New Guidelines for Anti-Coagulation Management Issued

Led by a team of 20 surgeons from a number of the top academic institutions and then published in the March 1, 2023, edition of Spine, important new guidelines for anticoagulation management in complex spine cases are now available.

The full report; “Management of Anticoagulation/Antiplatelet Medication and Venous Thromboembolism Prophylaxis in Elective Spine Surgery: Concise Clinical Recommendations Based on a Modified Delphi Process,” is available, as we noted above, in the March 1, 2023 edition of Spine.

“Some of the best research papers are born out of clinical scenarios where we previously did not have equipoise,” explained co-author Ronald A. Lehman, Jr., M.D., chief of Spine Surgery and director of Spine Research at The Daniel and Jane Och Spine Hospital at NewYork-Presbyterian/Columbia University.

“We treat patients that have a myriad of considerations when it comes to anticoagulation. Some patients have a history of a deep vein thrombosis (DVT) or pulmonary embolism (PE), some are on medication to thin their blood, and others may be at higher risk after a surgery to having a PE or DVT.”

Furthermore, said Dr. Lehman, there has never been a consensus statement on the topic of anticoagulation therapy, despite the clear need. So, Dr. Lehman and his 19 colleagues, which included leading hematologists from around the United States, developed guidelines for managing patients with these DVT, PT or are on blood thinning medications, then the team stratified risk into an objective format for all spine surgeons.

The used the Delphi method of consensus building to organize the new guidelines into a set of actionable guidelines.

Co-author Dr. Scott L. Zuckerman, M.D., M.P.H., assistant professor of Neurological Surgery at Vanderbilt University Medical Center explained the value and power of the Delphi method to OTW, “The Delphi method takes time and collaboration, and for a study such as this, multiple disciplines had to be involved, including spine surgeons from orthopaedics and neurosurgery, internal medicine doctors, and hematologists.”

“The topic of anticoagulation/antiplatelets management, and DVT prophylaxis affects all spine surgeons equally, regardless of your sub-specialty (deformity, degeneration, minimally invasive surgery, tumor, etc.), and there are very few clinical issues we can say that about.”

The study authors reported that spine surgeons and the other participants in the project reached consensus (>70% agreement) for 26/27 items. The principal recommendations were 2/5/7 or:

• preoperative Direct Oral Anticoagulants should be stopped two days before surgery,
• warfarin should be stopped five days before surgery;
• all remaining anticoagulation/antiplatelet medication and aspirin should be stopped seven days before surgery.

As for restarting anticoagulation/antiplatelet medication postoperatively, the study participants reached consensus for low-risk/medium-risk/high-risk patients who had any one or more of 5/5 risk factors (VTE history/cardiac/ambulation status/anterior approach/operation).

Project participants reached consensus for low/medium/high thresholds and set them at 7/5/2 postop days, respectively.

For VTE [venous thromboembolism] chemoprophylaxis, the project group reached consensus for low-risk/medium-risk/high-risk patients in 12/13 risk factors (age/body mass index/VTE history/cardiac/cancer/hormone therapy/operation/anterior approach/staged separate days/staged same days/operative time/transfusion).

In only one area did the group not achieve consensus—same-day staged surgery.

The low-threshold/medium-threshold/high-threshold ranges were postoperative day 5 or none/postop days 3-4/postop days 1-2, respectively.

Other VTE chemoprophylaxis issues for which the project group also achieved consensus were:

• postop day 1 defined as the morning after surgery regardless of operating finishing time, enoxaparin as the medication of choice, and
• standardized, rather than weight-based, dose given once daily.

“For the first time, medical providers, referring doctors and surgeons have up-to-date recommendations from experts about what to do with patients who are on anticoagulation prior to having complex spine surgery,” said Suken Shah, M.D., division chief of the Spine & Scoliosis Center at Nemours Children’s Hospital in Delaware.

“The goal now is to perform a prospective, multicenter cohort study utilizing these guidelines,” Dr. Lehman told OTW. “After a period of time, we will collate that data and determine if we need to refine the categories based upon the current stratification.”