Conference Proceeding - Restricted Access
BACKGROUND CONTEXTTranexamic Acid (TXA) has been proven safe and efficacious in procedures with large volume blood loss (joint replacement and cardiac surgery). Its role as a pharmaceutical agent for blood loss preservation for long-segment spinal fusion (complex spinal fusion, deformity cases) has also shown promising results. However, it remains unclear if the risk of potential thrombogenesis that could lead to venous thrombotic events (VTE) outweighs its benefits in shorter cases less likely to need blood transfusion. TXA is widely available in various forms, (ie, oral, topical, intravenous [IV]); consensus is lacking with regards to the optimal dosing regimen for spinal fusion.
PURPOSEOur study objective is to evaluate IV TXA use in lumbar fusion.
STUDY DESIGN/SETTINGRetrospective/single center.
PATIENT SAMPLEPatients undergoing 2-5 level lumbar fusion with instrumentation.
OUTCOME MEASURESEBL, POD 1 hemoglobin, blood transfusion requirements, LOS, post-dose incidence of VTE.
METHODSA total of 251 patients were included in this retrospective case series (2018-2019). Demographics, patient characteristics, estimated blood loss (EBL), postoperative day (POD) 1 hemoglobin, transfusion requirements, VTE, and length of stay (LOS) were compared between a group who received TXA (TXA) and a control group who did not (No TXA). The No TXA group are historical patients 6 months preTXA use, and those with contraindications during the treatment period (ie, history of hypersensitivity, bleeding, clotting, recent trauma or significant kidney disease). Treatment modality was 2 grams infused over 30 minutes perioperatively (1 gram prior to incision and repeated at closure). Data was analyzed with t-test (or Wilcoxon test) and Chi-squared test (or Fisher's exact test). P< 0.05 are to be considered statistically significant.
RESULTSThe two groups were similar in characteristics. There were no differences in age, gender, BMI and ASA score, all p>0.05. Both groups had similar smoking status (p=0711) and preoperative hemoglobin values (No TXA 13.9mg/dL ± 1.3mg/dL vs TXA 14.1± 1.5mg/dL, p=0.305). All patients had degenerative disease, approximately 10% had concurrent scoliotis. Number of levels intrumented: 2 (37%), 3 (23%), 4 (22%) and 5 (18%). No difference in the distribution in terms of primary vs revision surgery (p=0.209). Thirty-six percent (n-91) received 1-2 doses. Of the 91 treated patients, 90% (n-82) received the two doses, at preincision and closure; 99% (n-90) received a dose at preincision and 91% (n-83) at closure. With two doses, the average dose administered was 22mg/kg ±6.1mg/kg. EBL was skewed with outliers, No TXA median (IQR): 300 (150-450) vs TXA median (IQR): 250 (150-300), p=0.078. Cell saver utility by both groups were similar (No TXA 27%, TXA 24%); no difference in amount returned (p=0.739). Although the TXA group had significantly higher hemoglobin level on POD1 (No TXA 10.8±1.5 g/dL vs TXA 11.5±1.5 g/dL, p<0.001), both groups had similar low incidence of severe postoperative anemia requiring blood transfusion (No TXA 7.5% vs TXA 3.3%, p=0.268). A difference in LOS was observed (No TXA 3.5+1.3 days vs TXA 3.2+1.1 days, p=0.02). While hospitalized, one patient in the control group developed deep vein thrombosis on POD4; no VTE was reported in the TXA group.
CONCLUSIONSWith or without TXA, EBL was comparable in 2-5 level lumbar fusion. Patients in the TXA group, however, had a higher POD 1 hemoglobin and had shorter length of hospitalization. No VTE was reported among the TXA treated population.
Pestano C, Easton RW, Lipphardt M, Easton M, Chen NW, Papakonstantinou NS, et al. [Ahlgren B, Vibert B]. TXA vs no TXA: tranexamic acid in lumbar fusion, a retrospective study comparison. Spine J. 2022 Sep;22(9 Suppl):S148. doi:10.1016/j.spinee.2022.07.084
North American Spine Society 37th Annual Meeting, October 12-15, 2022, Chicago, IL.