Efficacy and safety of tranexamic acid in reducing blood loss in scoliosis surgery: a systematic review and meta-analysis

Tranexamic Acid Reduces Perioperative Blood Loss in Pediatric Spinal Deformity Surgery​​​: A Retrospective Analysis in Nonidiopathic Scoliosis Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To assess the efficacy of tranexamic acid (TXA) on reducing perioperative blood loss and blood transfusion requirements in nonidiopathic scoliosis patients undergoing primary posterior spinal fusion.

SUMMARY OF BACKGROUND DATA

Posterior spinal fusion for correcting scoliosis in pediatric patients is associated with substantial volumes of perioperative blood loss and high transfusion requirements. Patients with nonidiopathic scoliosis typically experience greater blood loss than those with idiopathic scoliosis.

METHODS

We retrospectively reviewed patients who underwent primary posterior fusion for nonidiopathic scoliosis between November 2014 and December 2020. Patients were assigned to the TXA or no-TXA group depending on intraoperative administration of TXA.

RESULTS

Despite longer surgical duration (P=0.009) and more spinal levels fused (P=0.014), perioperative blood loss [2602 (810-9262) mL in the TXA group vs. 2058 (1019-4170) mL in the no-TXA group, P=0.554] and allogenic red blood cell transfusion rates (63% in the TXA group vs. 55% in the no-TXA group, P=0.508) were similar in the TXA and the no-TXA groups. After adjustments, TXA administration was found to have a significant negative effect on estimated blood loss (Est=-513.73, 95% CI=-925.41 to 125.3, P=0.045).

CONCLUSIONS

Significant perioperative blood loss and high transfusion rates remain a challenge in the surgical treatment of nonidiopathic scoliosis patients. Given the demonstrated negative effect of TXA on estimated blood loss, its routine application may be considered in the perioperative blood management of pediatric nonidiopathic scoliosis patients.

LEVEL OF EVIDENCE

Level III.

The Utility of the Surgical Apgar Score in Assessing the Risk of Perioperative Complications Following Spinal Fusion Surgery for Pediatric Patients With Scoliosis and Cerebral Palsy

STUDY DESIGN

Cohort study.

OBJECTIVE

Validate the Surgical Apgar Score (SAS) as a means of predicting perioperative major complications occurring within 30 days after scoliosis surgery in pediatric patients with cerebral palsy (CP).

SUMMARY OF BACKGROUND DATA

A patient's SAS, which is composed of three commonly recorded intraoperative variables, predicts postoperative complications after various types of spine surgery. This has not; however, been studied in pediatric patients with scoliosis and CP, a population that experiences a high incidence of complications after corrective spinal surgery.

METHODS

Pediatric CP patients who underwent spinal correction surgery were included in this study. Patient background, surgical variables, and perioperative complications occurring within 30 days after surgery were collected. Patients were divided into 4 groups based on their SAS: SAS 0 to 4, SAS 5 to 6, SAS 7 to 8, and SAS 9 to 10. The incidences of perioperative complications for each group were compared using a receiver operating characteristic analysis. The area under the curve (AUC) is reported.

RESULTS

A total of 111 patients met the inclusion criteria. There were no death cases. There were 44 (39.6%) perioperative major complications in 37 (33.3%) patients that occurred within 30 days after spine surgery. The most frequent perioperative complications were pulmonary issues (13.5%). The incidence of perioperative major complication in each SAS group was as follows: SAS 0 to 4; 51.6%, SAS 5 to 6; 30.2%, SAS 7 to 8; 18.5%, SAS 9 to 10; 0/0. When the SAS 7 to 8 group was set as the reference, there was no significant difference compared to SAS 5 to 6 ( P =0.34), while the incidence rate was significantly increased in SAS 0 to 4 ( P =0.02). The AUC was 0.65 (95% CI: 0.54-0.75).

CONCLUSIONS

Overall, there were 37 (33.3%) patients with CP who had a major complication within 30 days after spinal surgery. Lower SAS, with the 0 to 4 group being the cutoff, were associated with significantly higher complication rates than higher SAS groups.

Can Intra-Operative Cell Salvage Reduce the Rate of Allogeneic Transfusion in Pediatric Spinal Deformity Surgery?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The objective of this study was to characterize the association between cell-salvage and allogeneic transfusion rate in pediatric patients undergoing posterior arthrodesis for scoliosis.

METHODS

NSQIP Pediatric database years 2016-2022 was used. Patients under the age of 18 who received posterior arthrodesis with 7 or more surgical levels for spinal deformity correction were included. Rates of cell-salvage and allogeneic transfusion were determined. We assessed the impact of cell-salvage on the rate of allogeneic transfusion using chi-square test and multivariable logistic regression.

RESULTS

There were 34,241 patients in this study. The rate of allogeneic transfusion was 21.6% (n = 7407). The allogeneic transfusion rates for idiopathic, neuromuscular, and congenital/syndromic scoliosis were 12.3%, 50.8%, and 25.9%, respectively. Cell-salvage was used in 71.1% of patients (n = 24,344). In the multivariable regression analysis, longer operative time (P < .001), non-idiopathic scoliosis (P < .001), hematocrit less than 35 (P < .001), and ≥13 surgical levels (P < .001) were associated with higher odds of allogeneic transfusion. Use of cell-salvage (P < .001), increasing age (P < .001), and increasing patient weight (P < .001) were associated with significantly lower odds of allogeneic transfusion. In a subanalysis, use of cell-salvage was associated with reduced rate of allogeneic transfusion in patients with idiopathic scoliosis. Cell-salvage was not associated with reduced rates of allogeneic transfusion in neuromuscular and congenital/syndromic scoliosis.

CONCLUSION

This is the largest study investigating the impact of cell-salvage on rate of allogeneic transfusion in pediatric spinal deformity surgery. Use of cell-salvage is associated with reduced allogeneic transfusion rates in idiopathic scoliosis surgery.

Surgical Treatment Strategies for Severe and Neglected Spinal Deformities in Children and Adolescents without the Use of Radical Three-Column Osteotomies

Background: Severe spinal deformity manifests as a pronounced deviation from the normal curvature of the spine in the frontal, sagittal, and horizontal planes, where the coronal plane curvature exceeds 90 degrees and may coincide with hyperkyphotic deformity. The most severe deformities exhibit rigidity, with flexibility below 30%. If left untreated or improperly treated, these deformities can result in serious complications associated with progression of the curvature. A combination of surgical techniques is frequently employed to attain optimal outcomes and minimize the risk of complications. The overall medical condition of the patient, their capacity to endure extensive procedures, the expertise of the surgeon, and the resources available all play significant roles in determining the course of management. A systematic and thorough review of the relevant literature was conducted utilizing a variety of electronic databases. The primary objective of this study was to scrutinize the surgical techniques commonly employed in complex spine surgeries for the management of severe scoliosis without resection vertebral body techniques, with higher potential risk of major complications, including permanent neurological deficit. Conclusions: Halo-gravity traction, halo femoral traction, and all techniques for releases of the spine (anterior, posterior, or combine), as well as thoracoplasty, have demonstrated significant effectiveness in managing severe and rigid idiopathic scoliosis. The combination of several of these methods can lead to optimal alignment correction without the need to perform high-risk techniques involving three-column osteotomies. Surgeons must customize the indications based on factors such as available resources, characteristics of the deformity, and the patient's individual profile. Surgical correction of severe scoliosis without vertebral body resection surgeries decreases the potential risks related to neurological and pulmonary complications while providing significant clinical improvement outcomes. The powerful Ponte osteotomy is indicated for severe scoliosis, curves with poor flexibility, for better restoration of hypokyphosis, and decrease of hyperkyphosis. These corrective techniques combined with HGT or temporary internal distraction rods are recommended as viable options for managing individuals with severe rigid spine deformity characteristics. Therefore, they also should be considered and performed by a proficient surgical team. The presence of neuromonitoring is crucial throughout these procedures.

Efficacy of tranexamic acid versus placebo in reducing blood loss during burn excisional surgery: a multi-center, double-blind, parallel, randomized placebo-controlled clinical trial (TRANEX)

BACKGROUND

Despite an increase in knowledge, blood loss during burn excisional surgery remains a major challenge and is an independent predictor of mortality. During burn surgery, limited measures are available to control the bleeding. Increased fibrinolysis could be one of the contributing factors of blood loss during burn excisional surgery. Tranexamic acid inhibits the fibrinolytic response, and a small body of evidence shows positive effects of tranexamic acid on the volume of blood loss.

METHODS

The main objectives of this study are twofold, (1) to investigate whether tranexamic acid reduces blood loss and (2) to investigate the changes in coagulation after burn trauma and during burn excisional surgery. This study is a multicenter double-blind randomized clinical trial in patients scheduled for burn excisional surgery within the Dutch burn centers. All adult patients scheduled for burn surgery with an expected blood loss of ≥ 250 are eligible for inclusion in this study. The study is powered on a blood loss reduction of 25% in the intervention group. In total, 95 subjects will be included. The intervention group will receive 1500 mg tranexamic acid versus placebo in the other group. Primary endpoint is reduction of blood loss. Secondary endpoints include occurrence of fibrinolysis during surgery, graft take of the split skin graft, and differences in coagulation and blood clot formation.

DISCUSSION

This protocol of a randomized controlled trial aims to investigate the efficacy of tranexamic acid in reducing blood loss during burn excisional surgery. Furthermore, this study aims to clarify the coagulation status after burn trauma and during the surgical process.

TRIAL REGISTRATION

EudraCT: 2020-005405-10; ClinicalTrial.gov: NCT05507983 (retrospectively registered in August 2022, inclusion started in December 2021).

Risk factors for allogeneic red blood cell transfusion in adult spinal deformity surgery

STUDY DESIGN

Retrospective study.

PURPOSE

To investigate the risk factors for allogeneic red blood cell (RBC) transfusion in adult spinal deformity (ASD) surgery.

