What are the American College of Chest Physicians (ACCP) guidelines for orthopedic spinal surgery?

From the Guidelines

The American College of Chest Physicians (ACCP) guidelines recommend thromboprophylaxis for patients undergoing orthopedic spinal surgery due to their moderate to high risk of venous thromboembolism (VTE). For most spinal surgery patients, mechanical prophylaxis with intermittent pneumatic compression devices should be used intraoperatively and continued throughout the hospital stay 1. Pharmacological prophylaxis with low molecular weight heparin (LMWH) such as enoxaparin 40 mg once daily or 30 mg twice daily should be considered for high-risk patients, typically starting 24-48 hours after surgery when hemostasis is established. High-risk factors include advanced age, malignancy, previous VTE, prolonged procedures (>4 hours), anterior-posterior approaches, and limited postoperative mobility.

Key Recommendations

• Mechanical prophylaxis with intermittent pneumatic compression devices should be used intraoperatively and continued throughout the hospital stay 1
• Pharmacological prophylaxis with LMWH should be considered for high-risk patients, typically starting 24-48 hours after surgery when hemostasis is established
• Combined mechanical and pharmacological prophylaxis is recommended for patients with multiple risk factors
• Prophylaxis should generally continue until the patient is fully mobile, typically 7-10 days for uncomplicated cases, and up to 28-35 days for high-risk patients

Rationale

The ACCP guidelines balance VTE prevention against the risk of epidural hematoma and surgical site bleeding, which are particular concerns in spinal procedures where neurological compromise could be catastrophic 1. The guidelines are based on the latest evidence and expert opinion, and are intended to reduce the risk of VTE and improve patient outcomes.

Clinical Considerations

When implementing these guidelines in clinical practice, it is essential to consider individual patient factors, such as bleeding risk and renal function, when selecting a prophylactic agent 1. Additionally, patients should be closely monitored for signs and symptoms of VTE and bleeding complications, and prophylaxis should be adjusted accordingly.

From the Research

ACCP Guidelines for Ortho Spinal Surgery

• The American College of Chest Physicians (ACCP) provides guidelines for the prevention of venous thromboembolism (VTE) in patients undergoing orthopedic surgery, including spinal surgery 2.
• The guidelines recommend that all patients undergo thrombosis- and bleeding-risk assessment as part of their preoperative evaluation, using validated risk-assessment models such as the Caprini score 2.
• For patients at low risk of VTE, mechanical or pharmacological prophylaxis is recommended, while patients at moderate to high risk of VTE should receive pharmacological prophylaxis either alone or combined with mechanical prophylaxis 2.

Thromboprophylaxis in Spinal Surgery

• Studies have shown that direct oral anticoagulants (DOACs) may have a favorable efficacy and safety profile in preventing VTE in patients undergoing spinal surgery 3, 4.
• A systematic review found that DOACs were associated with a significant reduction in major VTE and deep vein thrombosis (DVT) compared to low molecular weight heparin (LMWH) in patients undergoing orthopedic surgery, including spinal surgery 4.
• Another study found that combined anticoagulant and mechanical prophylaxis initiated within 72 hours of spinal cord injury resulted in lower risk of DVT than treatment commenced after 72 hours of injury 5.

Timing and Duration of Thromboprophylaxis

• The optimal timing to initiate and discontinue anticoagulant thromboprophylaxis in patients undergoing spinal surgery is not well established, but studies suggest that prophylaxis should be initiated within 72 hours of surgery or injury 5, 6.
• The duration of thromboprophylaxis is typically continued until the patient is ambulatory or until hospital dismissal, but longer durations can be considered in certain circumstances, such as high-risk patients undergoing malignant or complex surgery 2, 6.

Safety and Efficacy of Thromboprophylaxis

• Studies have shown that thromboprophylaxis with DOACs or LMWH is effective in preventing VTE in patients undergoing spinal surgery, with a low risk of bleeding complications 3, 4, 6.
• However, the use of anticoagulant prophylaxis may be associated with an increased risk of blood transfusion, particularly with aspirin and regular heparin 6.