The Journal of Bone and Joint Surgery (American). 2009;91:2568-2576.
doi:10.2106/JBJS.H.01411
© 2009 The Journal of Bone and Joint Surgery, Inc.
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Thromboprophylaxis in Patients with Acute Spinal Injuries: An Evidence-Based Analysis

A. Ploumis, MD, PhD1, R.K. Ponnappan, MD1, M.G. Maltenfort, PhD1, R.X. Patel, BS1, J.T. Bessey, BS1, T.J. Albert, MD1, J.S. Harrop, MD1, C.G. Fisher, MD1, C.M. Bono, MD1 and A.R. Vaccaro, MD, PhD1

1 Department of Orthopaedics, Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107. E-mail address for A. Ploumis: ploumis{at}med.auth.gr

Investigation performed at the Department of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania

A commentary by Ronald W. Lindsey, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from Medtronic. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (DePuy Spine).

Background: The increased risk for venous thromboembolic events following spinal trauma is well established. The purpose of the present study was to examine the literature in order to determine the optimum thromboprophylaxis regimen for patients with acute spinal injuries with or without spinal cord injury.

Methods: EMBASE, MEDLINE, and Cochrane databases were searched from the earliest available date to April 2008 for clinical trials comparing different methods of thromboprophylaxis in adult patients following acute spinal injuries (with or without spinal cord injury). Outcome measures included the prevalences of deep-vein thrombosis and pulmonary embolism and treatment-related adverse events.

Results: The search yielded 489 studies, but only twenty-one of them fulfilled the inclusion criteria. The prevalence of deep-vein thrombosis was significantly lower in patients without spinal cord injury as compared with patients with spinal cord injury (odds ratio = 6.0; 95% confidence interval = 2.9 to 12.7). Patients with an acute spinal cord injury who were receiving oral anticoagulants had significantly fewer episodes of pulmonary embolism (odds ratio = 0.1; 95% confidence interval = 0.01 to 0.63) than those who were not receiving oral anticoagulants (either untreated controls or patients managed with low-molecular-weight heparin). The start of thromboprophylaxis within the first two weeks after the injury resulted in significantly fewer deep-vein-thrombosis events than delayed initiation did (odds ratio = 0.2; 95% confidence interval = 0.1 to 0.4). With regard to heparin-based pharmacoprophylaxis in patients with spinal trauma, low-molecular-weight heparin significantly reduced the rates of deep-vein thrombosis and bleeding episodes in comparison with the findings in patients who received unfractionated heparin, with odds ratios of 2.6 (95% confidence interval = 1.2 to 5.6) and 7.5 (95% confidence interval = 1.0 to 58.4) for deep-vein thrombosis and bleeding, respectively.

Conclusions: The prevalence of deep-vein thrombosis following a spine injury is higher among patients who have a spinal cord injury than among those who do not have a spinal cord injury. Therefore, thromboprophylaxis in these patients should start as early as possible once it is deemed safe in terms of potential bleeding complications. Within this population, low-molecular-weight heparin is more effective for the prevention of deep-vein thrombosis, with fewer bleeding complications, than unfractionated heparin is. The use of vitamin K antagonists appeared to be effective for the prevention of pulmonary embolism.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.


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