Abstract
Background:Patients undergoing spinal surgery while under anticoagulation therapy are at risk of developing bleeding complications, even though lower incidences have been reported for joint arthroplasty surgery. There is a gap in the medical literature examining the incidence of postoperative spinal bleeding in patients who were under anticoagulation medication at the time of surgery.Methods:We prospectively followed a consecutive cohort of 100 patients (58 male, 42 female) undergoing spinal surgery. The average patient age was 48.7 years and the minimum follow up time was 12 months. Diagnosis was lumbar spinal stenosis in 20, herniated lumbar discs in 63, degenerative cervical disc disease in 3, and cervical disc herniation in 14 cases. In our study, platelet aggregation inhibitors (clopidogrel and/or acetylsalicylic acid) were given for the treatment of cardiovascular and cerebrovascular thrombotic events, to reduce risk of stroke in patients who have had transient ischemia of the brain or acute coronary syndrome, and as secondary prevention of atherosclerotic events (fatal or nonfatal myocardial infarction (MI). A cessation of anticoagulants (acetylsalicylic acid or clopidogrel) in our patients in the peri- and postoperative period was contraindicated.Results:Sixty-three patients were on both clopidogrel and acetylsalicylic acid and 37 on acetylsalicylic acid only. None of the patients suffered any postoperative bleeding complication. Three patients suffered postoperative wound dehiscence and one patient had an infection that required reoperation.Conclusion:The question of whether preoperative platelet aggregation inhibitors must be stopped before elective spinal surgery has never been answered in the literature. In our prospective series, we have found no increase in the risk of postoperative spinal bleeding with the use of clopidogrel or acetylsalicylic acid. This finding suggests that spine surgery can be done without stopping anticoagulation. Lacking specific guidelines, each patient should be treated on an individual basis, and the potential benefits of anticoagulation should be compared with the potential risks (risk–benefit ratio).
Highlights
Platelet aggregation inhibitors are indicated for primary and secondary prevention of myocardial infarction (MI), stable and unstable angina including coronary artery disease (CAD), arterial thromboembolism prophylaxis for patients with prosthetic heart valves in combination with warfarin, secondary prevention of stroke/transient ischemic attack (TIA), and acute treatment of stroke in patients not eligible for thrombolysis.[1]
Sixty‐three patients were on both clopidogrel and ASA, and 37 on acetylsalicylic acid only
Clopidogrel is routinely used in conjunction with aspirin to treat acute coronary system (ACS) and postpercutaneous coronary intervention (PCI) stenting
Summary
Platelet aggregation inhibitors are indicated for primary and secondary prevention of myocardial infarction (MI), stable and unstable angina including coronary artery disease (CAD), arterial thromboembolism prophylaxis for patients with prosthetic heart valves in combination with warfarin, secondary prevention of stroke/transient ischemic attack (TIA), and acute treatment of stroke in patients not eligible for thrombolysis.[1] The perioperative anticoagulant management of such patients is challenging because interruption of anticoagulation therapy may increase the risk of embolic stroke, which can be fatal or associated with major disability in 70% of patients.[16] In managing the perioperative anticoagulation of patients, one approach is to stop the platelet aggregation inhibitors approximately 5 days before surgery and to administer bridging anticoagulation with intravenous heparin or low‐molecular‐weight heparin (LMWH) before and after surgery when the international normalized ratio (INR) is sub‐therapeutic.[7] This approach aims to minimize the time patients are not therapeutically anticoagulated and the risk for thromboembolism Another approach is to continue the platelet aggregation inhibitors during the perioperative period, thereby mitigating the risk for thromboembolism. There is a gap in the medical literature examining the incidence of postoperative spinal bleeding in patients who were under anticoagulation medication at the time of surgery
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