Novel Oral Anticoagulants in Patients Undergoing Spine Surgery

Introduction: Novel oral anticoagulants (NOACs) were shown to be as effective as vitamin K antagonists for the prophylaxis and treatment of thromboembolism. Despite growing number of patients treated with NOACs, guidelines on the perioperative management are still lacking. The aim of the study was to present a cohort of patients treated with NOACs undergoing spine surgery, and to analyze the incidence of postoperative bleeding events and the factors might influence bleeding rates in these patients.

Material and Methods: Out of 2,777 patients undergoing spine surgery between January 2014 and December 2016, 82 (2.9%) were under NOACs preoperatively. The rate of peri- and postoperative bleeding events, postoperative thromboembolic events, hematologic findings, morbidity, and mortality was reviewed. A subanalysis of factors that might influence the bleeding risk of these patients and the bleeding rate depending on the preoperatively discontinuation time of NOACs, with a cutoff of 24 and 48 hours, was additionally completed.

Results: The overall rate of postoperative bleeding was 4.9% (n = 4) and the rate of postoperative anemia needing packed red blood cell (PRBC) substitution was 6.1% (n = 5). The mean discontinuation time was 3.5 days (range, 3–6 days) in the patients experiencing a bleeding event, as opposed to 4.2 days (range, 0–20 days) in patients without a bleeding event (p > 0.05). Preoperative discontinuation time of < 24 hours increased significantly the rate of PRBC substitution perioperatively (p = 0.007), but not the rate of postoperative bleeding and anemia. However, a combination therapy with other blood thinner showed an increase in incidence of bleeding events (p = 0.066) and pre-existing kidney failure affected significative the rate of postoperative anemia (p = 0.014). Postoperative resumption time of NOACs did not seem to significantly affect bleeding events and postoperative anemia. The rate of postoperative pulmonary embolism and deep venous thrombosis events was 3.4% and 1.1%, respectively, and all of them happened with a NOACs resumption time > 72 hours. The hospitalization time of patients resuming NOACs >72 hours after surgery was significative longer (p = 0.037).

Conclusions: The postoperative rate of bleeding and anemia in patients undergoing spinal surgery treated with NOACs is 4.9% and 6.1%, respectively. Preoperative discontinuation time < 24 hours seems to significantly increase the use of PRBC substitution perioperatively.

No conflict of interest has been declared by the author(s).