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Table 1. Demographic data of included studies.
Author
(Year)Study
DesignPopulationCondition and TreatmentProphylaxisBoakye (2008)Retrospective cohort
National Inpatient Sample databaseN = 58,115
Mean age: 51% were 45-64 yrs
42% maleCervical spondylotic myelopathy
Spinal fusion surgery NROtero-Fernandez
(2008)Prospective cohortN = 225
Mean age: NR for spine surgery*
NR% maleVarious spine conditions
Spine surgeryDaily bemiparin (LMWH) 2500 IU (moderate risk) or 3500 IU (high risk)Piasecki (2008)Prospective
cohortN = 66
Mean age: 52 yrs
14% maleScoliosis (n = 40) or revision surgery (n = 26) after failed fusion or laminectomy
Combined anterior/posterior fusion spine surgery;Mechanical prophylaxis with foot pumps during and post-opSchizas (2008)Prospective
cohortN = 270
Mean age: 44 yrs
NR% maleSpinal stenosis (n = 77), fractures or posttraumatic deformities (n = 57), DDD (n = 37), herniated discs (n = 26), spondylolisthesis (n = 27), scoliosis (n = 23), tumors (n = 8), infections (n = 8), rheumatoid arthritis (n = 7)
Anterior and/or posterior spinal fusions, discectomies and/or decompression surgeriesIPCs and enoxoparin (LMWH), 20mg daily for 3 days postop, then 40mg daily until dischargeChin (2007)Prospective and retrospective
cohortN = 89
Median age:
cases 36 yrs
controls 47 yrs
54% maleLumbar disc disease
Lumbar microdiscectomy
30 mg ketorolac (Toradol) immediately before wound closure (n = 44) or none (n = 45)Patel (2007)
Retrospective cohortN = 84
Mean age: 59 yrs
35% maleDegenerative disease
Elective lumbar and thoracic spinal fusionNREpstein
(2006)Retrospective cohortN = 139
Mean age: 53 yrs
56% maleStenosis with instability, spondylolisthesis
Multilevel lumbar laminectomies with instrumented fusionIPCs used for prophylaxisAwad (2005)Retrospective case-controlN = 134
Mean age:
cases 60 yrs
controls 55 yrs
52% maleVarious spine conditions
All levels of spinal surgery.
(Cases (n = 32) developed post-operative spinal epidural hematoma, controls were matched by complexity of spinal surgery procedure and time period.)NR Epstein
(2005) Retrospective cohort
Single-level, N = 100
Mean age: 46 yrs
57% male
Multilevel, N = 100
Mean age: 55 yrs
65% maleSpondylosis, stenosis, and/or OPLL
Single-level anterior corpectomy/fusion (ACF) (n = 100) and multilevel ACF/posterior fusion (n = 100) Intermittent compression stockings (IPCs)Brau (2004)Retrospective cohortN = 1310
Age range: 18-84 yrs
49% maleLumbar disc disease
ALIF or total disc replacement using mini-open, retroperitoneal approach NRGerlach (2004)Retrospective cohortN = 1954
Mean age: NR
NR% maleSpinal stenosis or disc herniation (n = 1618), stabilization (n = 55), tumor (n = 182), infection (n = 57), fractures (n = 28), hematoma (n = 14)
Cervical, thoracic and lumbar spinal proceduresReceived intra- and post-operative IPCs AND postop daily 0.3ml nadroparin calcium, 2850 IU anti-XaScaduto
(2003)Prospective cohortN = 119
Mean age: 44 yrs
44% maleLumbar disc disease
ALIF (n = 88) or PLF (n = 31) Brau (2002)Retrospective cohortN = 686
Age range: 19-84 yrs
50.3% maleLumbar disc disease
ALIF using mini-open, retroperitoneal approach NRLee (2000)Retrospective cohortN = 313
Mean age: 48 yrs
49% maleStenosis (n = 101), spondylolisthesis (n = 68), herniated disc (n = 8), scoliosis (n = 13), OPLL (n = 2), CSM (n = 25), infection (n = 26), fracture (n = 62), tumor (n = 8)
Multilevel anterior and/or posterior decompression and/or fusions No antithrombotic prophylaxisOda (2000)Retrospective cohortN = 110
Mean age: 59 yrs
58% maleStenosis (n = 20), scoliosis (n = 8), arthrodesis (n = 10), herniated disc (n = 24), scoliosis, OPLL (n = 11), myelopathy (n = 34), tumor (n = 3)
Posterior spinal surgery.No mechanical or medical antithrombotic prophylaxis Dearborn
