Incidence and management of pulmonary embolism following spinal surgery occurring while under chemical thromboprophylaxis |
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Authors: | C Schizas F Neumayer V Kosmopoulos |
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Institution: | 1.Centre Hospitalier Universitaire Vaudois and The University of Lausanne, Lausanne, Switzerland ;2.Hôpital Orthopédique de la Suisse Romande, Avenue Pierre-Decker 4, 1011 Lausanne, Switzerland |
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Abstract: | Patients undergoing spinal surgery are at risk of developing thromboembolic complications even though lower incidences have
been reported as compared to joint arthroplasty surgery. Deep vein thrombosis (DVT) has been studied extensively in the context
of spinal surgery but symptomatic pulmonary embolism (PE) has engaged less attention. We prospectively followed a consecutive
cohort of 270 patients undergoing spinal surgery at a single institution. From these patients, only 26 were simple discectomies,
while the largest proportion (226) was fusions. All patients received both low molecular weight heparin (LMWH) initiated after
surgery and compressive stockings. PE was diagnosed with spiral chest CT. Six patients developed symptomatic PE, five during
their hospital stay. In three of the six patients the embolic event occurred during the first 3 postoperative days. They were
managed by the temporary insertion of an inferior vena cava (IVC) filter thus allowing for a delay in full-dose anticoagulation
until removal of the filter. None of the PE patients suffered any bleeding complication as a result of the introduction of
full anticoagulation. Two patients suffered postoperative haematomas, without development of neurological symptoms or signs,
requiring emergency evacuation. The overall incidence of PE was 2.2% rising to 2.5% after exclusion of microdiscectomy cases.
The incidence of PE was highest in anterior or combined thoracolumbar/lumbar procedures (4.2%). There is a large variation
in the reported incidence of PE in the spinal literature. Results from the only study found in the literature specifically
monitoring PE suggest an incidence of PE as high as 2.5%. Our study shows a similar incidence despite the use of LMWH. In
the absence of randomized controlled trials (RCT) it is uncertain if this type of prophylaxis lowers the incidence of PE.
However, other studies show that the morbidity of LMWH is very low. Since PE can be a life-threatening complication, LMWH
may be a worthwhile option to consider for prophylaxis. RCTs are necessary in assessing the efficacy of DVT and PE prophylaxis
in spinal patients. |
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Keywords: | Deep vein thrombosis Pulmonary embolism Spinal surgery Incidence Low molecular weight heparin |
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