Venous thromboembolism prophylaxis following degenerative spine surgery: a narrative review

Background and Objective: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are feared thromboembolic complications following spinal surgery. Thromboembolism prophylaxis includes either mechanical prophylaxis or chemoprophylaxis with various pharmacological agents. Although mechanical prophylaxis is recommended by several evidence-based guidelines, chemoprophylaxis use remains controversial within the spine literature. Spinal surgeons face the difficult task of weighing the benefits of chemoprophylaxis against the risk of hemorrhagic complications. The aim of this critical review is to address the clinical consensus on the most appropriate thromboprophylaxis for degenerative spine surgery. Methods: A non-systematic search of the PubMed database was conducted in August 2023 utilizing the key words: [spine surgery], [thromboembolism], [prophylaxis]. Inclusion criteria included studies reporting on DVT or PE following degenerative spine surgery and those published in English, between the years 1980 and August 2023. Key Content and Findings: Upon review of the 200 resulting studies, we observed a broad range for venous thromboembolism (VTE) incidence (0.2-43%). Although prior literature demonstrates that both mechanical and chemical anticoagulation are efficacious in reducing thromboembolic complications, chemoprophylaxis use remains widely contested across the studies analyzed in this review. Due to the variability in thromboembolism management preference, surgeons must maintain a high index of suspicion for post-operative thromboembolic complications. Conclusions: Based on safety and efficacy profiles uncovered through this review, it is our practice that all patients receive intermittent pneumatic compression throughout their hospital course and patients at high risk for thrombotic complications due to underlying hypercoagulability or poor mobilization are considered for chemoprophylaxis, in the form of low molecular-weight heparin as early as post-operative day one. Though compressive devices have been shown to be efficacious for thromboprophylaxis, there remains a lack of high-level evidence regarding the most appropriate form of chemoprophylaxis in spine surgery. Future investigations may aim to develop guidelines for chemical anticoagulation administration in degenerative spine surgery as well as a perioperative model to identify risk for VTE in patients that can be integrated into electronic health records.