OVERVIEW OF LITERATURE

Studies have not thoroughly explored the roles of intraoperative hypothermia, autologous blood donation, and hemostatic agent administration, which would provide a better understanding of the risk for perioperative RBC transfusion in ASD surgery.

METHODS

The medical records of 151 patients with ASD who underwent correction surgery between 2012 and 2021 were retrospectively reviewed. Estimated blood loss and perioperative allogeneic transfusion were examined. Patients were categorized into two groups based on whether they received perioperative allogeneic blood transfusion. Logistic regression analysis was employed to investigate the effect of age, sex, blood type, body mass index, American Society of Anesthesiologists' physical status, preoperative hemoglobin level, autologous blood donation, global spine alignment parameters, preoperative use of anticoagulants or antiplatelet medicine and nonsteroidal anti-inflammatory drugs, number of instrumented fusion levels, total operative duration, three-column osteotomy, lateral interbody fusion, pelvic fixation, intraoperative hypothermia, use of gelatin-thrombin based hemostatic agents, and intraoperative tranexamic acid (TXA) with simultaneous exposure by two attending surgeons.

RESULTS

The estimated blood loss was 994.2±754.5 mL, and 71 patients (47.0%) received allogeneic blood transfusion. In the logistic regression analysis, the absence of intraoperative TXA use and simultaneous exposure (odds ratio [OR], 26.3; 95% confidence interval [CI], 7.6-90.9; p<0.001), lack of autologous blood donation (OR, 21.2; 95% CI, 4.4-100.0; p<0.001), and prolonged operative duration (OR, 1.6; 95% CI, 1.3-1.9; p<0.001) were significant independent factors for perioperative allogeneic blood transfusion in ASD surgery.

CONCLUSIONS

Autologous blood storage, intraoperative TXA administration, and simultaneous exposure should be considered to minimize perioperative allogeneic blood transfusion in ASD surgery, particularly in patients with anticipated lengthy surgeries.

Effect of Tranexamic Acid on Hidden Blood Loss in Percutaneous Endoscopic Transforaminal Lumbar Interbody Fusion: A Retrospective Study

Purpose

Percutaneous endoscopic transforaminal lumbar interbody fusion (PE-TLIF) has become one of the most popular minimally invasive surgeries today. However, the issue of hidden blood loss (HBL) in this surgery has received little attention. This study aims to examine the HBL in PE-TLIF surgery and the effect of tranexamic acid (TXA) on blood loss.

Methods

In our research, We conducted a retrospective analysis of 300 patients who underwent PE-TLIF from September 2019 to August 2023. They were divided into 2 groups based on whether they received intravenous TXA injection before surgery. The variables compared included: demographic data, pre-and postoperative hemoglobin (HB), hematocrit (HCT), platelets (PLT), red blood cells (RBC), total blood loss (TBL), visible blood loss (VBL), HBL, operation time, postoperative hospital stay, inflammatory markers, coagulation parameters, and adverse events.

Results

Regarding demographic characteristics, besides the operation time, no significant differences were observed between the two groups. Compared with the control group, the TXA group showed a significant reduction trend in TBL, HBL, and VBL (P < 0.05). On the first day after surgery, there were significant differences in prothrombin (PT), activated partial thromboplastin time (APTT), and D-dimer (D-D) levels between the two groups. Similarly, HCT also found similar results on the third day after surgery. No adverse events occurred in either group.

Conclusion

Research has found that there is a significant amount of HBL in patients undergoing PE-TLIF. Intravenous injection of TXA can safely and effectively reduce perioperative HBL and VBL. Additionally, compared to the control group, the TXA group shows a significant reduction in operation time.

The cost-utility of intraoperative tranexamic acid in adult spinal deformity patients undergoing long posterior spinal fusion

PURPOSE

This study aims to evaluate the cost-utility of intraoperative tranexamic acid (TXA) in adult spinal deformity (ASD) patients undergoing long posterior (≥ 5 vertebral levels) spinal fusion.

METHODS

A decision-analysis model was built for a hypothetical 60-year-old adult patient with spinal deformity undergoing long posterior spinal fusion. A comprehensive review of the literature was performed to obtain event probabilities, costs and health utilities at each node. Health utilities were utilized to calculate Quality-Adjusted Life Years (QALYs). A base-case analysis was carried out to obtain the incremental cost and effectiveness of intraoperative TXA. Probabilistic sensitivity analysis was performed to evaluate uncertainty in our model and obtain mean incremental costs, effectiveness, and net monetary benefits. One-way sensitivity analyses were also performed to identify the variables with the most impact on our model.

RESULTS

Use of intraoperative TXA was the favored strategy in 88% of the iterations. The mean incremental utility ratio for using intraoperative TXA demonstrated higher benefit and lower cost while being lower than the willingness-to-pay threshold set at $50,000 per quality adjusted life years. Use of intraoperative TXA was associated with a mean incremental net monetary benefit (INMB) of $3743 (95% CI 3492-3995). One-way sensitivity analysis reported cost of blood transfusions due to post-operative anemia to be a major driver of cost-utility analysis.

CONCLUSION

Use of intraoperative TXAs is a cost-effective strategy to reduce overall perioperative costs related to post-operative blood transfusions. Administration of intraoperative TXA should be considered for long fusions in ASD population when not explicitly contra-indicated due to patient factors.

Enhanced recovery after surgery (ERAS) in sacral tumour surgery and comprehensive description of a multidisciplinary program: a prospective study in a specialized hospital in China

PURPOSE

There were fewer data to guide the application of enhanced recovery after surgery (ERAS) theory into sacral tumour surgery. In the present study, we were aiming to describe a multidisciplinary program of ERAS and evaluate the availability in sacral tumour surgery.

METHODS

This was a prospective study of patients with sacral tumour between March 2021 and September 2021 at a single centre. We proposed a multidisciplinary program of ERAS for pre-admission, preoperative, intraoperative, postoperative, and post-discharge clinical care which positively influenced outcomes of patients with sacral tumour. All patients were prospectively assigned into two groups, ERAS group in which patients received ERAS protocols (n = 63), No-ERAS group in which patients had conventional clinical pathways (n = 62). Patient data were collected which included demographics, preoperative preparation, detailed information of surgical procedure, 60-day reoperation rate, 60-day readmission, postoperative length of stay (PLOS), time to first ambulation and flatus after surgery, time to removal of last drainage tube, and visual analogue scale (VAS) score at first ambulation and discharge. Complications referred to ones that occurred within 60 days after surgery. The above parameters were compared between ERAS group and No-ERAS group.

RESULTS

Time to first ambulation after surgery in ERAS group (mean 20.9 h) was significantly shorter than that in No-ERAS group (mean 104.3 ho). Meanwhile, time to first flatus after surgery in ERAS group (mean 26.7 h) was also significantly shorter than that in No-ERAS group (mean 37.3 h). Patients in ERAS group had statistically shorter PLOS (10.7 days) as compared to that in No-ERAS group (13.8 days). In ERAS group, 19 of 63 patients (30.2%) were discharged within seven days after surgery as compared to seven of 62 patients (11.3%) in No-ERAS group. VAS score at first ambulation in ERAS group was not obviously higher than that in No-ERAS group though the time of first ambulation in ERAS group was statistically earlier than one in No-ERAS group. Furthermore, VAS score at discharge in ERAS group was significantly lower than that in No-ERAS group. The rate of postoperative incision necrosis was 6.3% (4/63) in ERAS group and 8.1% (5/62) in No-ERAS group and all of these nine patients underwent reoperation before discharge. The difference was not statistically significant in the wound complication of incision necrosis and 60-day reoperation rate. Only one readmission occurred in No-ERAS group due to the surgical site infection and also there was no significant difference of 60-day readmission rate between these two groups. Furthermore, there was no statistical difference of complications of femoral artery thrombosis and rectal rupture between ERAS group and No-ERAS group.

CONCLUSIONS

Our proposed ERAS pathway for sacral tumour surgery and early walking facilitate safe and prompt discharge. ERAS protocols of sacral tumour surgery could decrease PLOS without significantly increasing postoperative complications, 60-day readmission rate and 60-day reoperation rate. The application of ERAS pathway in the field of sacral tumour surgery should have personalized feature with regard to resection type.

Safety and Efficacy of High-Dose Tranexamic Acid in Spine Surgery: A Retrospective Single-Institution Series

OBJECTIVE

Currently, tranexamic acid (TXA) is the most widely used antifibrinolytic agent in spine surgery and has been proven to reduce perioperative blood loss. However, the safety of high-dose regimens remains in established.

METHODS

A retrospective chart review was performed to identify all adult patients who underwent spine surgery with high-dose TXA (50 mg/kg loading dose, mg/kg/h maintenance dose) between September 2019 and March 2020.

RESULTS

Thirty-six patients were treated with intraoperative high-dose TXA during the study period. The mean age was 56.6 (range: 22-82). Average body mass index was 27.2 (5.1) kg/m2. Average preoperative Charlson Comorbidity Index was 3.0 (2.7). The mean number of spinal levels operated on was 6.9 (4.3). Seven cases (19.4%) were revision surgeries. The mean intraoperative blood loss was 587.1 (900.0) mL, and total blood loss was 623.8 (991.9) mL. Postoperatively, time to ambulation was on average 1.7 (1.7) days. The mean total length of stay was 9.8 days (7.9, range 2-41). The most common indication for surgery was tumor (n = 9, 25%), followed by fracture (n = 8, 22.2%), deformity (n = 7, 19.4%), pseudarthrosis (n = 6, 16.7%), and symptomatic lumbar disc herniation (n = 2, 5.6%). There were no thromboembolic or other significant complications among the 36 patients.

CONCLUSIONS

This retrospective case series demonstrates that the use of high-dose TXA provides is potentially safe and efficacious in adult patients undergoing complex spine surgeries. However, further investigations are required before the true safety and optimal dosing can be determined for high-dose TXA.

Is High-Dose Tranexamic Safe in Spine Surgery? A Systematic Review and Meta-Analysis

STUDY DESIGN

Literature review and meta-analysis.

