposure was VTEp timing. Outcomes included VTE events and in-hospital mortality. RESULTS: Of 46,868 IBST patients who underwent surgery, 35,367 (75.5%) received pharmacologic VTEp. There were 1,246 VTE events (2.6%) and 1,243 deaths (2.7%). On multivariate analysis, early VTEp was associated with lower odds of VTE compared with intermediate VTEp and late VTEp, respectively (OR: 1.40, 95% CI: 1.15–1.73, p =0.001; OR: 1.97, 95% CI: 1.61–2.43, p <0.001). When time was measured continuously, each hour of delay increased the odds of VTE by 0.2% ( p <0.001). CONCLUSIONS: Preoperative initiation of VTEp in operatively managed spinal trauma patients was associated with reduced mortality. Delays in VTEp increased the odds of both VTE events and mortality. These findings support early pharmacologic VTEp in this high-risk population. ( J Trauma Acute Care Surg . 2026;00:00-00. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. All rights reserved). LEVEL OF EVIDENCE: Level III.