Systematic review and meta-analysis of perioperative intravenous tranexamic acid use in spinal surgery

Abstract

Background: Tranexamic acid (TXA) is well-established as a versatile oral, intramuscular, and intravenous (IV) antifibrinolytic agent. However, the efficacy of IV TXA in reducing perioperative blood transfusion in spinal surgery is poorly documented.

Methodology: We conducted a meta-analysis of randomized controlled trials (RCTs) and quasi-randomized (qi-RCTs) trials that included patients for various spinal surgeries, such as adolescent scoliosis surgery administered with perioperative IV TXA according to Cochrane Collaboration guidelines using electronic PubMed, Cochrane Central Register of Controlled Trials, and Embase databases. Additional journal articles and conference proceedings were manually located by two independent researchers.

Results: Totally, nine studies were included, with a total sample size of 581 patients. Mean blood loss was decreased in patients treated with perioperative IV TXA by 128.28 ml intraoperatively (ranging from 33.84 to 222.73 ml), 98.49 ml postoperatively (ranging from 83.22 to 113.77 ml), and 389.21 ml combined (ranging from 177.83 to 600.60 ml). The mean volume of transfused packed cells were reduced by 134.55 ml (ranging 51.64 to 217.46) (95% CI; P = 0.0001). Overall, the number of patients treated with TXA who required blood transfusions was lower by 35% than that of patients treated with the comparator and who required blood transfusions (RR 0.65; 95% CI; 0.53 to 0.85; P<0.0001, I(2) = 0%). A dose-independent beneficial effect of TXA was observed, and confirmed in subgroup and sensitivity analyses. A total of seven studies reported DVT data. The study containing only a single DVT case was not combined.

Conclusions: The blood loss was reduced in spinal surgery patients with perioperative IV TXA treatment. Also the percentage of spinal surgery patients who required blood transfusion was significantly decreased. Further evaluation is required to confirm our findings before TXA can be safely used in patients undergoing spine surgery.

Figure 1. Method for study search and selection for inclusion.

Figure 2. Risk of bias summary.

review authors' judgments about each risk of bias item for each included study. + is “yes”, − is “no”, ? is “unclear”.

Figure 3. Forest plot diagram showing the effect of TXA on intra-operative blood loss.

The black diamond signifies that the mean difference is in favour of TXA. The size of each square depends on the weight of each study. A green square is given to continuous outcomes.

Figure 4. Forest plot diagram showing the effect of TXA on post-operative blood loss.

The black diamond signifies that the mean difference is in favour of TXA. The size of each square depends on the weight of each study. A green square is given to continuous outcomes.

Figure 5. Forest plot diagram showing the effect of TXA on total blood loss.

The black diamond signifies that the mean difference is in favour of TXA. The size of each square depends on the weight of each study. A green square is given to continuous outcomes.

Figure 6. Forest plot diagram showing the effect of TXA on blood transfusion rate.

The black diamond signifies that the mean difference is in favour of TXA. The size of each square depends on the weight of each study. A blue square is given to dichotomous outcomes.

Figure 7. Forest plot diagram showing the effect of TXA on Amount of transfusion.

Figure 8. Forest plot diagram showing the effect of TXA on DVT.

Figure 9. Funnel plot to assess publication.

Funnel plot to assess publication for the most frequently reported outcome –blood transfusion rate.