OBJECTIVES

Single-center series may be underpowered to detect whether high-dose (HD) tranexamic acid (TXA) confers a higher risk of complications. We sought to determine the safety and efficacy of HD TXA as compared to low-dose (LD) or placebo.

METHODS

A systematic literature review was performed to find studies where spine surgery patients were given HD TXA (loading dose ≥30 mg/kg). Complication rates were pooled, and meta-analyses performed on outcomes of interest. Articles were evaluated for risk of bias and a strength of evidence assessment was given for each conclusion.

RESULTS

Twenty three studies (n = 2331) were included. The pooled medical complication rate was 3.2% in pediatric patients, 8.2% in adults. Using lower dose TXA or placebo as the reference, meta-analysis showed no difference in medical complications (n = 1,723, OR 1.22 [95% CI, .78 to 1.22]; P = .388; I2 = 0%) or thrombotic events (n = 1158 patients, OR 1.27 [95% CI, .71 to 2.63]; P = .528; I2 = 0%). Compared to LD, HD TXA was associated with less intraoperative blood loss (823 patients, WMD = -285 [95% CI, -564 to -5.90]; P = .0454; I2 = 86%), fewer perioperative transfusions (n = 505, OR .28 [95% CI, .082 to .96]; P = .043; I2 = 76%) and lower perioperative transfusion volumes (n = 434, WMD -227.7 mL [95% CI, -377.3 to -78.02]; P = .0029; I2 = 0%).

CONCLUSION

Compared to LD TXA or placebo, there is moderate evidence that HD is not associated with an increased risk of medical complications. Compared to LD, there is moderate evidence that HD reduces transfusion requirements. High-Dose TXA can be safely utilized in healthy patients undergoing major spine surgery.

Tranexamic acid can reduce blood loss in adolescent scoliosis surgery: a systematic review and meta-analysis

BACKGROUND

Tranexamic acid (TXA) has been widely used in orthopedic surgery, but its efficacy in adolescent scoliosis (AS) surgery remains unclear in the literature. The purpose of this systematic review and meta-analysis is to evaluate the safety and efficacy of TXA compared to placebo treatment during or after AS surgery, by gathering data from randomized both controlled trials (RCTs) and non-RCTs.

METHODS

English and Chinese electronic databases including PubMed, Web of Science, Embase, Cochrane, CNKI, and Wan Fang database were searched to identify the relevant literature up until August 2022. The primary outcomes were intraoperative blood loss and total blood loss. The secondary outcomes included the need for transfusion, postoperative hemoglobin (Hb) level, and change in Hb level. Stata 17 was used for data analysis and the risk of bias was assessed. We followed the PRISMA checklist to ensure the quality of this article.

RESULTS

Twelve studies (795 participants) were included in the meta-analysis for intraoperative blood loss during surgery. The results suggest that TXA can reduce the intraoperative blood loss of the patients (MD = -306.40ml, 95%CI = -404.04ml to -208.77ml, p < 0.001). Six studies (2027 patients) were included in the meta-analysis for total blood loss. The pooled result shows that the total blood loss of the TXA group was significantly lower than that of the control group (MD = -779.24ml, 95% CI = -1157.10ml to -410.39ml, p < 0.001). Five studies (419 patients) were included in the meta-analysis for postoperative Hb level and shows a non-significant outcome (MD = 5.09 g/l, 95%CI = 2.92 g/l to 7.25 g/l, p = 0.611). Three studies (268 patients) were included in the meta-analysis for the postoperative Hb level. There is a non-significant decrease in the TXA group (MD = -0.23 g/l, 95%CI = -0.48 g/l to 0.01 g/l, p = 0.319). Eight studies (670 patients) reported data on the need for transfusion after surgery. The overall relative risks (RR) showed a significant difference between the TXA and control group, with a lower risk of transfusion in the TXA group (RR = 0.547, 95%CI = 0.308 to 0.972, p = 0.04).

CONCLUSIONS

The meta-analysis of the data reveals that TXA usage is associated with a significant reduction in intraoperative and total blood loss, a lower risk of transfusion, and a non-significant change in postoperative Hb levels in AS surgery However, it should be noted that the surgical operation situations varied across different studies. Therefore, further research is required to investigate the effects of TXA on specific subgroups of gender, operation time, and blood transfusion indicators. Overall, our study provides valuable evidence for the clinical management of AS surgery and may inform the development of practice guidelines and protocols for the use of TXA in this setting.

Randomized, controlled trial of two tranexamic acid dosing protocols in adult spinal deformity surgery

BACKGROUND

Tranexamic acid (TXA) is an anti-fibrinolytic effective in reducing blood loss in orthopedic surgery. The appropriate dosing protocol for adult spinal deformity (ASD) surgery is not known. The purpose of this study was to evaluate two TXA protocols [low dose (L): 10 mg/kg bolus, 1 mg/kg/hr infusion; high dose (H): 50 mg/kg, 5 mg/kg/hr] in complex ASD surgery.

METHODS

Inclusion criteria were ASD reconstructions with minimum 10 fusion levels or planned 3-column osteotomy (3CO). Standard demographic and surgical data were collected. Intraoperative estimated blood loss (EBL) was calculated by suction canisters minus irrigation plus estimated blood lost in sponges, estimated to the nearest 50 mL. Serious adverse events (SAE) were defined a priori as: venothromboembolic event (VTE), cardiac arrhythmia, myocardial infarction, renal dysfunction, and seizure. All SAE were recorded. Simple t tests compared EBL between groups. Mean EBL by total blood volume (TBV), transfusion volume, complications related to TXA were secondary outcomes.

RESULTS

Sixty-two patients were enrolled and 52 patients completed the study; 25 were randomized to H and 27 to L. Demographic and surgical variables were not different between the two groups. EBL was not different between groups (H: 1596 ± 933 cc, L: 2046 ± 1105 cc, p = 0.12, 95% CI: - 1022 to 122 cc). EBL as a percentage of TBV was lower for the high-dose group (H: 29.5 ± 14.8%, L: 42.5 ± 26.2%, p = 0.03). Intraoperative transfusion volume (H: 961 ± 505 cc, L: 1105 ± 808 cc, p = 0.5) and post-operative transfusion volume (H: 513 ± 305 cc, L: 524 ± 245 cc, p = 0.9) were not different. SAE related to TXA were not different (p = 0.7) and occurred in 2 (8%) H and 3 (11%) L. There was one seizure (H), 2 VTE, and 2 arrhythmias.

CONCLUSION

No differences in EBL, transfusion volume, nor SAE were observed between H and L dose TXA protocols. High dose was associated with decreased TBV loss (13%). Further prospective study, with pharmacologic analysis, is required to determine appropriate TXA dosage in ASD surgeries.

LEVEL OF EVIDENCE

Therapeutic Level II.

TRIAL REGISTRATION

The study was registered at Clinicaltrials.gov (NCT02053363) February 3, 2014.

Tranexamic acid dosage for spinal surgery: a meta-analysis

PURPOSE

We conducted this meta-analysis of randomized controlled trials (RCTs) to compare the efficacy of different doses of intravenous tranexamic acid (TXA) in spinal surgery.

METHODS

We searched relevant academic articles from PubMed, Embase, the Cochrane Library, and CNKI. Two reviewers independently selected studies, assessed quality, extracted data, and evaluated the risk of bias. RevMan 5.4 was used for data analysis.

RESULTS

Ten randomized controlled trials (RCTs) met the inclusion criteria and were identified, including 740 patients. According to the different dose regimens of intravenous TXA, the included studies' patients were divided into the high dose of intravenous TXA group and the low dose of intravenous TXA group. Compared with the low-dose group, the high-dose group can reduce the intraoperative blood loss (MD = - 100.87, 95% CI: [- 147.81, - 53.92], P < 0.0001). For the postoperative Hb and HCT, the high-dose group can separately maintain 4.54 g/dL (MD = 4.54, 95% CI: [2.08, 6.99], P = 0.003) and 1.27% (MD = 1.27, 95% CI: [0.59, 1.94], P = 0.0002). There were no statistically significant differences in total blood loss, preoperative Hb and HCT, operative time, and blood transfusion rate between the high-dose group and the low-dose group.

CONCLUSIONS

Based on the present meta-analysis, compared with the low-dose of intravenous TXA in spinal surgery, the high dose of intravenous TXA decreases the intraoperative blood loss and preserves higher postoperative Hb and HCT levels without increasing the operative time and blood transfusion rate.

Post-operative tranexamic acid decreases chest tube drainage following vertebral body tethering surgery for scoliosis correction

PURPOSE

Anterior vertebral body tethering (VBT) is a non-fusion surgical treatment for Adolescent Idiopathic Scoliosis requiring chest tube(s) (CT). We sought to assess the efficacy of post-op intravenous tranexamic acid (IV TXA) in reducing CT drainage and retention.

METHODS

35 VBT patients received 24 h of post-op IV TXA (2 mg/kg/h) were compared to 49 who did not. Group comparisons were performed using Wilcoxon rank-sum and chi-squared tests. Multivariate linear regression analysis was used to assess the relationships between TXA and both CT drainage and retention time.

RESULTS

There were no group differences at baseline (Table). CTs placed for thoracic (T) and thoracolumbar (TL) curves were assessed separately. For TH CT, there was less total CT drainage in the TXA group (TXA 569.4 ± 337.4 mL vs. Non-TXA 782.5 ± 338.9 mL; p = 0.003) and shorter CT retention time (TXA 3.0 ± 1.3 vs. Non-TXA 3.9 ± 1.4 days; p = 0.003). For TL CT, there was less total CT drainage in the TXA group (TXA 206.8 ± 152.2 mL vs. Non-TXA 395.7 ± 196.1 mL; p = 0.003) and shorter CT retention time (TXA 1.7 ± 1.3 vs. Non-TXA 2.7 ± 1.0 days; p = 0.001). Following multivariate analysis, use of TXA was the only significant predictor of both drainage in T and TL CTs (p = 0.012 and p = 0.002, respectively) as well as T and TL CT retention time (p = 0.008 and p = 0.009, respectively). There were no differences in LOS (p = 0.863) or ICU stay (p = 0.290).

