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High Risk of Symptomatic Venous Thromboembolism After Surgery for Spine Metastatic Bone Lesions

A Retrospective Study

Groot, Olivier Q. BSc; Ogink, Paul T. MD; Paulino Pereira, Nuno Rei MD, PhD; Ferrone, Marco L. MD; Harris, Mitchell B. MD; Lozano-Calderon, Santiago A. MD, PhD; Schoenfeld, Andrew J. MD; Schwab, Joseph H. MD, MS

Clinical Orthopaedics and Related Research®: July 2019 - Volume 477 - Issue 7 - p 1674–1686
doi: 10.1097/CORR.0000000000000733

Background Cancer and spinal surgery are both considered risk factors for venous thromboembolism (VTE). However, the risk of symptomatic VTE for patients undergoing surgery for spine metastases remains undefined.

Questions/purposes The purposes of this study were to: (1) identify the proportion of patients who develop symptomatic VTE within 90-days of surgical treatment for spine metastases; (2) identify the factors associated with the development of symptomatic VTE among patients receiving surgery for spine metastases; (3) assess the association between the development of postoperative symptomatic VTE and 1-year survival among patients who underwent surgery for spine metastases; and (4) assess if chemoprophylaxis increases the risk of wound complications among patients who underwent surgery for spine metastases.

Methods Between 2002 and 2014, 637 patients at two hospitals underwent spine surgery for metastases. We considered eligible for analysis adult patients whose procedures were to treat cervical, thoracic, or lumbar metastases (including lymphoma and multiple myeloma). At followup after 90 days and 1 year, respectively, 21 of 637 patients (3%) and 41 of 637 patients (6%) were lost to followup. In general, we used 40 mg of enoxaparin or 5000 IUs subcutaneous heparin every 12 hours. Patients on preoperative chemoprophylaxis continued their initial medication postoperatively. All chemoprophylaxis was started 48 hours after surgery and continued day to day but was discontinued if a bleeding complication developed. Low-molecular-weight heparin (including enoxaparin and dalteparin, in general dosages of respectively 40 mg and 5000 IUs daily) was the most commonly used chemoprophylaxis in 308 patients (48%). Subcutaneous heparin was injected into 127 patients (20%); aspirin was used for 92 patients (14%); and warfarin was administered in 21 patients (3.3%). No form of chemoprophylaxis was prescribed for 89 patients (14%). The primary outcome variable, VTE, was defined as any symptomatic pulmonary embolism (PE) or symptomatic deep venous thromboembolism (DVT) within 90 days of surgery as determined by chart review. The secondary outcome was defined as any documented wound complication within 90 days of surgery that might be attributable to chemoprophylaxis. Statistical analysis was performed using multivariable logistic and Cox regression and Kaplan-Meier.

Results Overall, 72 of 637 patients (11%) had symptomatic VTE; 38 (6%) developed a PE–eight (1.3%) of which were fatal–and 40 (6%) a DVT. After controlling for relevant confounding variables such as age, the modified Charlson Comorbidity Index, visceral metastases, and chemoprophylaxis, longer duration of surgery was independently associated with an increased risk of symptomatic VTE (odds ratio 1.15 for each additional hour of surgery; 95% confidence interval [CI], 1.04-1.28; p = 0.009). After controlling for relevant confounding variables such as age, the modified Charlson Comorbidity Index, visceral metastases, and primary tumor type, patients with symptomatic VTE had a worse 1-year survival rate (VTE, 38%; 95% CI, 27–49 versus nonVTE, 47%; 95% CI, 42–51; p = 0.044). After controlling for relevant confounding variables, no association was found between wound complications and the use of chemoprophylaxis (odds ratio, 1.34; 95% CI, 0.62–2.90; p = 0.459). The overall proportion of patients who developed a wound complication was 10% (66 of 637), including 1.1% (seven of 637) spinal epidural hematomas.

Conclusions The risk of both symptomatic PE and fatal PE is high in this patient population, and those with symptomatic VTE were less likely to survive 1-year than those who did not, though this may reflect overall infirmity as much as anything else, because many of these patients did not die from VTE-related complications. Further study, such as randomized controlled trials with consistent postoperative VTE screening comparing different chemoprophylaxis regimens, are needed to identify better VTE prevention strategies.

Level of Evidence Level III, therapeutic study.

O. Q. Groot, P. T. Ogink, N. R. P. Pereira, S. A. Lozano-Calderon, J. H. Schwab, Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital – Harvard Medical School, Boston, MA, USA

M. L. Ferrone, M. B. Harris, A. J. Schoenfield, Department of Orthopaedic Surgery, Orthopaedic Spine Service, Brigham and Women’s Hospital – Harvard Medical School, Boston, MA, USA

O. Q. Groot, Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital – Harvard Medical School, 55 Fruit Street, Boston, MA 02114 USA, Email:

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that neither he, nor any member of his immediate family, have funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his institution approved the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at Massachusetts General Hospital and Brigham and Women’s Hospital, Boston, MA, USA.

Received September 16, 2018

Accepted February 28, 2019

© 2019 Lippincott Williams & Wilkins LWW
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