(1999) Prospective and retrospective cohortProspective, N = 116
Mean age: 46 yrs
29% male
Retrospective, N = 267
Mean age: 48 yrs
28% maleScoliosis, stenosis, spondylolisthesis, kyphosis, pseudoarthrosis, or other degenerative spinal conditions
Anterior, posterior or combined ant/post spinal reconstruction surgeryThigh-length elastic antiembolism stockings and IPCs during and postop; no pharmacologic anticoagulationRajaraman (1999)Prospective cohortN = 60
Mean age: 42 yrs
52% maleDiscogenic back pain (n = 33), failed back syndrome (n = 11), pseudoarthrosis, (n = 5) postlaminectomy syndrome (n = 4), spondylolisthesis (n = 3), fracture (n = 2), tumor (n = 2)
ALIF via retroperitoneal (n = 57) or transperitoneal (n = 3)NRRokito (1996)Prospective cohort N = 110
Mean age: 44 yrs
40% male
lumbar disorder (n = 86), scoliosis (n = 14), thoracic disorder (n = 7), cervical disorder (n = 1), trauma (n = 2)
Anterior and/or posterior spinal fusions and/or decompression surgery Thigh-high compression stockings (n = 42), compression stockings and thigh-length IPCs (n = 33), or compression stockings and 10mg Coumadin on the evening before surgery and daily postop (n = 35)Smith (1994)Prospective cohortN = 317
Mean age: NR
NR% maleDegenerative spine disease (n = 172), spondylolisthesis (n = 31) spinal trauma (n = 34), scoliosis (n = 77), infection (n = 3)
Spinal surgery Thigh-length IPCs, no medical antithrombotic prophylaxisFerreea (1993)Prospective cohortN = 86
Mean age: 43 yrs
53% maleScoliosis, degenerative disc disease, spondylolisthesis, instability
Lumbar (n = 78) or thoracic (n = 8) decompression and/or fusion spineIPCsWest (1992)Prospective cohortN = 41
Mean age: 38 yrs
NR% maleSpinal deformity (n = 14), trauma (n = 16), degenerative spine disease (n = 11)
Anterior and/or posterior instrumented fusion No preoperative or intraoperative thrombotic prophylaxis; used postop compression stockingsRamirez (1989)Prospective cohortN = 35,708
Mean age: NR
NR% male
Commission on Professional and Hospital Activities DatabaseLumbar disc displacement or degeneration, no history of previous surgery;
Lumbar discectomy at one or two levels without fusionNRUden (1979)Prospective cohortN = 1229
Mean age: 57 yrs
33% maleScoliosis
Fusion using Harrington rodsNRGruber
(1984)Prospective cohortN = 50
Heparin
Mean age: 47 yrs
57% male
Placebo
Mean age: 45 yrs
65% maleHerniated lumbar disc
(treatments)2500 IU miniheparin-dihydroergotamine two times daily (n = 25) or placebo (n = 20), beginning 2 hrs preoperatively and continuing at least 7 days or until hospital dischargeVoth (1992)Prospective cohortN = 179
LMWH
Mean age: 53 yrs
44% male
HDHE
Mean age: 53 yrs
45% male
(conditions)
Lumbar-vertebral disc procedures
Fenestration (n = 166)
Hemilaminectomy (n = 7)
Laminectomy (n = 3)
Sequestrotomy (n = 1)
NR (n = 2)1500 U-aPTT LMWH plus dihydroergotamine 0.5 mg once daily plus placebo injection daily (n = 87) or 5000 U heparin plus dihydroergotamine 0.5 mg twice a day (n = 92), beginning 2 hrs preoperatively and continued for at least 7 daysFereeb (1993)Prospective cohortN = 185
Elastic compression:
Mean age: 43 yrs
NR% male
Pneumatic compression:
Mean age: 50 yrs
NR% maleLaminectomy or laminotomy (n = 84); posterior spinal fusion with or without laminectomy or laminotomy (n = 101)Elastic compression stockings (n = 74) or intermittent pneumatic compression (n = 111)Flinn
(1996)Prospective cohortN = 2643
Mean age: 58 yrs
52% maleCraniotomies for treatment of neoplasms or cerebrovascular disorders (n = 1439); ventriculoperitoneal or other shunting procedures (n = 299); cervical or lumbar spinal surgeries (n = 454)Elastic stockings and IPCWood
(1997)
Prospective cohortN = 136
Plexi Pulse:
Mean age: 39 yrs
52% male
SCD:
Mean age: 40 yrs
66% male
