Comprehensive assessment of prophylactic preoperative inferior vena cava filters for major spinal reconstruction in adults

Jamal McClendon, Brian A Oʼshaughnessy, Timothy R Smith, Patrick A Sugrue, Ryan J Halpin, Mark Morasch, Tyler Koski, Stephen L Ondra
Spine 2012 June 1, 37 (13): 1122-9

STUDY DESIGN: A retrospective data analysis.

OBJECTIVE: To report a comprehensive assessment of preoperative prophylactic inferior vena cava (IVC) filter placement in spine surgery.

SUMMARY OF BACKGROUND DATA: Venous thromboembolism (VTE) is a serious complication after major spinal reconstructive surgery in adults. Specifically, pulmonary embolism (PE) can result in significant morbidity and mortality, and it has been reported in up to 13% of patients. Prophylactic IVC filter placement was initiated for all "high-risk" spinal surgery patients after a pilot study demonstrated decreased VTE-related morbidity and mortality.

METHODS: After institutional review board approval, the medical records of all patients receiving an IVC filter at a single institution from 2000 to 2007 were reviewed. Age, sex, surgical approach, postoperative deep vein thrombosis (DVT), postoperative superficial thrombus, presence of pulmonary or paradoxical embolus, mortality, and IVC filter complications were all evaluated. Indications for IVC filter placement included history of DVT or PE, malignancy, hypercoagulability, prolonged immobilization, staged procedures of longer than 5 segment levels, combined anterior-posterior approaches, iliocaval manipulation during exposure, and anesthetic time of more than 8 hours. Descriptive statistics were used for the analysis of patient characteristics. Nonparametric frequency statistics (odds ratios [OR], χ) were used for analysis of main outcomes.

RESULTS: A total of 219 patients (150 women, 69 men) with a mean age of 58.8 (range, 17-86) years, were analyzed. There were 2 complications from IVC filter placement (66 Greenfield filters; 157 retrievable filters). The incidence of lower extremity DVT was 18.7% (41/219) in 36 patients. PE incidence was 3.7% (8/219 patients), and the paradoxical embolus rate was 0.5% (1 patient). Prophylactic IVC filter use reduced the odds of developing a pulmonary embolus (OR = 3.7, P < 0.05) compared with population controls. Patients receiving Greenfield filters had significantly higher VTE incidence than those receiving retrievable filters (OR = 2.8, P = 0.008). Anesthesia duration of more than 8 hours significantly increases VTE incidence (P = 0.029). No statistical significance (P < 0.05) was noted with combined anterior-posterior approach (118 patients) versus posterior-only approach (101 patients) and the incidence of DVT (24/118, 20.3% for former; 17/101, 16.8% for latter). There were a total of 14 deaths; none related to PE or paradoxical embolism during an 8-year period. Mean and median follow-up was 2.8 and 2.4 years, respectively, with 126 achieving 2 or more years of follow-up.

CONCLUSION: VTE-related morbidity and mortality have heightened the awareness within the spine community to the perioperative management of patients undergoing major spinal reconstruction. Prophylactic IVC filter placement significantly lowers VTE-related events, including PE development, than population controls.

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