What is the clinical evidence from this study?

Study design: Cohort. Population: Elective spine surgery (n=56476). Intervention: Preoperative antithrombotic therapy vs. No antithrombotic therapy. Primary outcome: Total thrombo-ischemic events at 90 days (OR 5.52, 95% CI 5.18-5.89).

December 5, 2023Open Access

The Impact of Preoperative Antithrombotic Therapy on the Risks for Thrombo-ischemic Events and Bleeding among Patients Undergoing Elective Spine Surgery

Q: What does this research mean for the field?

Preoperative antithrombotic therapy significantly increases the odds of 90-day thrombo-ischemic events and bleeding events in patients undergoing elective spine surgery. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

SKSyed KhalidBeijing Institute of Technology PMPranav MirpuriUniversity of Minnesota SCSai ChilakapatiUniversity of Massachusetts Amherst

Key Result

Preoperative antithrombotic therapy significantly increased the odds of 90-day thrombo-ischemic events (OR 5.52) and bleeding events (OR 2.03) in patients undergoing elective spine surgery.

Study Design

Type

Cohort (n=56,476)

Structured PICO

Does preoperative antithrombotic therapy increase thrombo-ischemic and bleeding events in patients undergoing elective spine surgery?

Population

56,476 matched patients undergoing elective cervical and lumbar spine interventions, predominantly aged >65 years, with comorbidities including hypertension (83.56%) and diabetes mellitus (49.89%).

Intervention

Preoperative antithrombotic therapy (filled an outpatient prescription for therapeutic antithrombotic drugs within a 90-day preoperative window, excluding aspirin monotherapy, low-molecular-weight heparin, and unfractionated heparin).

Comparator

Not taking antithrombotics preoperatively (matched 1:1 based on age and comorbidities).

Outcome

Rates of thrombo-ischemic events (deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke) and bleeding complications (hematoma, need for transfusion) at 90 days following surgery.safety

Preoperative antithrombotic therapy in patients undergoing elective spine surgery is associated with significantly increased risks of both 90-day thrombo-ischemic and bleeding complications.

Main Result

Effect estimate: OR 5.52 (95% CI 5.18-5.89)

Absolute Event Rate: 19.9% vs 4.3%

Limitations

Retrospective design and non-uniform procedures introduced heterogeneity
Misclassification errors from ICD and CPT coding
Lack of granularity regarding the duration of preoperative interruption timing and postoperative resumption interval
Did not account for medication type and type of surgery

Abstract

STUDY DESIGN: Retrospective matched analysis. PURPOSE: To evaluate the effect of antithrombotic drug therapy on the rates of thrombo-ischemic or bleeding events 90 days following elective spine surgery. OVERVIEW OF LITERATURE: Thrombo-ischemic and bleeding complications in patients undergoing spine surgery are major causes of morbidity. Many patients who pursue elective spine surgery are concurrently receiving antithrombotic therapy for unrelated conditions; however, at this time, the effects of preoperative antithrombotic use on postoperative bleeding and thrombosis are unclear. METHODS: Using an all-payer claims database, patients who underwent elective cervical and lumbar spine interventions between January 1, 2010, and June 30, 2018, were identified. Individuals were categorized into groups taking and not taking antithrombotics. A 1:1 analysis was constructed based on comorbidities found to be independently associated with bleeding or ischemic complications using logistic regression models. The primary outcomes were the rates of thrombo-ischemic events and bleeding complications. RESULTS: A total of 660,866 patients were eligible for inclusion. Following the matching procedure, 56,476 patient records were analyzed, with 28,238 in each group. The antithrombotic agent group had significantly greater odds of developing any 90-day thromboischemic event after surgery: deep vein thrombosis (odds ratio OR, 3.61; 95% confidence interval CI, 3.06-4.25), pulmonary embolism (OR, 3.93; 95% CI, 3.34-4.62), myocardial infarction (OR, 6.20; 95% CI, 5.69-6.76), and ischemic stroke (OR, 3.76; 95% CI, 3.31-4.27). In addition, the antithrombotic agent group had an increased likelihood of experiencing hematoma (OR, 1.54; 95% CI, 1.35-1.76) and need for transfusion (OR, 2.61; 95% CI, 2.29-2.96). CONCLUSIONS: Patients taking antithrombotic medications before elective surgery of the cervical and lumbar spine had increased risks of both ischemic and bleeding events. Spine surgeons should carefully consider these implications when appraising patients for surgery, given the lack of guidelines on perioperative management of antithrombotic agents.

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