Major reconstructive spinal surgeries defined as anterior and/or posterior thoracic, lumbar, or thoracolumbar spinal fusions and/or multilevel decompression surgeryThigh-high pneumatic compression wraps or pneumatic foot-compression wrapsNelson
(1996)Prospective cohortN = 117
Mean age: NR
NR% maleDegenerative spinal disease; posterior lumbar decompression with fusion and fixationTED stockings and acetylsalicyclic acid (ASA) 600 mg bid (n = 60) or TED and pneumatic compression boots and ASA 600 mg bid (n = 57)
ALIF = anterior lumbar interbody fusion ; CSM = cervical spondylotic myelopathy; DDD = degenerative disc disease; DVT = deep vein thrombosis; INR = International Normalized Ratio; IPCs = intermittent compression stockings; LMWH = low-molecular weight heparin; NR = not reported; OPLL = ossification of the posterior longitudinal ligament; PE = pulmonary embolism.
*Study included orthopedic surgery patients; data reported for spine surgery only.
Table 2. Frequencies of thromboembolism by spine condition in patients whose chemical antithrombotic prophylaxis was not reported.
Spine Condition treated
AuthorDVT
n/N (%) PE
n/N (%)Fatal PE
n/N (%)DegenerativeBoakye (2008) ADDIN EN.CITE Boakye200894949417Boakye, M.Patil, C. G.Santarelli, J.Ho, C.Tian, W.Lad, S. P.Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305, USA.Cervical spondylotic myelopathy: complications and outcomes after spinal fusionNeurosurgeryNeurosurgery455-61; discussion 461-2622AdolescentAdultAge FactorsAgedAged, 80 and overCervical VertebraeChildChild, PreschoolComorbidityFemaleHumansInfantInfant, NewbornMaleMiddle AgedMultivariate Analysis*Postoperative ComplicationsSpinal Cord Diseases/*surgerySpinal Fusion/*adverse effectsSpondylolysis/*surgeryTreatment Outcome2008Feb1524-4040 (Electronic)18382324http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18382324 eng8
Patel (2007) ADDIN EN.CITE ADDIN EN.CITE.DATA 10
Brau (2002) ADDIN EN.CITE Brau200210110110117Brau, S. A.Department of Surgery, University of Southern California School of Medicine, 501 E. Handy St., Suite 424, Inglewood, CA 90301, USA. salvo@labridge.comMini-open approach to the spine for anterior lumbar interbody fusion: description of the procedure, results and complicationsSpine J216-2323AdultAgedFemaleHumansIntervertebral Disk/ surgeryLumbar Vertebrae/ surgeryMaleMiddle AgedRetrospective StudiesRisk FactorsSpinal Fusion/ adverse effects/ methods2002May-Jun1529-9430 (Print)145894969
Ramirez (1989) ADDIN EN.CITE Ramirez198910210210217Ramirez, L. F.Thisted, R.Department of Neurosurgery, University of Wisconsin, Madison.Complications and demographic characteristics of patients undergoing lumbar discectomy in community hospitalsNeurosurgeryNeurosurgery226-30; discussion 230-1252DemographyHospitals, CommunityHumansIntervertebral Disk/*surgeryIntraoperative Complications/epidemiology/mortalityLumbosacral RegionPostoperative Complications/epidemiology/mortalityUnited States1989Aug0148-396X (Print)2770987http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=2770987 eng7
Scaduto (2003)---------
2/84 (2.4)
7/686 (1.0)
---------
2/88 (2.3)407/58115 (0.7)
---------
0/686 (0.0)
38/35708 (0.11)
------------------
---------
---------
4/35708 (0.01)
---------DeformityUden (1979) ADDIN EN.CITE Uden197910710710717Uden, A.Thromboembolic complications following scoliosis surgery in ScandinaviaActa Orthop Scand175-8502AdolescentAdultFemaleFemoral VeinFollow-Up StudiesHumansIliac VeinMalePostoperative Complications/ epidemiologyPulmonary Embolism/ epidemiologyScoliosis/ surgeryThrombophlebitis/ epidemiology1979Apr0001-6470 (Print)43358068/1229 (0.65)1/1229 (0.08)1/1229 (0.08)Multiple spine conditionsRajaraman (1999) ADDIN EN.CITE ADDIN EN.CITE.DATA 41/60 (1.7)------------------ Table 3. Level of Evidence grade for studies reporting rate of thromboembolic events in spine surgery.
