Pennington Zach, Ehresman Jeff, Schilling Andrew, Feghali James, Hersh Andrew M, Hung Bethany, Kalivas Eleni N, Lubelski Daniel, Sciubba Daniel M
1Department of Neurosurgery, Johns Hopkins University School of Medicine; and.
2Department of Pharmacy, Division of Critical Care and Surgery Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland.
J Neurosurg Spine. 2021 Aug 13;35(5):663-673. doi: 10.3171/2021.1.SPINE201935. Print 2021 Nov 1.
Patients with spine tumors are at increased risk for both hemorrhage and venous thromboembolism (VTE). Tranexamic acid (TXA) has been advanced as a potential intervention to reduce intraoperative blood loss in this surgical population, but many fear it is associated with increased VTE risk due to the hypercoagulability noted in malignancy. In this study, the authors aimed to 1) develop a clinical calculator for postoperative VTE risk in the population with spine tumors, and 2) investigate the association of intraoperative TXA use and postoperative VTE.
A retrospective data set from a comprehensive cancer center was reviewed for adult patients treated for vertebral column tumors. Data were collected on surgery performed, patient demographics and medical comorbidities, VTE prophylaxis measures, and TXA use. TXA use was classified as high-dose (≥ 20 mg/kg) or low-dose (< 20 mg/kg). The primary study outcome was VTE occurrence prior to discharge. Secondary outcomes were deep venous thrombosis (DVT) or pulmonary embolism (PE). Multivariable logistic regression was used to identify independent risk factors for VTE and the resultant model was deployed as a web-based calculator.
Three hundred fifty patients were included. The mean patient age was 57 years, 53% of patients were male, and 67% of surgeries were performed for spinal metastases. TXA use was not associated with increased VTE (14.3% vs 10.1%, p = 0.37). After multivariable analysis, VTE was independently predicted by lower serum albumin (odds ratio [OR] 0.42 per g/dl, 95% confidence interval [CI] 0.23-0.79, p = 0.007), larger mean corpuscular volume (OR 0.91 per fl, 95% CI 0.84-0.99, p = 0.035), and history of prior VTE (OR 2.60, 95% CI 1.53-4.40, p < 0.001). Longer surgery duration approached significance and was included in the final model. Although TXA was not independently associated with the primary outcome of VTE, high-dose TXA use was associated with increased odds of both DVT and PE. The VTE model showed a fair fit of the data with an area under the curve of 0.77.
In the present cohort of patients treated for vertebral column tumors, TXA was not associated with increased VTE risk, although high-dose TXA (≥ 20 mg/kg) was associated with increased odds of DVT or PE. Additionally, the web-based clinical calculator of VTE risk presented here may prove useful in counseling patients preoperatively about their individualized VTE risk.
脊柱肿瘤患者发生出血和静脉血栓栓塞（VTE）的风险增加。氨甲环酸（TXA）已被提出作为一种潜在的干预措施，以减少该手术人群的术中失血，但许多人担心它会因恶性肿瘤中存在的高凝状态而增加VTE风险。在本研究中，作者旨在：1）开发一种针对脊柱肿瘤患者术后VTE风险的临床计算器；2）研究术中使用TXA与术后VTE之间的关联。
回顾了一家综合癌症中心的成人脊柱肿瘤患者的回顾性数据集。收集了关于所进行的手术、患者人口统计学和合并症、VTE预防措施以及TXA使用情况的数据。TXA的使用分为高剂量（≥20mg/kg）或低剂量（<20mg/kg）。主要研究结局是出院前发生VTE。次要结局是深静脉血栓形成（DVT）或肺栓塞（PE）。采用多变量逻辑回归来确定VTE的独立危险因素，并将所得模型部署为基于网络的计算器。
共纳入350例患者。患者平均年龄为57岁，53%为男性，67%的手术是针对脊柱转移瘤进行的。使用TXA与VTE增加无关（14.3%对10.1%，p = 0.37）。多变量分析后，VTE的独立预测因素为血清白蛋白降低（每克/分升比值比[OR]为0.42，95%置信区间[CI]为0.23 - 0.79，p = 0.007）、平均红细胞体积增大（每飞升OR为0.91，95%CI为0.84 - 0.99，p = 0.035）以及既往VTE病史（OR为2.60，95%CI为1.53 - 4.40，p < 0.001）。手术时间延长接近显著水平并被纳入最终模型。虽然TXA与VTE的主要结局没有独立关联，但高剂量使用TXA与DVT和PE的发生几率增加有关。VTE模型对数据的拟合度较好，曲线下面积为0.77。
在本队列接受脊柱肿瘤治疗的患者中，TXA与VTE风险增加无关，尽管高剂量TXA（≥20mg/kg）与DVT或PE的发生几率增加有关。此外，本文介绍的基于网络的VTE风险临床计算器可能有助于在术前为患者提供关于其个体化VTE风险的咨询。
