The Spine Journal
Volume 9, Issue 12, December 2009, Pages 1046-1051

NASS Evidence-Based Clinical Guideline

An evidence-based clinical guideline for the use of antithrombotic therapies in spine surgery

Christopher M. Bono MDa, William C. Watters III MDb, Michael H. Heggeness MD, PhDc, Daniel K. Resnick MDd, William O. Shaffer MDe, Jamie Baisden MDf, Peleg Ben-Galim MDc, John E. Easa MDg, Robert Fernand MDh, Tim Lamer MDi, Paul G. Matz MDj, Richard C. Mendel MDk, Rajeev K. Patel MDl, Charles A. Reitman MDc and John F. Toton MDm

aDepartment of Orthopedic Surgery, Brigham & Women's Hospital, 75 Francis St, Boston, MA 02115-6110, USA. bBone & Joint Clinic of Houston, 6624 Fannin St, Ste 2600, Houston, TX 77030-2338, USA. cOrthopedic Department, Baylor College of Medicine, 1709 Dryden Rd, Ste 1230, Houston, TX 77030-2400, USA. dDepartment of Neurosurgery, University of Wisconsin Medical School, 600 Highland, K4/834 Clinical Science Center, Madison, WI 53792-0001, USA. eUniversity of Kentucky, 740 S Limestone St, Kentucky Clinic K-416, Lexington, KY 40536-0001, USA. fDepartment of Neurosurgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226-3522, USA. gMichigan Medical, PC, 12662 Riley St, Ste 120, Holland, MI 49424-8023, USA. hNorth Jersey Medical Village, 516 Hamburg Turnpike, Wayne, NJ 07470-2062, USA. iMayo Clinic Rochester, 200 1st St SW, Charlton 1-145, Rochester, MN 55905-0001, USA. jNeurosurgery & Neurology, LLC, 232 S Woods Mill Rd, Suite 400E, Chesterfield, MO 63017-3417, USA. kSouth Florida Neurosurgery, 4290 Professional Center Dr, Ste 105, Palm Beach Gardnes, FL 33410-4275, USA. lUniversity of Rochester Spine Center, 322 Sandringham Rd, Rochester, NY 14610-3456, USA. m1310 Prentice Dr, Ste G, Healdsburg, CA 95448-5005, USA. Copyright © 2009 Elsevier Inc.

Background context

The objective of the North American Spine Society (NASS) Evidence-Based Clinical Guideline on antithrombotic therapies in spine surgery was to provide evidence-based recommendations to address key clinical questions surrounding the use of antithrombotic therapies in spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of February 2008. The goal of the guideline recommendations was to assist in delivering optimum, efficacious treatment with the goal of preventing thromboembolic events.

Purpose

To provide an evidence-based, educational tool to assist spine surgeons in minimizing the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE).

Study design

Systematic review and evidence-based clinical guideline.

Methods

This report is from the Antithrombotic Therapies Work Group of the NASS Evidence-Based Guideline Development Committee. The work group was composed of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member of the group was involved in formatting a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answers to each clinical question were arrived at via Web casts among members of the work group using standardized grades of recommendation. When Level I to IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline.

Results

Fourteen clinical questions were formulated, addressing issues of incidence of DVT and PE in spine surgery and recommendations regarding utilization of mechanical prophylaxis and chemoprophylaxis in spine surgery. The answers to these 14 clinical questions are summarized in this article. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.

Conclusions

A clinical guideline addressing the use of antithrombotic therapies in spine surgery has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to assist spine surgeons in minimizing the risk of DVT and PE. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (Home) and will remain updated on a timely schedule.

Antithrombotic therapies; Chemoprophylaxis; Mechanical prophylaxis; Deep venous thrombosis; Pulmonary embolism; Spine surgery