Methodological PrincipleBoakye 2008Brau
2002Dearborn 1999Epstein 2005Epstein 2006Ferreea 1993Ferreeb 1993Ferree 1994Lee 2000Nelson 1996Study designProspective cohort study(((((Retrospective cohort study((((((Case controlPatients at similar point in the course of their disease or treatment((((((((((Patients followed long enough for outcomes to occur((((((((((Complete follow-up of >80%((((((((((Controlling for extraneous prognostic factors*Evidence LevelIIIIIIII-IIIIIIIIIIIIIIIIIIII
Methodological PrincipleOda 2000Patel 2007Piasecki 2008Rajaraman 1999Ramirez 1989Scaduto 2003Smith 1994Uden 1979West 1992Wood 1997Flinn 1996Study designProspective cohort study((((((((Retrospective cohort study(((Case ControlPatients at similar point in the course of their disease or treatment(((((((((((Patients followed long enough for outcomes to occur(((((((((((Complete follow-up of >80%(((((((((((Controlling for extraneous prognostic factors*(Evidence LevelIIIIIIIIIIIIIIIIIIIIIIII
Table 4. Level of Evidence grade for studies reporting significant hemorrhage secondary to anticoagulant use.
Methodological PrincipleChin 2007Gerlach 2004Otero-Fernandez 2008Rokito 1996Shizas 2008Gruber 1984Voth
1992Study designProspective cohort study((((((Retrospective cohort study(Case ControlPatients at similar point in the course of their disease or treatment(((((((Patients followed long enough for outcomes to occur(((((((Complete follow-up of >80%(((((((Controlling for extraneous prognostic factorsEvidence LevelIIIIIIIIIIIIIII
Table 1. Demographic data of included studies.
Author
(Year)Study
DesignPopulationCondition and TreatmentProphylaxisBoakye (2008)Retrospective cohort
National Inpatient Sample databaseN = 58,115
Mean age: 51% were 45-64 yrs
42% maleCervical spondylotic myelopathy
Spinal fusion surgery NROtero-Fernandez
(2008)Prospective cohortN = 225
Mean age: NR for spine surgery*
NR% maleVarious spine conditions
Spine surgeryDaily bemiparin (LMWH) 2500 IU (moderate risk) or 3500 IU (high risk)Piasecki (2008)Prospective
cohortN = 66
Mean age: 52 yrs
14% maleScoliosis (n = 40) or revision surgery (n = 26) after failed fusion or laminectomy
Combined anterior/posterior fusion spine surgery;Mechanical prophylaxis with foot pumps during and post-opSchizas (2008)Prospective
cohortN = 270
Mean age: 44 yrs
NR% maleSpinal stenosis (n = 77), fractures or posttraumatic deformities (n = 57), DDD (n = 37), herniated discs (n = 26), spondylolisthesis (n = 27), scoliosis (n = 23), tumors (n = 8), infections (n = 8), rheumatoid arthritis (n = 7)
Anterior and/or posterior spinal fusions, discectomies and/or decompression surgeriesIPCs and enoxoparin (LMWH), 20mg daily for 3 days postop, then 40mg daily until dischargeChin (2007)Prospective and retrospective
cohortN = 89
Median age:
cases 36 yrs
controls 47 yrs
54% maleLumbar disc disease
Lumbar microdiscectomy
30 mg ketorolac (Toradol) immediately before wound closure (n = 44) or none (n = 45)Patel (2007)
Retrospective cohortN = 84
Mean age: 59 yrs
35% maleDegenerative disease
Elective lumbar and thoracic spinal fusionNREpstein
(2006)Retrospective cohortN = 139
Mean age: 53 yrs
56% maleStenosis with instability, spondylolisthesis
Multilevel lumbar laminectomies with instrumented fusionIPCs used for prophylaxisAwad (2005)Retrospective case-controlN = 134
Mean age:
cases 60 yrs
controls 55 yrs
52% maleVarious spine conditions
All levels of spinal surgery.
