title: Prothrombin complex concentrate facilitates emergency spinal surgery in anticoagulated patients.
abstract: BACKGROUND
  Oral anticoagulants are commonly used in the ageing population and therefore, spine surgeons are increasingly confronted with anticoagulated patients requiring surgical therapy. 'Bridging therapies' with heparins are established in elective settings, but the time frame for haemostasis restoration may be too long for patients presenting with acute spinal pathology and impending disability. The goal of this study was to analyse the feasibility of prothrombin complex concentrate (PCC) administration to facilitate emergency spinal surgery in anticoagulated patients.
  
  
  METHODS
  A retrospective analysis of the institutional database of neurosurgical patients receiving PCC from February 2007 to December 2013 (n = 485) identified 18 patients who received PCC prior to emergency spinal surgery. Clinical characteristics, as well as modalities of PCC administration and parameters of haemostasis were analysed. Furthermore, haemorrhagic complications and thromboembolic events in the further course were evaluated.
  
  
  RESULTS
  Spinal pathologies requiring urgent neurosurgical decompression were spinal haematoma (n = 9), spinal metastasis (n = 5), vertebral body fracture (n = 2), and disc herniation (n = 2). The mean international normalized ratio (INR) on admission was 2.27 ± 1.20 and after administration of PCC (mean: 1,944 ± 953 I.U.), INR significantly decreased to 1.12 ± 0.10 (p < 0.001). Emergency surgery was initiated within 4.4 h after PCC administration (range: 0-16.6 h). Postoperatively, symptoms improved in 12 patients (66.7 %). There were two deaths (11 %), one caused by acute myocardial infarction on the fourth postoperative day. Bleeding complications occurred in two patients (epidural haemorrhage n = 1, rectal tumour haemorrhage n = 1).
  
  
  CONCLUSIONS
  The administration of PCC facilitates emergency spinal surgery in anticoagulated patients who present with acute spinal pathology requiring urgent neurosurgical decompression. The risk of PCC-associated thromboembolic events seems to be low and justifies the use of PCC in order to avoid permanent disablement resulting from delayed surgery or non-operation.
authors.affiliation: Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany, christopher.beynon@med.uni-heidelberg.de.
authors.forename: Christopher
authors.initials: C
authors.lastname: Beynon
authors.forename: Anna
authors.initials: A
authors.lastname: Potzy
authors.forename: Andreas W
authors.initials: AW
authors.lastname: Unterberg
authors.forename: Oliver W
authors.initials: OW
authors.lastname: Sakowitz
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001777:Blood Coagulation / Q000187:drug effects; D001779:Blood Coagulation Factors / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use*; D004638:Emergency Treatment; D005240:Feasibility Studies; D005260:Female; D006406:Hematoma / Q000601:surgery; D006470:Hemorrhage / Q000517:prevention & control*; D006488:Hemostasis, Surgical; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000601:surgery; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures; D012189:Retrospective Studies; D012307:Risk Factors; D016103:Spinal Fractures / Q000601:surgery; D013125:Spinal Neoplasms / Q000601:surgery; D013131:Spine / Q000601:surgery*; D013923:Thromboembolism / Q000453:epidemiology / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D001779:Blood Coagulation Factors; C025667:prothrombin complex concentrates