What is the recommended prophylaxis for Deep Vein Thrombosis (DVT) in a post-operative patient with a posterior cervical spine fusion and elevated D-dimer at baseline?

From the Research

For DVT prophylaxis in a post-operative posterior cervical spine fusion patient with elevated baseline D-dimer, I recommend mechanical prophylaxis with sequential compression devices (SCDs) initially, followed by chemical prophylaxis with fondaparinux 2.5mg subcutaneously once daily starting 24-48 hours after surgery if there are no signs of bleeding, as it has been shown to reduce the risk of VTE without increasing the risk of clinically relevant bleeding 1. The use of fondaparinux in this context is supported by a study that demonstrated its efficacy in reducing symptomatic venous thromboembolism after elective lumbar spine surgery 1. Although other studies have compared fondaparinux to enoxaparin in the context of major orthopedic surgery, showing fondaparinux to be more effective in preventing VTE but with a higher risk of major bleeding 2, 3, the most recent and relevant study to this specific scenario supports the use of fondaparinux 1. An elevated baseline D-dimer alone is not a contraindication to standard prophylaxis but may indicate higher thrombotic risk. The timing of chemical prophylaxis is crucial in spine surgery patients due to the risk of epidural hematoma and neurological compromise. Early mobilization should also be encouraged as soon as the patient is stable. If the patient has additional risk factors like prior DVT/PE or known thrombophilia, consider extending prophylaxis for 2-4 weeks post-discharge. The decision should be individualized based on the patient's bleeding risk versus thrombotic risk. Mechanical prophylaxis works by increasing venous flow and reducing stasis, while fondaparinux inhibits factor Xa in the coagulation cascade, preventing thrombus formation. Key points to consider include:

• The patient's elevated baseline D-dimer indicates a higher risk of thrombotic events
• The use of fondaparinux has been shown to reduce the risk of VTE in spine surgery patients
• The timing and duration of chemical prophylaxis should be individualized based on the patient's risk factors and clinical status
• Mechanical prophylaxis with SCDs should be used initially, with chemical prophylaxis added when safe to do so.