(Cases (n = 32) developed post-operative spinal epidural hematoma, controls were matched by complexity of spinal surgery procedure and time period.)NR Epstein
(2005) Retrospective cohort
Single-level, N = 100
Mean age: 46 yrs
57% male
Multilevel, N = 100
Mean age: 55 yrs
65% maleSpondylosis, stenosis, and/or OPLL
Single-level anterior corpectomy/fusion (ACF) (n = 100) and multilevel ACF/posterior fusion (n = 100) Intermittent compression stockings (IPCs)Brau (2004)Retrospective cohortN = 1310
Age range: 18-84 yrs
49% maleLumbar disc disease
ALIF or total disc replacement using mini-open, retroperitoneal approach NRGerlach (2004)Retrospective cohortN = 1954
Mean age: NR
NR% maleSpinal stenosis or disc herniation (n = 1618), stabilization (n = 55), tumor (n = 182), infection (n = 57), fractures (n = 28), hematoma (n = 14)
Cervical, thoracic and lumbar spinal proceduresReceived intra- and post-operative IPCs AND postop daily 0.3ml nadroparin calcium, 2850 IU anti-XaScaduto
(2003)Prospective cohortN = 119
Mean age: 44 yrs
44% maleLumbar disc disease
ALIF (n = 88) or PLF (n = 31) Brau (2002)Retrospective cohortN = 686
Age range: 19-84 yrs
50.3% maleLumbar disc disease
ALIF using mini-open, retroperitoneal approach NRLee (2000)Retrospective cohortN = 313
Mean age: 48 yrs
49% maleStenosis (n = 101), spondylolisthesis (n = 68), herniated disc (n = 8), scoliosis (n = 13), OPLL (n = 2), CSM (n = 25), infection (n = 26), fracture (n = 62), tumor (n = 8)
Multilevel anterior and/or posterior decompression and/or fusions No antithrombotic prophylaxisOda (2000)Retrospective cohortN = 110
Mean age: 59 yrs
58% maleStenosis (n = 20), scoliosis (n = 8), arthrodesis (n = 10), herniated disc (n = 24), scoliosis, OPLL (n = 11), myelopathy (n = 34), tumor (n = 3)
Posterior spinal surgery.No mechanical or medical antithrombotic prophylaxis Dearborn
(1999) Prospective and retrospective cohortProspective, N = 116
Mean age: 46 yrs
29% male
Retrospective, N = 267
Mean age: 48 yrs
28% maleScoliosis, stenosis, spondylolisthesis, kyphosis, pseudoarthrosis, or other degenerative spinal conditions
Anterior, posterior or combined ant/post spinal reconstruction surgeryThigh-length elastic antiembolism stockings and IPCs during and postop; no pharmacologic anticoagulationRajaraman (1999)Prospective cohortN = 60
Mean age: 42 yrs
52% maleDiscogenic back pain (n = 33), failed back syndrome (n = 11), pseudoarthrosis, (n = 5) postlaminectomy syndrome (n = 4), spondylolisthesis (n = 3), fracture (n = 2), tumor (n = 2)
ALIF via retroperitoneal (n = 57) or transperitoneal (n = 3)NRRokito (1996)Prospective cohort N = 110
Mean age: 44 yrs
40% male
lumbar disorder (n = 86), scoliosis (n = 14), thoracic disorder (n = 7), cervical disorder (n = 1), trauma (n = 2)
Anterior and/or posterior spinal fusions and/or decompression surgery Thigh-high compression stockings (n = 42), compression stockings and thigh-length IPCs (n = 33), or compression stockings and 10mg Coumadin on the evening before surgery and daily postop (n = 35)Smith (1994)Prospective cohortN = 317
Mean age: NR
NR% maleDegenerative spine disease (n = 172), spondylolisthesis (n = 31) spinal trauma (n = 34), scoliosis (n = 77), infection (n = 3)
Spinal surgery Thigh-length IPCs, no medical antithrombotic prophylaxisFerreeb (1993)Prospective cohortN = 86
