What are the perioperative considerations for a patient with a history of splenectomy (removal of the spleen) undergoing elective spine surgery?

Perioperative Management of Elective Spine Surgery in Splenectomized Patients

Patients with prior splenectomy undergoing elective spine surgery require mandatory preoperative vaccination verification, aggressive infection prophylaxis, and enhanced thromboembolism prevention due to their lifelong immunocompromised state and increased thrombotic risk.

Preoperative Assessment and Optimization

Vaccination Status Verification

• All splenectomized patients must have documented immunization against encapsulated bacteria at least 2-4 weeks before elective surgery 1, 2
• Required vaccines include polyvalent pneumococcal, meningococcal C conjugate, and Haemophilus influenzae type B (Hib) 1
• If vaccinations were not administered at time of splenectomy or are outdated, delay elective spine surgery until appropriate immunization is completed and adequate immune response has developed (minimum 2 weeks, preferably 4 weeks) 2
• Patients who received rituximab or other B-cell depleting therapies may require revaccination once B-cell recovery occurs 1

Infection Risk Assessment

• Splenectomized patients face lifelong risk of overwhelming post-splenectomy infection (OPSI) with mortality rates approaching 50% for pneumococcal sepsis 1, 3
• Risk is highest within first 2 years post-splenectomy but persists indefinitely, particularly for infections with Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae 1, 3
• Document any history of post-splenectomy infections, current antibiotic prophylaxis regimen, and compliance 4
• Any active infection is an absolute contraindication to elective spine surgery 1

Thrombotic Risk Evaluation

• Post-splenectomy patients have significantly elevated thrombotic risk affecting both portal and systemic venous systems 3
• Review complete blood count with particular attention to platelet count—thrombocytosis increases thrombotic complications 1
• Assess for history of prior thrombotic events (deep vein thrombosis, pulmonary embolism, portal vein thrombosis) 3
• Document any underlying myeloproliferative disorders which further amplify thrombotic risk 1, 3

Perioperative Infection Prophylaxis

Antibiotic Coverage

• Administer broad-spectrum perioperative antibiotics covering encapsulated organisms in addition to standard surgical prophylaxis 5
• A randomized controlled trial demonstrated significant reduction in total septic complications (p<0.01) and pneumonia with prophylactic cefuroxime 1500mg three times daily for 3 days starting 1 hour preoperatively 5
• Consider extended antibiotic prophylaxis beyond standard surgical protocols given the 21-45% infection rate after splenectomy without prophylaxis 5
• Ensure patients have home supply of antibiotics (penicillin VK, erythromycin, or levofloxacin) for any post-discharge febrile illness 1

Patient Education

• Educate patients that any fever >38°C (101°F) requires immediate emergency department evaluation 1
• Provide written instructions and medical alert identification (card, bracelet, or pendant) documenting asplenic status 1
• Emphasize that post-splenectomy infections can progress rapidly to septic shock within hours 3

Thromboembolism Prevention

Mechanical Prophylaxis

• Initiate mechanical prophylaxis (sequential compression devices) immediately and continue throughout hospitalization 1
• Mechanical prophylaxis is safe and should be used in all patients without absolute contraindications 1

Pharmacologic Prophylaxis

• Administer perioperative low molecular weight heparin (LMWH) to all splenectomized patients undergoing spine surgery 6, 3
• Start LMWH as soon as surgically safe, typically within 24 hours postoperatively for spine surgery 1
• Consider prolonged thromboprophylaxis (extending beyond hospitalization) for high-risk patients including those with thrombocytosis, myeloproliferative disorders, or obesity 6, 3
• Monitor platelet counts—if thrombocytosis develops (>400 × 10⁹/L), consider anti-platelet therapy in addition to anticoagulation 1, 3

Intraoperative Considerations

Anesthetic Management

• Use multimodal analgesia including epidural anesthesia when feasible to reduce opioid requirements and facilitate early mobilization 2
• Maintain low tidal volumes with adequate PEEP to prevent atelectasis 2
• Avoid hypothermia throughout the procedure as it impairs immune function and increases infection risk 1

Surgical Technique

• Minimize operative time and tissue trauma to reduce infection risk 7
• Maintain meticulous hemostasis as post-splenectomy patients may have altered coagulation profiles 4

Postoperative Management

Respiratory Care

• Implement aggressive pulmonary hygiene protocol including incentive spirometry, deep breathing exercises, and early mobilization 2
• Mobilize patient out of bed within 6 hours and ambulate within 24 hours post-surgery 2
• Consider CPAP for high-risk patients (obesity, sleep apnea, oxygen saturation <92%) 2
• Left lower lobe atelectasis is particularly common after splenectomy and requires vigilant prevention 2

Infection Surveillance

• Monitor closely for signs of infection including fever, tachycardia, hypotension, or altered mental status 1, 3
• Maintain low threshold for blood cultures and empiric broad-spectrum antibiotics (third-generation cephalosporins) for any fever 3
• Continue prophylactic antibiotics for minimum 3 days postoperatively, potentially longer based on clinical course 5

Thrombosis Monitoring

• Continue LMWH prophylaxis throughout hospitalization 6, 3
• Monitor for signs of venous thromboembolism (leg swelling, chest pain, dyspnea) 3
• Check platelet counts—extreme thrombocytosis (>1000 × 10⁹/L) may require cytoreduction 1

Fluid Management

• Use goal-directed fluid therapy to avoid overhydration which increases pulmonary complications 2
• Maintain adequate hydration to prevent venous stasis and thrombosis 1

Special Populations

Patients with Myeloproliferative Disorders

• These patients have 5-10% perioperative mortality risk and 50% complication rate if splenectomy was performed for myelofibrosis 1
• Require experienced surgical team and intensive care monitoring 1
• Maintain platelet count <400 × 10⁹/L perioperatively to prevent extreme thrombocytosis 1

Pediatric Patients with Sickle Cell Disease

• If splenectomy was performed for sickle cell disease, ensure prior immunization was completed 1
• These patients require additional SCD-specific perioperative protocols including potential transfusion 1

Elderly or High-Risk Patients

• Age is an independent prognostic indicator for mortality (p=0.002) 4
• Require more aggressive prophylactic measures and closer monitoring 2
• Consider ICU admission for postoperative monitoring 1

Discharge Planning

• Ensure patient has adequate supply of prophylactic antibiotics at home 1
• Provide clear written instructions about fever management and when to seek emergency care 1
• Schedule early follow-up to assess wound healing and monitor for delayed complications 4
• Continue thromboprophylaxis for 2-4 weeks post-discharge for major spine surgery 3