CONCLUSION

IV TXA results in a significant decrease in CT drainage and retention time. CT retention is decreased by 1 day for those that receive TXA.

LEVEL OF EVIDENCE

III.

Omission of tranexamic acid does not increase the amount of perioperative blood transfusions in patients undergoing one-level spinal fusion surgery: a retrospective propensity score-matched noninferiority study

INTRODUCTION

Application of tranexamic acid (TXA) in spine surgery is very frequent even without signs of hyperfibrinolysis, although its beneficial blood-saving effects are offset by harmful adverse events such as thromboembolic incidents. Thus, we investigated whether in relatively less invasive spinal procedures such as one-level posterior spinal fusion, omission of TXA affects the requirement for blood transfusions.

METHODS

We conducted a retrospective propensity score-matched noninferiority study with 212 patients who underwent one-level posterior spine fusion and who were stratified according to whether they received TXA intraoperatively at our tertiary care center. The primary endpoint was the volume of transfused packed red cells. Testing for noninferiority or equivalence was performed by two one-sided testing procedure (TOST) with a priori defined noninferiority margins ([Formula: see text]).

RESULTS

After propensity score matching a total of five patients (11.6%) treated with TXA were transfused compared with five patients (11.6%) who did not receive TXA. The majority of patients (51.2%) had a risk-increasing condition. The risk difference (no TXA-TXA) of intraoperative transfusion was - 4.7% (CI 90% - 13.62 to 4.32%), and omitting TXA was noninferior ([Formula: see text] = [Formula: see text]  10%). The mean intergroup difference in transfused volume (no TXA-TXA) was - 23.26 ml intraoperatively (CI 90% - 69.34 to 22.83 ml) and - 46.51 ml overall (CI 90% - 181.12 to 88.1 ml), respectively, suggesting equivalence of TXA omission ([Formula: see text] = [Formula: see text] 300 ml). The hemoglobin decline between both groups was also equivalent (with [Formula: see text] = [Formula: see text] 1 g/dl) both on the first postoperative day ([Formula: see text] Hb = 0.02 g/dl, CI 90% - 0.53 to 0.56 g/dl) and at discharge ([Formula: see text] Hb = - 0.29 g/dl, CI 90% - 0.89 to 0.31 g/dl).

CONCLUSION

We demonstrated that requirement of transfusion is rare among one-level fusion surgery and the omission of TXA is noninferior with regard to blood transfusion in high-risk patients undergoing this procedure. Therefore, the prophylactic use of TXA cannot be recommended here, suggesting to focus on alternative blood conservation strategies, if necessary.

The efficacy and safety of intravenous tranexamic acid in patients with posterior operation of multilevel thoracic spine stenosis: a prospective randomized controlled trial

Background

This study was a randomized controlled trial to evaluate efficacy and safety of the usage of intravenous tranexamic acid during posterior operation of multilevel thoracic spine stenosis for controlling perioperative blood loss.

Methods

Sixty eight patients with multilevel thoracic spine stenosis were randomized into the tranexamic acid group receiving 15 mg/kg body weight before the skin incision was made and 1 mg/kg body weight per hour during operation or the control group receiving the same dose of placebo (0.9% sodium chloride solution) intravenously. Pedicle screw fixation, laminectomy and selective discectomy were performed. Intraoperative and perioperative total blood loss were compared. The necessity and amount for blood transfusion, blood coagulation function, durations of postoperative hospital stays were compared. The complications of tranexamic acid were also investigated such as cardiovascular and cerebrovascular events, lower limb venous thrombosis.

Results

There were no statistically significant differences in age, gender, body mass index, ASA status, pathology required surgery, preoperative hemoglobin, operation time, laminectomy segments and discectomy segments between the tranexamic acid and control groups. The intraoperative blood loss (455.9 ± 206.6 ml vs 580.6 ± 224.3 ml, p < 0.05) and total blood loss (675.3 ± 170.3 ml vs 936.8 ± 306.4 ml, p < 0.01) in tranexamic acid group were significant lower than those in control group. The means of blood unit transfused (2.5 ± 1.0 vs 4.7 ± 2.4, p < 0.05) and Hb reduction in 48 h (22.5 ± 3.4 g/L vs 25.3 ± 3.9 g/L, p < 0.01) were significantly lower in tranexamic acid group than that in control group. There were no statistically significant differences in blood coagulation function pre-operation or 48 h post-operation between the tranexamic acid and the control groups. The requirements for patients to receive blood transfusion were fewer and durations of post-operational hospital stays were shorter in the tranexamic acid group, however, the difference did not achieve statistical significance. There was no significant difference in superficial or deep venous thrombosis of lower limbs or deterioration of neurological function between tranexamic acid group and control group.

Conclusions

Application of intravenous tranexamic acid significantly reduces intraoperative and perioperative total blood loss without significant side effects in posterior operation of multilevel thoracic spine stenosis.

Trial registration

At Chinese Clinal Trial Registry. http://www.chictr.org.cn/, ChiCTR2100054221. Registered on 11/12/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05361-2.

[Prospective randomized controlled trial on the effectiveness of low-dose and high-dose intravenous tranexamic acid in reducing perioperative blood loss in single-level minimally invasive transforaminal lumbar interbody fusion]

OBJECTIVE

A prospective randomized controlled trial was conducted to study the effectiveness and safety of intravenous different doses tranexamic acid (TXA) in single-level unilateral minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).

METHODS

The patients treated with single-level unilateral MIS-TLIF between September 2019 and October 2020 were enrolled and randomly classified into low-dose TXA (LD) group (n=39), high-dose TXA (HD) group (n=39), and placebo-controlled (PC) group (n=38). The LD, HD, and PC groups received intravenous TXA 20 mg/kg, TXA 50 mg/kg, the same volume of normal saline at 30 minute before skin incision after general anesthesia, respectively. There was no significant difference on baseline characteristics and preoperative laboratory results among 3 groups (P>0.05), including age, gender, body mass index, surgical segments, hematocrit (HCT), hemoglobin (HGB), prothrombin time (PT), international normalized ratio (INR), D-dimer, fibrin degradation products (FDP), activated partial prothromboplastin time (APTT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatinine (Cr), urea. The intraoperative blood loss (IBL), postoperative drainage volume, operation time, total blood loss (TBL), hidden blood loss (HBL), blood transfusion, hematological examination indexes on the first day after operation, and the incidence of complications within 1 month were compared among the 3 groups.

RESULTS

There were 3, 2, and 4 patients in the LD, HD, and PC groups who underwent autologous blood transfusion, respectively, and there was no allogeneic blood transfusion patients in the 3 groups. There was no significant difference in IBL, postoperative drainage volume, and operation time between groups (P>0.05). The TBL, HBL, and the decreased value of HGB in LD and HD groups were significantly lower than those in PC group (P<0.05), and TBL and HBL in HD group were significantly lower than those in LD group (P<0.05); the decreased value of HGB between LD group and HD group showed no significant difference (P>0.05). On the first day after operation, D-dimer in LD and HD groups were significantly lower than that in PC group (P<0.05); there was no significant difference between LD and HD groups (P>0.05). There was no significant difference in other hematological indexes between groups (P>0.05). All patients were followed up 1 month, and there was no TXA-related complication such as deep venous thrombosis of lower extremity, pulmonary embolism, and epilepsy in the 3 groups.

CONCLUSION

Intravenous administration of TXA in single-level unilateral MIS-TLIF is effective and safe in reducing postoperative TBL and HBL within 1 day in a dose-dependent manner. Also, TXA can reduce postoperative fibrinolysis markers and do not increase the risk of thrombotic events, including deep venous thrombosis and pulmonary embolism.

The administration of tranexamic acid for corrective surgery involving eight or more spinal levels: A systematic review and meta-analysis

As the number of fusion levels increases, the complexity of spinal correction surgery also increases. Thus, we conducted this study to determine the safety and efficacy of tranexamic acid (TXA) involving eight or more spinal fusion levels. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines, a search of the PubMed, Embase, CENTRAL, Web of Science, and ClinicalTrials.gov databases was conducted for relevant studies published prior to May 30, 2019. The primary outcomes, including blood loss and transfusion requirement, and the secondary outcomes, including general indices, postoperative hemoglobin, and coagulation function, were analyzed using Rev Man 5.3.5 software and STATA version 12.0. Eight randomized controlled trials (473 participants) were included in the study. Compared to the control treatments, TXA reduced intraoperative blood loss, total blood loss, transfusion volume, and prothrombin time. There were no significant differences between the TXA and non-TXA groups in transfusion rate, operative time, hospital stay, complications, hemoglobin level, and other coagulation function parameters. In the pediatric subgroup analysis, TXA additionally improved hemoglobin levels, platelet count, and prothrombin time international normalized ratio. The present meta-analysis showed that TXA reduced blood loss and transfusion volume in both adults and children. In pediatric patients, TXA led to a greater benefit in postoperative hemoglobin levels and coagulation function. Intravenous TXA is safe and effective in children with eight or more spinal corrective levels.

Hidden blood loss in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgery: a retrospective study of 765 cases at a single centre

Background

In scoliosis corrective surgery, total blood loss is composed of visible blood loss, including intraoperative haemorrhage and drainage, and hidden blood loss in which blood extravasates into the tissues and accumulates in the surgical field. The purpose of this study was to investigate hidden blood loss (HBL) and its potential risk factors in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgery and elucidate the influence of HBL on the necessity for postoperative blood transfusion.

Methods

We retrospectively studied adolescent idiopathic scoliosis patients undergoing posterior spine fusion for adolescent idiopathic scoliosis from January 2014 to December 2018 at our hospital. The patients’ demographics, blood loss-related parameters, surgeries and blood loss data were extracted. The association between patient characteristics and HBL was analyzed by Pearson or Spearman correlation analyses. Multivariate linear regression analysis was used to determine independent risk factors associated with HBL. Binary logistic regression analysis was used to analyze the influence of HBL on the necessity for postoperative blood transfusion.