Mean age: 43 yrs
53% maleScoliosis, degenerative disc disease, spondylolisthesis, instability
Lumbar (n = 78) or thoracic (n = 8) decompression and/or fusion spineIPCsWest (1992)Prospective cohortN = 41
Mean age: 38 yrs
NR% maleSpinal deformity (n = 14), trauma (n = 16), degenerative spine disease (n = 11)
Anterior and/or posterior instrumented fusion No preoperative or intraoperative thrombotic prophylaxis; used postop compression stockingsRamirez (1989)Prospective cohortN = 35,708
Mean age: NR
NR% male
Commission on Professional and Hospital Activities DatabaseLumbar disc displacement or degeneration, no history of previous surgery;
Lumbar discectomy at one or two levels without fusionNRUden (1979)Prospective cohortN = 1229
Mean age: 57 yrs
33% maleScoliosis
Fusion using Harrington rodsNRGruber
(1984)Prospective cohortN = 50
Heparin
Mean age: 47 yrs
57% male
Placebo
Mean age: 45 yrs
65% maleHerniated lumbar disc
(treatments)2500 IU miniheparin-dihydroergotamine two times daily (n = 25) or placebo (n = 20), beginning 2 hrs preoperatively and continuing at least 7 days or until hospital dischargeVoth (1992)Prospective cohortN = 179
LMWH
Mean age: 53 yrs
44% male
HDHE
Mean age: 53 yrs
45% male
(conditions)
Lumbar-vertebral disc procedures
Fenestration (n = 166)
Hemilaminectomy (n = 7)
Laminectomy (n = 3)
Sequestrotomy (n = 1)
NR (n = 2)1500 U-aPTT LMWH plus dihydroergotamine 0.5 mg once daily plus placebo injection daily (n = 87) or 5000 U heparin plus dihydroergotamine 0.5 mg twice a day (n = 92), beginning 2 hrs preoperatively and continued for at least 7 daysFereea (1993)Prospective cohortN = 185
Elastic compression:
Mean age: 43 yrs
NR% male
Pneumatic compression:
Mean age: 50 yrs
NR% maleLaminectomy or laminotomy (n = 84); posterior spinal fusion with or without laminectomy or laminotomy (n = 101)Elastic compression stockings (n = 74) or intermittent pneumatic compression (n = 111)Flinn
(1996)Prospective cohortN = 2643
Mean age: 58 yrs
52% maleCraniotomies for treatment of neoplasms or cerebrovascular disorders (n = 1439); ventriculoperitoneal or other shunting procedures (n = 299); cervical or lumbar spinal surgeries (n = 454)Elastic stockings and IPCWood
(1997)
Prospective cohortN = 136
Plexi Pulse:
Mean age: 39 yrs
52% male
SCD:
Mean age: 40 yrs
66% male
Major reconstructive spinal surgeries defined as anterior and/or posterior thoracic, lumbar, or thoracolumbar spinal fusions and/or multilevel decompression surgeryThigh-high pneumatic compression wraps or pneumatic foot-compression wrapsNelson
(1996)Prospective cohortN = 117
Mean age: NR
NR% maleDegenerative spinal disease; posterior lumbar decompression with fusion and fixationTED stockings and acetylsalicyclic acid (ASA) 600 mg bid (n = 60) or TED and pneumatic compression boots and ASA 600 mg bid (n = 57)
DVT = Deep vein thrombosis; PE = Pulmonary embolism
NR = no report
INR = International Normalized Ratio
Ossification of the posterior longitudinal ligament (OPLL)
CSM = cervical spondylotic myelopathy
LMWH = low-molecular weight heparin
DDD = degenerative disc disease
Intermittent compression stockings (IPCs)
Anterior lumbar interbody fusion (ALIF)
*Study included orthopedic surgery patients; data reported for spine surgery only
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