Thromboembolic Prophylaxis in Neurosurgical Practice: A Review

Purpose: Literature is ambiguous on the incidence of deep venous thrombosis and pulmonary embolism by neurosurgical patients.The objective of this systematic review is to assess the incidence of thromboembolic complications associated with neurosurgical interventions, evaluate current prophylaxis methods and propose a prophylaxis strategy.Methods: PubMed, Embase and Cochrane Central were searched systematically and studies involving neurosurgical procedures describing postoperative complications DVT and PE.The risk of bias was assessed using (adjusted) Cowley criteria.Results: Twenty studies (14 case series, 3 comparative studies, 3 RCT's) were included, describing 8905 neurosurgical patients.Without prophylaxis the incidence of DVT was reported in 28% of neurosurgical cases (range 21-34%).Studies that provided any kind of prophylaxis, in which clinical evaluation was used to diagnose DVT, reported a 2.5% incidence of DVT (range 0 to 5%), however, when systematically assessed with ultrasound the occurrence was 6.4% (range 0-17%).Pulmonary embolism was presented in 0 to 4% of all cases.Venous thromboembolic events were more frequent in intracranial procedures compared to spinal procedures.Patients, receiving a combination of low molecular weight heparins and compression stockings, showed a 50% lower incidence of DVT than patients receiving mechanical or chemical prophylaxis alone.Conclusion: Optimal antithrombotic prophylaxis regime in neurosurgical interventions lowers the incidence of DVT's from 28% to about 3 to 6%.We recommend a combination of LMWH and compression stockings for intracranial procedures.For spinal procedures this same prophylactic regimen is indicated, however it is defendable to choose single treatment with LMWH or compression stockings alone.