Results

A total of 765 patients, of whom 128 were male and 637 were female (age range 10–18 years), were included in this study. The mean volume of HBL was 693.5 ± 473.4 ml, accounting for 53.9 % of the total blood loss. The multivariate linear regression analysis revealed that preoperative Hct (p = 0.003) and allogeneic blood transfusion (p < 0.001) were independent risk factors for HBL, while tranexamic acid (p = 0.003) was negatively correlated with HBL. Binary logistic regression analysis showed that HBL > 850 ml (P < 0.001, OR: 8.845, 95 % CI: 5.806–13.290) was an independent risk factor for the necessity for postoperative blood transfusion.

Conclusions

Substantial HBL occurred in adolescent idiopathic scoliosis patients undergoing posterior spinal fusion surgeries. Allogeneic blood transfusion and preoperative Hct were independent risk factors for HBL, while tranexamic acid was negatively related to HBL. HBL and its influencing factors should be considered when planning perioperative transfusion management. Patients with HBL greater than 850 ml should be closely monitored in cases of postoperative anaemia.

Level of evidence

Level III.

Cost-Benefit Analysis of Using A Single Dose of Tranexamic Acid in Degenerative Lumbar Scoliosis Patients Undergoing Long-Segment Spinal Fusion Surgery: A Retrospective Study

Background

Degenerative lumbar scoliosis (DLS) patients undergoing posterior long-segment spinal fusion surgery often require perioperative blood transfusions, and previous studies have reported that increased complications and additional costs accompany these transfusions. One method for decreasing transfusions is the administration of tranexamic acid (TXA). We sought to evaluate the costs and benefits of preoperative administration of 1 g of intravenous TXA, without maintenance, in DLS patients undergoing long-segment spinal fusion surgery.

Material/Methods

Patients who received TXA (TXA group) were compared with patients who did not receive TXA (NTXA group) with regard to blood loss, units of packed red blood cells (PRBC) transfused, hemostasis costs, and perioperative complications. The benefits and costs were estimated through analysis of the spending on NTXA and TXA patients, and were compared. The difference between the cost per patient in the 2 groups was designated as the net cost-benefit. Then, both groups were substratified into non-osteotomy and osteotomy subgroups for further analysis.

Results

Of the 173 patients who met the inclusion criteria, 54 TXA patients had significantly reduced perioperative blood loss and total hemostasis costs compared with NTXA patients (n=119). In the group without osteotomy (n=72), TXA (n=13) reduced perioperative blood loss but did not significantly decrease PRBC units and hemostasis costs. However, in patients undergoing osteotomy (n=101), a remarkable net cost savings of ¥648.77 per patient was shown in the TXA group (n=41) (P<0.001). This was because patients undergoing osteotomy in the TXA group received fewer PRBC units (3.7 vs 5.7, P=0.001).

Conclusions

A single dose of TXA significantly decreased perioperative blood loss and total hemostasis costs for DLS patients undergoing osteotomy. Furthermore, TXA led to no additional net costs in patients without osteotomy.

Tranexamic acid for chronic subdural hematoma

BACKGROUND

There is no consensus on optimal treatment for a chronic subdural hematoma (cSDH). In patients with only moderate symptoms treatment with tranexamic acid (TXA) has been suggested. We report off-label use of TXA in seven patients.

METHODS

Between August 2016 and May 2018 we identified seven patients for primary conservative treatment with TXA until satisfactory clinical and radiological status was achieved. Primary outcome was surgery for cSDH evacuation. Radiological follow-up was performed at regular intervals for hematoma volume measurements.

RESULTS

Five patients experienced complete resolution of symptoms, one patient had a burr-hole craniostomy five days after initiation of TXA treatment due to an increase of left-sided weakness and dysarthria and in one patient symptoms did not improve. Median follow-up was 15 weeks (range 6-25, without the operated patient). The median total volume before start of treatment was 83 mL (range 11-137) for all patients. At the last follow-up, the median total volume in the non-operated patients decreased by 73% to 33 mL (range 0-77).

CONCLUSIONS

TXA could be considered as primary medical treatment in patients with a cSDH and mild symptoms. The results of current randomized clinical trials must be awaited.

Plasma Technology Reduces Blood Loss in Adolescent Idiopathic Scoliosis Surgery: A Prospective Randomized Clinical Trial

STUDY DESIGN

Prospective randomized clinical trial.

OBJECTIVES

To assess the effectiveness of PEAK Plasmablade (PPB), compared with bipolar sealer and standard electrocautery, in the posterior spinal instrumentation and fusion (PSF) surgery performed for adolescent idiopathic scoliosis (AIS).

METHODS

Ninety-three patients undergoing PSF surgery for AIS were randomized in 2 groups: group-A patients (n = 45) underwent PSF surgery using PPB; group-B patients (n = 48) were treated with bipolar sealer and standard electrocautery. Demographic and surgical data was recorded. All the patients underwent serial blood tests on the day before surgery (T0) and at 24 (T1), 48 (T2), 72 (T3), and 96 (T4) hours postoperatively. Visual analogue scale for pain (VAS) score, the percentage of paracetamol assumption, and the blood transfusion rate were recorded in the time-lapse T1 to T4. Intergroup variability was assessed. Pearson correlation test was performed. A P value <.05 was considered significant.

RESULTS

In group A, a significantly shorter total operative time (P = .0087), a significantly lower total intraoperative blood loss (TBL) (P = .001), and a higher postoperative hemoglobin (Hb) (P = .01) were recorded. A significant higher mean Hb concentration and mean albumin value was recorded in group A at 24 and 48 hours postoperatively. A significant correlation between TBL and hospital stay was recorded in both groups (group A, P = .00 001; group B, P = .00 006); moreover, in both groups, a significant correlation was observed between TBL and mean VAS at 72 hours postoperatively (group A, P = .0009; group B, P = .0001) and at 96 hours postoperatively (group A, P = .000 044; group B, P = .00 001).

CONCLUSIONS

PPB reduces the intraoperative blood loss in PSF performed for AIS, thus allowing a patient's faster recovery.

Clinical utility of enhanced recovery after surgery pathways in pediatric spinal deformity surgery: systematic review of the literature

OBJECTIVES

More than 7500 children undergo surgery for scoliosis each year, at an estimated annual cost to the health system of $1.1 billion. There is significant interest among patients, parents, providers, and payors in identifying methods for delivering quality outcomes at lower costs. Enhanced recovery after surgery (ERAS) protocols have been suggested as one possible solution. Here the authors conducted a systematic review of the literature describing the clinical and economic benefits of ERAS protocols in pediatric spinal deformity surgery.

METHODS

The authors identified all English-language articles on ERAS protocol use in pediatric spinal deformity surgery by using the following databases: PubMed/MEDLINE, Web of Science, Cochrane Reviews, EMBASE, CINAHL, and OVID MEDLINE. Quantitative analyses of comparative articles using random effects were performed for the following clinical outcomes: 1) length of stay (LOS); 2) complication rate; 3) wound infection rate; 4) 30-day readmission rate; 5) reoperation rate; and 6) postoperative pain scores.

RESULTS

Of 950 articles reviewed, 7 were included in the qualitative analysis and 6 were included in the quantitative analysis. The most frequently cited benefits of ERAS protocols were shorter LOS, earlier urinary catheter removal, and earlier discontinuation of patient-controlled analgesia pumps. Quantitative analyses showed ERAS protocols to be associated with shorter LOS (mean difference -1.12 days; 95% CI -1.51, -0.74; p < 0.001), fewer postoperative complications (OR 0.37; 95% CI 0.20, 0.68; p = 0.001), and lower pain scores on postoperative day (POD) 0 (mean -0.92; 95% CI -1.29, -0.56; p < 0.001) and POD 2 (-0.61; 95% CI -0.75, -0.47; p < 0.001). There were no differences in reoperation rate or POD 1 pain scores. ERAS-treated patients had a trend toward higher 30-day readmission rates and earlier discontinuation of patient-controlled analgesia (both p = 0.06). Insufficient data existed to reach a conclusion about cost differences.

CONCLUSIONS

The results of this systematic review suggest that ERAS protocols may shorten hospitalizations, reduce postoperative complication rates, and reduce postoperative pain scores in children undergoing scoliosis surgery. Publication biases exist, and therefore larger, prospective, multicenter data are needed to validate these results.

Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery

OBJECTIVE

Spine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate.

METHODS

Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care.

RESULTS

Of 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference -1.22 days [95% CI -1.98 to -0.47]) and lumbar spine ERAS protocols (-1.53 days [95% CI -2.89 to -0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use.

CONCLUSIONS

Present data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.

Perioperative and Anesthetic Considerations for Patients with Degenerative Spine Disease

The demand for spine surgery has dramatically increased over the last 2 decades. As the population ages and surgical and anesthetic techniques advance, the perioperative care of spine surgery patients poses challenges to anesthesiologists. Perioperative outcomes in terms of a decrease in complication rates and total health care expenditures have directed perioperative care to focus on enhanced recovery after surgery protocols, which many institutions have adopted. The role of anesthesiologists in the care of patients undergoing spine surgery is expanding beyond intraoperative care; consequently, a multidisciplinary approach is the best direction for optimal patient care.

Is There a Role for Preoperative Local Infiltration of Tranexamic Acid in Elective Spine Surgery? A Prospective Randomized Controlled Trial Analyzing the Efficacy of Intravenous, Local Infiltration, and Topical Administration of Tranexamic Acid

STUDY DESIGN

Randomized control trial.

OBJECTIVE

The purpose of the study is to evaluate the safety and efficacy of tranexamic acid in reducing blood loss when administered through various routes in instrumented spine surgeries.

