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Postoperative Deep Vein Thrombosis, Pulmonary Embolism, and Myocardial Infarction: Complications After Therapeutic Anticoagulation in the Patient With Spine Trauma

Shiu, Brian, MD; Le, Elizabeth, MD; Jazini, Ehsan, MD; Weir, Tristan B., MD; Costales, Timothy, MD; Caffes, Nicholas, MD; Paryavi, Ebrahim, MD MPH; O’Hara, Nathan, MHA; Gelb, Daniel E., MD; Koh, Eugene Y., MD PhD; Ludwig, Steven C., MD

doi: 10.1097/BRS.0000000000002513
Clinical Case Series

Study Design. A retrospective review (2001–2014) was conducted using prospectively collected data at a level I trauma center.

Objective. We sought to determine the incidence and characteristics of complications occurring secondary to therapeutic anticoagulation in adult spine trauma patients.

Summary of Background Data. Numerous studies have assessed prophylactic anticoagulation after spine surgery, but none has investigated the risks of therapeutic doses of anticoagulation for treatment of postoperative thromboembolic events.

Methods. Patients were included if they sustained a postoperative thromboembolic event (deep venous thrombosis, pulmonary embolism, or myocardial infarction). Patients were excluded if anticoagulation was subtherapeutic. Of 1712 patients, 62 who received therapeutic anticoagulation and 174 propensity-matched control patients who did not receive therapeutic anticoagulation were included in the study.

Results. Initial anticoagulation was obtained by heparin infusion (51%), low-molecular-weight heparin (LMWH, 46%), and warfarin (3%). Complications requiring unplanned reoperation occurred in 18% of anticoagulated patients and 10% of nonanticoagulated patients (P = 0.17). The reoperation rate after heparin infusion was 31% and after LMWH was 6.5% (P = 0.02). Epidural hematoma occurred in 3% and 1% of anticoagulated and nonanticoagulated patients, respectively. Multivariate logistic regression analysis of the two groups showed a trend toward increased risk of reoperation in the anticoagulation group. Analysis of the heparin infusion subgroup separate from the LMWH subgroup compared with the control group showed an increased risk of reoperation for any complication (odds ratio, 3.57; P = 0.01) and for bleeding complications (odds ratio, 43.1; P = 0.01).

Conclusion. This is the first study to quantify complications secondary to postoperative therapeutic anticoagulation in spine patients. Postoperative spine trauma patients who underwent therapeutic anticoagulation experienced an unplanned reoperation rate of 18%, including a 3% incidence of spinal epidural hematoma. Therapeutic anticoagulation using heparin infusion seems to drive the overall rate of reoperation (31%) compared with LMWH.

Level of Evidence: 3

Department of Orthopaedics

Department of Neurosurgery, University of Maryland, Baltimore, MD.

Address correspondence and reprint requests to Steven C. Ludwig, MD, Department of Orthopaedics, University of Maryland, 110 South Paca St, 6th Floor, Suite 300, Baltimore, MD 21201; E-mail:

Received 1 September, 2017

Revised 2 November, 2017

Accepted 16 November, 2017

The device(s)/drug(s) is/are FDA approved or approved by corresponding national agency for this indication.

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, payment for lecture, grants, patents, royalties, stocks, travel/accommodations/meeting expenses.

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