Risk-to-Benefit Ratio of Venous Thromboembolism Prophylaxis for Neurosurgical Procedures at a Quaternary Referral Center

BACKGROUND: Pharmacological prophylaxis for venous thromboembolism (VTE) in the neurosurgical population is still a matter of debate, as the risk-to-benefit ratio is not well defined. OBJECTIVE: To further evaluate the risk-to-benefit ratio of VTE prophylaxis (VTEP) for all neurosurgical procedures. METHODS: A prospective evaluation was performed after the initiation of a VTEP protocol for 11 436 patients undergoing neurosurgical procedures over 24 mo. Unless a bleeding complication was present, 5000 international units of subcutaneous heparin every 8 h was ordered on postoperative day (POD) 1 for spine, POD2 for cranial, and by POD4 for subdural, intracerebral, and epidural hematoma cases. Incidence of VTE and any subsequent bleeding complications were noted. RESULTS: A total of 70 VTEs (0.6% overall) were documented (28 deep vein thrombosis, 42 pulmonary embnolism). The highest rates of VTE were associated with deformity (6.7%); open cerebrovascular (6.5%); subdural, intracerebral, and epidural hematoma (3.2%); spinal trauma (2.4%); and craniotomy for tumor (1.6%) cases. Seven cases of deep vein thrombosis progressed to pulmonary embolisms, and 66 of 70 VTEs occurred while on pharmacological VTEP. Fifty-four bleeding complications occurred on or after POD2 following initiation of VTEP. These bleeding complications consisted of any new clinically or radiographically observed hemorrhages. Twenty-eight of the 54 delayed bleeding complications required operative intervention with 1 mortality. Forty-five patients were on anticoagulation when the initial bleeding event occurred. Overall, an estimated 0.5% incidence of delayed bleeding complications was noted with 99.4% of patients within the study cohort remaining VTE free. CONCLUSION: This VTEP protocol was determined to afford a good risk-to-benefit ratio for a wide variety of neurosurgical procedures.