METHODS

A total of 104 patients undergoing instrumented spine surgery were randomly assigned to 4 groups (n = 26 in each group). Groups included (1) ivTXA-intravenous administration of tranexamic acid (TXA) 1 hour prior to surgery, (2) loTXA-local infiltration of TXA bilaterally into the paraspinal musculature prior to incision, (3) tTXA-topical application of TXA just before wound closure, and (4) control group. Outcome measures included intraoperative blood loss, postoperative blood loss, need for blood transfusion, length of hospital stay, and hematological parameters.

RESULTS

All the 3 different modes of TXA administration were found to be effective in reducing blood loss in the treated groups compared with the control group. Intraoperative blood loss was significantly reduced in ivTXA (223.6 ± 40.1 mL, P < .0001) and loTXA (256.07 ± 119 mL, P = .0039) groups when compared with controls (344 ± 88.5 mL).The postoperative blood loss was least in tTXA followed by ivTXA, loTXA, and controls. There was 67% reduction in need for blood transfusion in tTXA group, 55.5% reduction in ivTXA group, and 33% reduction in loTXA group when compared with the control group.

CONCLUSION

In instrumented spine surgery, ivTXA and loTXA were found to be equally effective in reducing the intraoperative blood loss. The tTXA has better postoperative blood conserving effects. This is the first study to detail about safety and efficacy on local infiltration of TXA in spine surgery, which is an effective and safe method for reducing intraoperative blood loss.

A novel predictive model of intraoperative blood loss in patients undergoing elective lumbar surgery for degenerative pathologies

BACKGROUND CONTEXT

Intraoperative blood loss (IOBL) is unavoidable during surgery; however, high IOBL is associated with increased morbidity and increased risk for requiring allogenic blood transfusion, itself associated with poorer outcomes.

PURPOSE

Here we sought to develop and validate a predictive calculator for IOBL that could be used by surgeons to estimate likely blood loss.

STUDY DESIGN/SETTING

Retrospective cohort.

PATIENT SAMPLE

Series of consecutive patients who underwent elective lumbar spine surgery for degenerative pathologies over a 27-month period at a single tertiary care center.

OUTCOME MEASURES

Primary outcome was IOBL. Secondary outcome was the occurrence of "major intraoperative bleeding," defined as IOBL exceeding 1 L.

METHODS

Charts of included patients were reviewed for medical comorbidities, preoperative laboratory data, surgical plan, and anesthesia records. Univariate linear regressions were performed to find significant predictors of IOBL, which were then subjected to a multivariate analysis to identify the final model. Model training was performed using 70% of the included cohort and external validation was performed using 30% of the cohort. Results of the model were deployed as a freely available online calculator.

RESULTS

We identified 1,281 patients who met inclusion/exclusion criteria. Mean age was 60±15 years, mean Charlson Comorbidity score was 1.1±1.6, and 51.8% were male. There were no significant differences between the training and validation cohorts with regard to any of the demographic variables or intraoperative variables; tranexamic acid use and surgical invasiveness were also similar in both cohorts. Multivariate analysis identified body mass index (βₙ=7.14; 95% confidence interval [3.15, 11.13]; p<.001), surgical invasiveness (βₙ=29.18; [24.62, 33.74]; p<.001), tranexamic acid use (βₙ=-0.093; [-0.171, -0.014]; p=.02), and surgical duration (βₙ=2.13; [1.75, 2.51]; p<.001) as significant predictors of IOBL. The model had an overall fit of r=0.693 in the validation cohort. Construction of a receiver-operating curve for predicting major IOBL showed a C-statistic of 0.895 within the validation cohort.

CONCLUSION

Here we identify and validate a model for predicting IOBL in patients undergoing lumbar spine surgery. The model was a moderately strong predictor of absolute IOBL and was demonstrated to predict the occurrence of major IOBL with a high degree of accuracy. We propose it may have future utility when counseling patients about surgical morbidity and the probability of requiring transfusion.

[Progress on the application of tranexamic acid in adolescent spine corrective surgery]

OBJECTIVE

To review the advances in the application of tranexamic acid (TXA) in adolescent spinal corrective surgery.

METHODS

The mechanism of action and pharmacokinetic, effectiveness, dosage, safety as well as methods of administration were comprehensively summarized by consulting domestic and overseas related literature about the application of TXA in adolescent spinal corrective surgery in recent years.

RESULTS

TXA efficaciously reduce intraoperative blood loss, transfusion rate and volume, postoperative drainage volume in adolescent spinal corrective surgery. At present, the most common method of administration in adolescent spinal corrective surgery is that a loading dose is given intravenously before skin incision or induction of anesthesia, followed by a maintenance dose until the end of the surgery. The range of loading dose and maintenance dose is 10-100 mg/kg and 1-10 mg/(kg·h), respectively. No drug related adverse event has been reported in this range.

CONCLUSION

The effectiveness and safety of TXA in adolescent spinal surgery have been basically confirmed. However, further studies are needed to determine the optimal dosage, method of administration as well as whether it could reduce blood loss after surgery.

Comparison of Blood-Conserving and Allogenic Transfusion-Sparing Effects of Antifibrinolytics in Scoliosis Correction Surgery

Background:

Intraoperative antifibrinolytic drug administration is a safe and effective method of reducing blood loss and allogenic transfusions in patients undergoing spine deformity correction.

Aim:

This study aimed to compare the effectiveness of two antifibrinolytic drugs tranexamic acid (TXA) and epsilon amino caproic acid (EACA) in reducing peri-operative blood loss and transfusion requirements against a placebo control in patients with idiopathic scoliosis undergoing correction surgery.

Setting and Design:

This is a prospective, randomized, double-blinded, controlled comparative study.

Methodology:

Patients in TXA group received 50 mg.kg⁻¹ bolus and 10 mg.kg⁻¹.h⁻¹ infusion as against 100 mg.kg⁻¹ and 10 mg.kg⁻¹.h⁻¹ infusion in EACA group. The placebo group had saline bolus and infusion. Parameters observed included baseline demographic and deformity data, duration of surgery, total peri-operative blood loss, and allogenic packed red cell transfusion requirements.

Statistical Analysis:

Mean and standard deviation were used to represent the quantitative continuous data, and percentage was used to represent categorical data. The Student's t-test and ANOVA were used to compare means between groups. Bonferroni's multiple comparison test was used to find out the association between categorical variables.

Results:

A total of 36 patients were enrolled with 12 patients in each group. Peri-operative blood loss was 50.1% lower in patients receiving TXA and 17.7% lower in patients receiving EACA compared with the placebo group. The volume of total packed red cell transfusion was 66.7% lower in patients receiving TXA and 45.6% lower in patients receiving EACA compared with placebo.

Conclusion:

TXA was more effective in reducing total peri-operative blood loss and allogenic transfusion requirement in idiopathic scoliosis correction surgery compared to EACA.

[Efficacy and safety of tranexamic acid sequential rivaroxaban on blood loss in elderly patients during lumbar interbody fusion]

OBJECTIVE

To investigate the effect and safety of tranexamic acid sequential rivaroxaban on perioperative blood loss and preventing thrombosis for elderly patients during lumbar interbody fusion (LIF) with a prospective randomized controlled study.

METHODS

Between April and October 2019, the elderly patients with lumbar degenerative diseases requiring LIF were included in the study, among which were 80 patients met the selection criteria. According to the antifibrinolysis and anticoagulation protocols, they were randomly divided into a tranexamic acid sequential rivaroxaban group (trial group) and a simple rivaroxaban group (control group) on average. Finally, 69 patients (35 in the trial group and 34 in the control group) were included for comparison. There was no significant difference in general data ( P>0.05) such as gender, age, body mass index, disease duration, diseased segment, type of disease, and preoperative hemoglobin between the two groups. The operation time, intraoperative blood loss, drainage within 3 days after operation, perioperative total blood loss, and proportion of blood transfusion patients were compared between the two groups, as well as postoperative venous thrombosis of lower extremities, pulmonary embolism, and bleeding-related complications.

RESULTS

The operations of the two groups completed successfully, and there was no significant difference in the operation time ( P>0.05); the intraoperative blood loss, drainage within 3 days after operation, and perioperative total blood loss in the trial group were significantly lower than those in the control group ( P<0.05). The proportion of blood transfusion patients in the trial group was 25.71% (9/35), which was significantly lower than that in the control group [52.94% (18/34)] ( χ 2=5.368, P=0.021). Postoperative incision bleeding occurred in 4 cases of the trial group and 3 cases of the control group, and there was no significant difference in bleeding-related complications between the two groups ( P=1.000). There was 1 case of venous thrombosis of the lower extremities in each group after operation, and there was no significant difference in the incidence between the two groups ( P=1.000). Besides, no pulmonary embolism occurred in the two groups.

CONCLUSION

Perioperative use of tranexamic acid sequential rivaroxaban in elderly LIF patients can effectively reduce the amount of blood loss and the proportion of blood transfusion patients without increasing the risk of postoperative thrombosis.

Cost-benefit analysis of tranexamic acid and blood transfusion in elective lumbar spine surgery for degenerative pathologies

OBJECTIVE

Blood transfusions are given to approximately one-fifth of patients undergoing elective lumbar spine surgery, and previous studies have shown that transfusions are accompanied by increased complications and additional costs. One method for decreasing transfusions is administration of tranexamic acid (TXA). The authors sought to evaluate whether the cost of TXA is offset by the decrease in blood utilization in lumbar spine surgery patients.

METHODS

The authors retrospectively reviewed patients who underwent elective lumbar or thoracolumbar surgery for degenerative conditions at a tertiary care center between 2016 and 2018. Patients who received intraoperative TXA (TXA patients) were matched with patients who did not receive TXA (non-TXA patients) by age, sex, BMI, ASA (American Society of Anesthesiologists) physical status class, and surgical invasiveness score. Primary endpoints were intraoperative blood loss, number of packed red blood cell (PRBC) units transfused, and total hemostasis costs, defined as the sum of TXA costs and blood transfusion costs throughout the hospital stay. A subanalysis was then performed by substratifying both cohorts into short-length (1-4 levels) and long-length (5-8 levels) spinal constructs.

