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

Enhanced Recovery After Surgery Protocol in Patients With Adult Spinal Deformity: A Systematic Review and Meta-Analysis

Study DesignSystematic review and meta-analysis.ObjectivesPerioperative interventions in Enhanced recovery after surgery (ERAS) protocols for managing adult spinal deformity (ASD) patients vary widely across institutions without widespread standardization. This study aims to evaluate the various interventions performed in ERAS protocols and the impact of these protocols on postoperative outcomes following ASD surgery.MethodsA comprehensive systematic review was conducted following PRISMA guidelines. Studies that addressed the implementation of ERAS protocol for thoraco-lumbar corrective surgery were included. We conducted a meta-analysis on postoperative outcomes, where possible, calculating the pooled standardized mean difference between conventional care (pre-ERAS) and ERAS pathways (post-ERAS).ResultsOut of 63 articles, 8 were included in the systematic review. Common interventions in the ERAS protocols included: (1) preoperative anesthesia-related risk assessment and multidisciplinary assessment, (2) intraoperative tranexamic acid (TXA) administration and continuous monitoring of lab data, and (3) postoperative early mobilization and early nutritional support. Multimodal analgesia plans were commonly observed in many of the ERAS protocols. Although meta-analysis demonstrated no significant difference in length of stay (LOS) between the groups, the post-ERAS group generally tended to exhibit lower rates of readmission and medical complications, and reductions in total opioid consumption.ConclusionsThe goals of ERAS protocols for ASD surgery often address preoperative optimization, intraoperative stress minimization, and postoperative recovery facilitation. While the implementation of the ERAS protocol has shown improvements in postoperative outcomes, further studies are required to standardize the ERAS protocol for ASD surgery and enhance the impact on multiple postoperative outcomes.

The Statistical Fragility of Tranexamic Acid in Spinal Surgery: A Systematic Review of Randomized Controlled Trials

STUDY DESIGN

Systematic review.

OBJECTIVE

To evaluate the statistical robustness of TXA use in spine surgery as a potential contributor to controversies in this field.

SUMMARY OF BACKGROUND DATA

Tranexamic acid (TXA) is an antifibrinolytic medication administered during spinal surgery to limit blood loss. Existing randomized controlled trials (RCTs) on the efficacy of TXA contain varied results, particularly when reporting outcomes related to blood transfusion rates and thromboembolic events. By calculating the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ), statistical robustness was quantified and compared across all included RCTs.

METHODS

PubMed, Embase, and MEDLINE were systematically searched for recent RCTs (January 1, 2000-August 1, 2023) assessing TXA use in patients undergoing spine surgery. The FI and rFI were calculated for each outcome, representing the number of event reversals required to alter statistical significance for significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI/rFI by the study sample size.

RESULTS

Of the 297 RCTs screened, 31 studies were included for analysis, yielding 80 dichotomous outcomes. Across these outcomes, the median FI (mFI) was 5.0, with an associated median FQ (mFQ) of 0.060. Nine outcomes were statistically significant (mFQ=0.018), and 71 were nonsignificant (mFQ=0.064). The most common outcome categories included blood/platelet transfusions (38 outcomes), thromboembolic events (15 outcomes), and other adverse events (27 outcomes), resulting in mFQs of 0.056, 0.049, and 0.064, respectively.

CONCLUSIONS

Outcomes examining TXA in spinal surgery demonstrated statistical fragility, with significant and thromboembolic outcomes proving the most fragile. Among all outcomes, there was a lack of significant results. To better guide future research on TXA use in spine surgery, this study recommends RCTs report fragility statistics along with P values and include these metrics when proposing clinical implications.

LEVEL OF EVIDENCE

Level III.

Application of high-dose tranexamic acid in the perioperative period: a narrative review

Objective

To investigate the efficacy and safety of high-dose tranexamic acid in different types of surgeries and provide a reference for clinical practice.

Methods

We systematically searched PubMed, Cochrane Library, Science, Embase, and CNKI databases, from their inception to January 2025, to include representative literature related to high-dose tranexamic acid in the perioperative period for a thematic synthesis. The analysis focused on clinical evidence related to obstetric, cardiac, urologic, orthopedic, and spinal surgeries.

Results

High-dose tranexamic acid markedly reduces blood loss and transfusion requirements in most types of surgery; however, the optimal dose varies by surgery type. Available studies have shown a favorable safety profile; however, some areas (e.g., cardiac surgery) still require careful monitoring for seizures and risk of thrombotic events.

Conclusion

The clinical benefit of high-dose tranexamic acid should be assessed based on surgical characteristics and patient individualization. More multicenter studies are needed to clarify the dose-effect relationship and long-term safety.

Tranexamic acid in hip and spine surgery for children with cerebral palsy - a PRISMA-compliant scoping review

Many children with cerebral palsy (CP) are frail and require major hip and/or spine surgeries associated with substantial blood loss. Tranexamic acid (TXA) is commonly used to reduce blood loss, but there is uncertainty around the optimal dose and timing of administration. There have been reviews in sub-populations and specific dosing regimens, but a broad overview of the available literature is lacking. The aim of this review was to map available evidence on TXA in hip and spine surgery for children with CP. Given the heterogeneous literature, a prospectively registered scoping review was conducted. Eligibility criteria were broad. Three screeners were involved, with the senior author consulted when disagreements were not resolved through discussion.Titles and abstracts of 14,609 records were screened, with 52 records included. Two additional records were obtained from grey literature and citation searching. Cohort studies (50.0%) were the most common. Most records (76.9%) were on spine surgery. TXA dose varied widely. Loading doses range from 5 to 100 mg/kg and intraoperative infusions from 1 to 10 mg/kg/h. Dose was not reported in 35.2% of records. Primary outcome measures included blood loss and transfusion requirements. TXA was generally reported to be safe. None of the included records reported postoperative TXA administration.While TXA is generally considered safe, there was mixed evidence on efficacy. Much of the evidence was drawn from studies in which TXA was used in patients at higher risk of bleeding or with reduced physiological reserve. There was no evidence for TXA being used postoperatively, when a large proportion of transfusions occur.

