title: Decreased incidence of venous thromboembolism after spine surgery with early multimodal prophylaxis: Clinical article.
abstract: OBJECTIVE
  Venous thromboembolism (VTE) represents a significant complication after spine surgery, with reported rates as high as 2%-4%. Published institutional practices for VTE prophylaxis are highly variable. In 2008, the authors implemented a departmental protocol for early VTE prophylaxis consisting of combined compressive devices and subcutaneous heparin initiated either preoperatively or on the same day of surgery. In this study, the authors compared the incidence of VTE in spine surgery patients before and after implementing this protocol.
  
  
  METHODS
  An institutional review board-approved retrospective review of outcomes in patients undergoing spine surgery 2 years before protocol implementation (representing the preprotocol group) and of outcomes in patients treated 2 years thereafter (the postprotocol group) was conducted. Inclusion criteria were that patients were 18 years or older and had been admitted for 1 or more days. Before 2008 (preprotocol), VTE prophylaxis was variable and provider dependent without any uniform protocol. Since 2008 (postprotocol), a new VTE-prophylaxis protocol was administered, starting either preoperatively or on the same day of surgery and continuing throughout hospitalization. The new protocol consisted of 5000 U heparin administered subcutaneously 3 times daily, except in patients older than 75 years or weighing less than 50 kg, who received this dose twice daily. All patients also received sequential compression devices (SCDs). The incidence of VTE in the 2 protocol phases was identified by codes of the International Classification of Diseases, Ninth Revision (ICD-9) codes for deep vein thrombosis (DVT) and pulmonary embolus (PE). Bleeding complications arising from anticoagulation treatments were evaluated by the Current Procedural Terminology (CPT) code for postoperative epidural hematoma (EDH) requiring evacuation.
  
  
  RESULTS
  In total, 941 patients in the preprotocol group met the inclusion criteria: 25 had DVT (2.7%), 6 had PE (0.6%), and 6 had postoperative EDH (0.6%). In the postprotocol group, 992 patients met the criteria: 10 had DVT (1.0%), 5 had PE (0.5%), and 4 had postoperative EDH (0.4%). This reduction in DVT after the protocol's implementation was statistically significant (p = 0.009). Despite early aggressive prophylaxis, the incidence of postoperative EDH did not increase and compared favorably to the published literature.
  
  
  CONCLUSIONS
  At a high-volume tertiary center, an aggressive protocol for early VTE prophylaxis after spine surgery decreases VTE incidence without increasing morbidity.
authors.affiliation: Department of Neurological Surgery, University of Florida, Gainesville, Florida.
authors.forename: J Bridger
authors.initials: JB
authors.lastname: Cox
authors.forename: Kristin J
authors.initials: KJ
authors.lastname: Weaver
authors.forename: Daniel W
authors.initials: DW
authors.lastname: Neal
authors.forename: R Patrick
authors.initials: RP
authors.lastname: Jacob
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Hoh
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology* / Q000517:prevention & control*; D011655:Pulmonary Embolism / Q000453:epidemiology / Q000517:prevention & control; D012189:Retrospective Studies; D012307:Risk Factors; D013131:Spine / Q000601:surgery*; D016896:Treatment Outcome; D054556:Venous Thromboembolism / Q000453:epidemiology* / Q000517:prevention & control*
keywords: CPT = Current Procedural Terminology; CS = compression stocking; DVT = deep vein thrombosis; EDH = epidural hematoma; LOS = length of stay; PE = pulmonary embolus; SCD = sequential compression device; VTE = venous thromboembolism; deep venous thrombosis; hospital-acquired condition; patient quality; pulmonary embolism; spinal disorders; spine surgery; venous thromboembolism