RESULTS

Of the 1353 patients who met inclusion criteria, 68 TXA patients were matched to 68 non-TXA patients. Patients in the TXA group had significantly decreased mean intraoperative blood loss (1039 vs 1437 mL, p = 0.01). There were no differences between the patient groups in the total costs of blood transfusion and TXA (p = 0.5). When the 2 patient groups were substratified by length of construct, the long-length construct group showed a significant net cost savings of $328.69 per patient in the TXA group (p = 0.027). This result was attributable to the finding that patients undergoing long-length construct surgeries who were given TXA received a lower amount of PRBC units throughout their hospital stay (2.4 vs 4.0, p = 0.007).

CONCLUSIONS

TXA use was associated with decreased intraoperative blood loss and significant reductions in total hemostasis costs for patients undergoing surgery on more than 4 levels. Furthermore, the use of TXA in patients who received short constructs led to no additional net costs. With the increasing emphasis put on value-based care interventions, use of TXA may represent one mechanism for decreasing total care costs, particularly in the cases of larger spine constructs.

The efficacy and safety of multiple-dose intravenous tranexamic acid in reducing perioperative blood loss in patients with thoracolumbar burst fracture

OBJECTIVE

To evaluate the efficacy and safety of tranexamic acid (TXA) for single-segment thoracolumbar burst fracture without neurologic injury underwent pedicle screw fixation via Wiltse approach.

PATIENTS AND METHODS

We identified 264 patients with single-segment thoracolumbar burst fracture without neurologic injury underwent pedicle screw fixation via Wiltse approach (January 2016-June 2019) at a single center. The cohort was separated into three groups. Group A received 20 mg/kg TXA at 5 min before skin incision and 16 h after first dose; Group B received 20 mg/kg TXA at 5 min before skin incision; Group C received NS at each same time point. The outcomes were evaluated by hidden blood loss (HBL), total blood loss (TBL), intraoperative blood loss (IBL), transfusion rate, maximum hemoglobin (Hb) drop, prethrombotic state molecular markers, liver and renal function, coagulation function, inflammatory factor and adverse events.

RESULTS

The HBL, TBL and maximum Hb drop were significantly lower in Group A than those of Group B and Group C, while the difference between Group B and Group C was statistically significant. The IBL was significantly lower in Group A and Group B than that of Group C. However, there was no significantly difference among the three groups in live and renal function, coagulation function, prethrombotic state molecular markers, transfusion rate and complications during the perioperative period. There was significantly lower level of interleukin-6 (IL-6) in Group A than Group C at the day after surgery, and lower level of C-reactive protein (CRP) at the third day after surgery.

CONCLUSIONS

Intravenous TXA used in the treatment of thoracolumbar burst fracture underwent pedicle screw fixation via Wiltse approach is effective and safe in decreasing perioperative blood loss. The two-dose TXA regimen can further reduce blood loss and alleviate post-operative inflammation response, without affecting prethrombotic state molecular marks and without increasing the risk of complications.

Efficacy and Safety of Tranexamic Acid in Reducing Blood Loss of Lower Extremity Osteotomy in Peri-acetabulum and High Tibia: A Systematic Review and Meta-analysis

Objective

To assess the efficacy of tranexamic acid (TXA) in reducing total blood loss and transfusion, and the risk of thromboembolic events in patients undergoing periacetabular osteotomy (PAO) and high tibial osteotomy (HTO).

Methods

A systematic literature search was performed using PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Embase (Ovid), Medline (Ovid), and Web of Science. ClinicalTrials.gov, American Academy of Orthopaedic Surgeons (AAOS), and Orthopaedic Trauma Association (OTA) conference proceedings were also searched to gain more eligible studies. The primary outcome measure was total blood loss and the blood transfusion rate of the TXA group versus control. The meta‐analysis was conducted using the RevMan 5.3 and Stata 14.0 software.

Results

A total of six studies were included involving 665 patients. Three studies were PAO, and the other three were HTO. The total blood loss in PAO (WMD, −330.49; 95% CI, −390.16 to −270.83; P < 0.001) and HTO (WMD, −252.50; 95% CI, −356.81 to −148.18; P < 0.001) and hemoglobin decline (WMD, −0.74; 95% CI, −1.09 to −0.38; P < 0.001) were significantly less in the TXA group than in the control group. TXA could reduce transfusion rates in PAO (RR, 0.26; 95% CI, 0.09 to 0.75; P = 0.01) but had no effect on HTO (RR, 0.20; 95% CI, 0.01 to 4.10; P = 0.30). The wound complications (RR, 0.62; 95% CI, 0.13 to 2.94; P = 0.54) had no significant difference between TXA and control groups.

Conclusions

This meta‐analysis demonstrated that TXA reduces total blood loss and hemoglobin decline in patients undergoing PAO and is safe, but it has little benefit in regard to reducing transfusion rates or wound complications in HTO, so TXA might be unwarranted for routine use for HTO.

Reducing Allogenic Blood Transfusion in Pediatric Scoliosis Surgery:: Reporting 15 Years of a Multidisciplinary, Evidence-Based Quality Improvement Project

STUDY DESIGN

Retrospective review of prospectively collected spinal surgery and transfusion databases.

OBJECTIVES

To evaluate the efficacy of a care pathway developed at our institution since 2003 with a focus on reducing the need for blood transfusions in children undergoing scoliosis correction surgery. The care pathway includes nurse-led clinics facilitating preoperative hemoglobin optimization, intraoperative cell salvage, the use of tranexamic acid, and a transfusion criteria awareness program.

METHODS

Retrospective review of our institution's prospectively recorded spinal surgery and transfusion databases including all cases of scoliosis surgery in patients 18 years and younger between 2001 and 2015.

RESULTS

A total of 1039 procedures were included in the analysis. Overall, 24.4% of patients received a transfusion. The proportion of patients transfused was 89.2% in 2001-2003, 39.6% in 2004-2006, 16.5% in 2007-2009, 15.6% in 2010-2012, and 20.1% in 2013-2015. The volume of blood products transfused in those undergoing transfusion was 9.1 units in 2001-2003, 4.8 units in 2004-2006, 5.0 units in 2007-2009, 2.3 units in 2010-2012, and 2.1 units in 2013-2015. A multivariate logistic regression demonstrated adjusted odds ratios for the probability of receiving any transfusion of 5.45 (95% confidence interval 3.62-8.11) for patients with neuromuscular diagnoses and 11.17 (5.02-24.86) for those undergoing combined anterior and posterior surgical approach.

CONCLUSIONS

We have demonstrated over a 15-year period that the introduction of a multifaceted, multidisciplinary pathway can dramatically and sustainably reduce the need for blood transfusions and their attendant risks in pediatric scoliosis surgery. This data lends weight to the adoption of such a care pathway in pediatric scoliosis surgery.

Efficacy and safety of tranexamic acid usage in patients undergoing posterior lumbar fusion: a meta-analysis

Background

The purpose of this meta-analysis is to evaluate the efficacy and safety of tranexamic acid (TXA) for patients with degenerative lumbar disc herniation, stenosis or instability undergoing posterior lumbar fusion (PLF) surgery.

Methods

We searched PubMed, Embase, and Cochrane Library until May 1, 2018. Two reviewers selected studies, assessed quality, extracted data, and evaluated the risk of bias independently. Weighted mean difference (WMD) and relative risk (RR) were calculated as the summary statistics for continuous data and dichotomous data, respectively. We chose fixed-effects or random-effects models based on I² statistics. RevMan 5.0 and STATA 14.0 software were used for data analysis.

Results

Nine studies enrolling 713 patients for the study. The pooled outcomes demonstrated that TXA can decrease total blood loss (TBL) in patients underwent PLF surgery [WMD = -250.68, 95% CI (− 325.06, − 176.29), P<0.001], intraoperative blood loss (IBL) [WMD = -72.57, 95% CI (− 103.94, − 41.20), P<0.001], postoperative blood loss (PBL) [WMD = -127.57, 95% CI (− 149.39, − 105.75), P<0.001], and the loss of hemoglobin (Hb) in postoperative 24 h [WMD = -0.31, 95% CI (− 0.44, − 0.18), P<0.001]. However, there is no significant difference between two groups in transfusion rate [RR =0.34, 95% CI (0.09, 1.28), P = 0.11], and none thrombotic event was happened in the two groups.

Conclusion

Our meta-analysis demonstrated that TXA can decrease the Hb loss, TBL, IBL, PBL, and without increasing the risk of thrombotic event in patients with degenerative lumbar disc herniation, stenosis or instability underwent PLF surgery. However, there was no significant difference in blood transfusion rates between the two groups.

Efficacy and safety of antifibrinolytic agents in spinal surgery: a network meta-analysis

Background:

Significant blood loss is still one of the most frequent complications in spinal surgery, which often necessitates blood transfusion. Massive perioperative blood loss and blood transfusion can create additional risks. Aprotinin, tranexamic acid (TXA), and epsilon-aminocaproic acid (EACA) are antifibrinolytics currently offered as prophylactic agents to reduce surgery-associated blood loss. The aim of this study was to evaluate the efficacy and safety of aprotinin, EACA, and low/high doses of TXA in spinal surgery, and assess the use of which agent is the most optimal intervention using the network meta-analysis (NMA) method.

Methods:

Five electronic databases were searched, including PubMed, Cochrane Library, ScienceDirect, Embase, and Web of Science, from the inception to March 1, 2018. Trials that were randomized and compared results between TXA, EACA, and placebo were identified. The NMA was conducted with software R 3.3.2 and STATA 14.0.