Efficacy of high-dose versus low-dose tranexamic acid for reduction of blood loss in adolescent idiopathic scoliosis surgery: A systematic review and meta-analysis

Background

Recent studies have suggested that high-dose tranexamic acid (TXA) may be an effective method for reducing blood loss during adolescent idiopathic scoliosis (AIS) surgery. This study aims to perform a systematic review and meta-analysis to compare the outcomes of high-dose versus low-dose TXA for AIS surgery.

Methods

Searches were conducted in major databases such as PubMed, Scopus, Google Scholar, and Cochrane Library for relevant studies comparing high-dose and low-dose TXA outcomes in terms of blood loss, red blood cell transfusions, and hemoglobin changes. This systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and registered with PROSPERO (CRD42024547735).

Results

Four studies were included, published between 2009 and 2022, encompassing a total of 531 patients. High-dose TXA showed less blood loss compared to low-dose TXA, with a pooled mean difference of -0.40 (95% CI, -0.79--0.01). Neither the volume of blood products used nor the decrease in hemoglobin levels showed significant differences between the groups.

Conclusion

High-dose TXA appears to be more effective in reducing blood loss during AIS surgery compared to low-dose TXA. Further robust clinical trials with larger sample sizes are necessary to confirm these results and establish optimal dosing regimens for maximizing efficacy while ensuring safety.

The Impact of Tranexamic Acid on Blood Loss Management in Primary Total Knee Arthroplasty: A Comprehensive Review

Total knee arthroplasty (TKA) is a widely performed surgical procedure to restore function and relieve pain in patients with advanced knee arthritis. One of the key challenges in TKA is managing perioperative blood loss, which can lead to complications such as postoperative anemia and the need for blood transfusions. Tranexamic acid (TXA), an antifibrinolytic agent, has shown promising results in reducing blood loss and transfusion requirements in various surgical settings, including TKA. This comprehensive review synthesizes current evidence regarding the efficacy and safety profile of TXA in primary TKA. Mechanistically, TXA functions by inhibiting the breakdown of fibrin clots, promoting hemostasis, and minimizing blood loss. Clinical studies evaluating TXA in TKA have consistently demonstrated significant reductions in blood loss parameters, including total blood loss, postoperative drain output, and transfusion rates. Key findings highlight the efficacy of TXA across different dosing regimens and administration routes, with minimal associated risks of thromboembolic events or adverse effects. Comparative analyses with other blood conservation strategies underscore TXA's superiority in reducing transfusion requirements and its cost-effectiveness in clinical practice. The review also discusses current clinical guidelines and recommendations for TXA use in TKA, emphasizing optimal dosing strategies and patient selection criteria. Future research directions include exploring the long-term outcomes of TXA administration and its impact on functional recovery, and refining protocols to enhance its efficacy and safety further. In conclusion, TXA represents a valuable adjunct in blood loss management during primary TKA, offering substantial benefits in patient outcomes, healthcare resource utilization, and cost-effectiveness. Continued research efforts are warranted to optimize its use and expand its applicability in orthopedic surgery.

Unravelling the Antifibrinolytic Mechanism of Action of the 1,2,3-Triazole Derivatives

A new family of antifibrinolytic drugs has been recently discovered, combining a triazole moiety, an oxadiazolone, and a terminal amine. Two of the molecules of this family have shown activity that is greater than or similar to that of tranexamic acid (TXA), the current antifibrinolytic gold standard, which has been associated with several side effects and whose use is limited in patients with renal impairment. The aim of this work was to thoroughly examine the mechanism of action of the two ideal candidates of the 1,2,3-triazole family and compare them with TXA, to identify an antifibrinolytic alternative active at lower dosages. Specifically, the antifibrinolytic activity of the two compounds (1 and 5) and TXA was assessed in fibrinolytic isolated systems and in whole blood. Results revealed that despite having an activity pathway comparable to that of TXA, both compounds showed greater activity in blood. These differences could be attributed to a more stable ligand-target binding to the pocket of plasminogen for compounds 1 and 5, as suggested by molecular dynamic simulations. This work presents further evidence of the antifibrinolytic activity of the two best candidates of the 1,2,3-triazole family and paves the way for incorporating these molecules as new antifibrinolytic therapies.

Perioperative Blindness in Spine Surgery: A Scoping Literature Review

Perioperative vision loss (POVL) is a devastating surgical complication that impacts both the recovery from surgery and quality of life, most commonly occurring after spine surgery. With rates of spine surgery dramatically increasing, the prevalence of POVL will increase proportionately. This scoping review aims to aggregate the literature pertinent to POVL in spine surgery and consolidate recommendations and preventative measures to reduce the risk of POVL. There are several causes of POVL, and the main contribution following spine surgery is ischemic optic neuropathy (ION). Vision loss often manifests immediately following surgery and is irreversible and severe. Diffusion weighted imaging has recently surfaced as a diagnostic tool to identify ION. There are no effective treatments; therefore, risk stratification for counseling and prevention are vital. Patients undergoing prone surgery of long duration and/or with significant expected blood loss are at greatest risk. Future research is necessary to develop effective treatments.

Perioperative Management for Complex Spine Fusion Surgery

Complex spine surgeries performed worldwide continue to increase in number, as do the age and comorbidity of patients undergoing these operations. Perioperative care protocols related to blood management, postoperative pain control, and intraoperative measures to mitigate morbidity may improve clinical workflows and patient outcomes.

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.