Management of aspirin in lumbar fusion: a systematic review and meta-analysis

BACKGROUND: The perioperative management of acetylsalicylic acid (ASA) in spine surgery remains a daily clinical dilemma. While ASA discontinuation is traditionally recommended to minimize bleeding risk, cessation may expose patients with cardiovascular comorbidities to thromboembolic complications. In the absence of clear evidence-based guidelines, neurosurgeons frequently rely on institutional practices or personal judgment. METHODS: Following PRISMA guidelines, PubMed, EMBASE, Scopus, and Cochrane databases were searched for studies published from January 2000 to September 2025 comparing perioperative ASA use versus no ASA in adult lumbar fusion surgery. Random-effects models calculated mean differences (MD) with 95% confidence intervals (CI). Risk of bias was assessed using ROBINS-I. RESULTS: Four observational studies including 700 patients (316 ASA, 384 controls) were analyzed. ASA continuation or discontinuation did not significantly affect intraoperative blood loss (MD 31.29 mL; 95% CI -2.89 to 65.47; P=0.07), postoperative drainage, operative time, or hospital stay. Subgroup analysis stratified by timing of ASA discontinuation (≤3 days vs. ≥7 days) revealed no significant differences within or between subgroups. Complication rates, morbidity, and mortality were comparable across treatment arms. CONCLUSIONS: Continuation of low-dose ASA during lumbar fusion does not appear to increase perioperative bleeding, complications, or mortality. Given the potential cardiovascular risks of interruption, discontinuation should be reserved for carefully selected patients following multidisciplinary evaluation and individualized risk assessment. However, the available evidence in this field is limited by retrospective designs and small sample sizes, requiring further high-quality prospective trials to confirm these findings.