Results:

Thirty randomized controlled trial (RCT) studies were analyzed. Aprotinin (standardized mean difference [SMD]=−0.65, 95% credibility intervals [CrI;−1.25, −0.06]), low-dose TXA (SMD = −0.58, 95% CrI [−0.92, −0.25]), and high-dose TXA (SMD = −0.70, 95% CrI [−1.04, −0.36]) were more effective than the respective placebos in reducing intraoperative blood loss. Low-dose TXA (SMD = −1.90, 95% CrI [−3.32, −0.48]) and high-dose TXA (SMD = −2.31, 95% CrI [−3.75, −0.87]) had less postoperative blood loss. Low-dose TXA (SMD = −1.07, 95% CrI [−1.82, −0.31]) and high-dose TXA (SMD = −1.07, 95% CrI [−1.82, −0.31]) significantly reduced total blood loss. However, only high-dose TXA (SMD = −2.07, 95% CrI [−3.26, −0.87]) was more effective in reducing the amount of transfusion, and was significantly superior to low-dose TXA in this regard (SMD = −1.67, 95% CrI [−3.20, −0.13]). Furthermore, aprotinin (odds ratio [OR] = 0.16, 95% CrI [0.05, 0.54]), EACA (OR = 0.46, 95% CrI [0.22, 0.97]) and high dose of TXA (OR = 0.34, 95% CrI [0.19, 0.58]) had a significant reduction in transfusion rates. Antifibrinolytics did not show a significantly increased risk of postoperative thrombosis. Results of ranking probabilities indicated that high-dose TXA had the greatest efficacy and a relatively high safety level.

Conclusions:

The antifibrinolytic agents are able to reduce perioperative blood loss and transfusion requirement during spine surgery. And the high-dose TXA administration might be used as the optimal treatment to reduce blood loss and transfusion.

Evolution in Surgical Approach, Complications, and Outcomes in an Adult Spinal Deformity Surgery Multicenter Study Group Patient Population

STUDY DESIGN

Retrospective review of a prospectively collected multicenter database.

OBJECTIVES

To evaluate the evolution of surgical treatment strategies, complications, and patient-reported outcomes for adult spinal deformity (ASD) patients.

SUMMARY OF BACKGROUND DATA

ASD surgery is associated with high complication rates. Evolving treatment strategies may reduce these risks.

METHODS

Adult patients undergoing ASD surgery from 2009 to 2016 were analyzed (n = 905). Preoperative and surgical parameters were compared across years. Subgroup analysis of 436 patients with minimum two-year follow-up was also performed.

RESULTS

From 2009 to 2016, there was a significant increase in the mean preoperative age (52 to 63.1, p < .001), body mass index (26.3 to 32.2, p = .003), Charlson Comorbidity index (1.4 to 2.2, p < .001), rate of previous spine surgery (39.8% to 53.1%, p = .01), and baseline disability (visual analog scale [VAS] back and leg pain) scores (p < .01), Oswestry Disability Index, and 22-item Scoliosis Research Society Questionnaire scores (p < .001). Preoperative Schwab sagittal alignment modifiers and overall surgical invasiveness index were similar across time. Three-column osteotomy utilization decreased from 36% in 2011 to 16.7% in 2016. Lateral lumbar interbody fusion increased from 6.4% to 24.1% (p = .004), anterior lumbar interbody fusion decreased from 22.9% to 16.7% (p = .043), and transforaminal lumbar interbody fusion/posterior lumbar interbody fusion utilization remained similar (p = .448). Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in 2012 was 84.6%, declined to 58% in 2013, and rebounded to 76.3% in 2016 (p = .006). Tranexamic acid use increased rapidly from 2009 to 2016 (13.3% to 48.6%, p < .001). Two-year follow-up sagittal vertical axis, pelvic tilt, pelvic incidence-lumbar lordosis, and maximum Cobb angles were similar across years. Intraoperative complications decreased from 33% in 2010 to 9.3% in 2016 (p < .001). Perioperative (<30 days, <90 days) complications peaked in 2010 (42.7%, 46%) and decreased by 2016 (24.1%, p < .001; 29.6%, p = .007). The overall complication rate decreased from 73.2% in 2008-2014 patients to 62.6% in 2015-2016 patients (p = .03). Two-year health-related quality of life outcomes did not significantly differ across the years (p > .05).

CONCLUSIONS

From 2009 to 2016, despite an increasingly elderly, medically compromised, and obese patient population, complication rates decreased. Evolving strategies may result in improved treatment of ASD patients.

LEVEL OF EVIDENCE

Level IV.

Antifibrinolytic agents for paediatric scoliosis surgery: a systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis of randomised controlled trials.

OBJECTIVE

The purpose of this study is to perform a systematic review and meta-analysis of antifibrinolytic agents for paediatric spine surgery.

BACKGROUND

Bleeding is an important consideration in paediatric scoliosis surgery; blood loss leads directly to higher morbidity and mortality. Antifibrinolytics are an attractive non-invasive method of reducing bleeding as evidenced in arthroplasty, cardiac surgery and adult scoliosis surgery.

METHODS

A thorough database search of Medline, PubMed, EMBASE and Cochrane was performed according to PRISMA guidelines, and a systematic review was performed.

RESULTS

Five randomised controlled trials were identified in this meta-analysis, consisting of a total of 285 spine surgery patients with subgroups of tranexamic acid (n = 101), epsilon aminocaproic acid (n = 61) and control (n = 123). This meta-analysis found that antifibrinolytics lead to statistically significant reductions in peri-operative blood loss (MD - 379.16, 95% CI [- 579.76, - 178.57], p < 0.001), intra-operative blood loss (MD - 516.42, 95% CI [- 1055.58, 22.74], p < 0.001), reduced fresh frozen plasma requirements (MD - 307.77, 95% CI [- 369.66, - 245.88], p < 0.001) and reduced post-operative blood loss (MD -  185.95, 95% CI [- 336.04, - 35.87], p = 0.02).

CONCLUSION

This meta-analysis concludes that antifibrinolytics lead to statistically significant reductions in peri-operative blood loss, intra-operative blood loss, reduced fresh frozen plasma requirements and reduced post-operative blood loss with TXA. These slides can be retrieved under Electronic Supplementary Material.

Can tranexamic acid conserve blood and save operative time in spinal surgeries? A meta-analysis

BACKGROUND CONTEXT

It is widely accepted that tranexamic acid (TXA) effectively reduces blood losses and transfusions in major surgeries. However, limited studies investigated the role of TXA in conserving blood and saving operative time in spine surgeries.

PURPOSE

This meta-analysis was conducted to gather scientific evidence for TXA efficacy on conserving blood and saving operative time in spine surgeries.

STUDY DESIGN

A meta-analysis was performed.

PATIENT SAMPLE

Eighteen RCTs and 18 non-RCT studies involving 2,572 patients were included in the final analyses, comparing the effectiveness of intravenous TXA with a placebo/no treatment group.

OUTCOME MEASURES

Outcomes of interest included intraoperative, postoperative, and perioperative blood losses, allogeneic blood transfusion rates, cell salvage transfusion amounts, operative time, and the number of postoperative thrombosis events.

METHODS

An exhaustive literature search was conducted in the MEDLINE and EMBASE databases from January 2000 through March 2017. Meta-analysis was performed using Review Manager (RevMan) version 5.0. For continuous outcomes, the means and standard deviations were pooled to a mean difference and 95% confidence interval (CI). Odds ratios (OR) and 95% CI were calculated for dichotomous outcomes. The quantity of heterogeneity was assessed using I² statistics. When there was no statistical evidence of substantial heterogeneity (I²≤50%), a fixed-effect model was adopted; otherwise, a random-effect model was chosen. Subgroup analysis was performed when more than three studies were included on one issue, based on low or high the dose of TXA. Beijing Talent Fund (2016) was received to support this work.

RESULTS

Significantly reduced intraoperative (weighted mean difference [WMD]=-280.09.00, p<.00001), postoperative (WMD=-120.15, p<.00001), perioperative (WMD=-310.86, p<.00001) blood losses, cell salvage transfusion amount (WMD=-471.79, p=.01), perioperative transfusion rate (odds ratio [OR], 0.33 [0.17, 0.65], p=.001), and operative time (WMD=-4.69, p=.003) were observed in TXA group. Furthermore, subgroup analysis revealed that high-dose TXA could reduce both intraoperative-perioperative allogeneic transfusion rates and operative time, whereas low dose of the drug does not convey such effects.

CONCLUSIONS

With the most comprehensive literature inclusion up to the present, this meta-analysis suggests that intravenous TXA use constitutes an important measure for conserving blood and saving operative time in spinal surgeries. High-dose TXA significantly reduces intraoperative-perioperative allogeneic transfusion rates and operative time, whereas low-dose TXA does not convey such efficacies. Larger prospective trials are still required to define the optimal regimen and to confirm the safety of TXA use in such surgeries.

The efficacy and safety of topical administration of tranexamic acid in spine surgery: a meta-analysis

BACKGROUND

We conducted a meta-analysis from randomized controlled trials (RCTs) and non-RCTs to assess the efficacy and safety of tranexamic acid (TXA) in spine surgery.

METHODS

Potentially relevant academic articles were identified from the Cochrane Library, MEDLINE (1966-2017.11), PubMed (1966-2017.11), Embase (1980-2017.11), and ScienceDirect (1985-2017.11). Secondary sources were identified from the references of the included literature. The pooled data were analyzed using RevMan 5.1.

RESULTS

Three RCTs and one non-RCT met the inclusion criteria. There were significant differences in total blood loss (MD = - 267.53, 95% CI - 373.04 to - 106.02, P < 0.00001), drainage volume (MD = - 157.00, 95% CI - 191.17 to - 122.84, P < 0.00001), postoperative hemoglobin level (MD = 0.95, 95% CI 0.44 to 1.47, P = 0.0003), and length of hospital stay (MD = - 1.42, 95% CI - 1.92 to - 0.93, P < 0.00001). No significant differences were found regarding transfusion requirement, deep vein thrombosis (DVT), pulmonary embolism (PE), wound hematoma, and infection between the two groups.

CONCLUSIONS

The present meta-analysis indicated that the topical application of TXA in spinal surgery decreases the total blood loss and drainage volume and preserves higher postoperative hemoglobin level without increasing the risk of DVT infection, hematoma, DVT, and PE.