A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis

doi:10.1177/2192568217702107

. 2017 Sep;7(3 Suppl):212S-220S.

doi: 10.1177/2192568217702107. Epub 2017 Sep 5.

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis

Michael G Fehlings^{1

2}, Lindsay A Tetreault^{1

3}, Bizhan Aarabi⁴, Paul Anderson⁵, Paul M Arnold⁶, Darrel S Brodke⁷, Anthony S Burns⁸, Kazuhiro Chiba⁹, Joseph R Dettori¹⁰, Julio C Furlan^{2

8}, Gregory Hawryluk⁷, Langston T Holly¹¹, Susan Howley¹², Tara Jeji¹³, Sukhvinder Kalsi-Ryan¹, Mark Kotter¹⁴, Shekar Kurpad¹⁵, Brian K Kwon¹⁶, Ralph J Marino¹⁷, Allan R Martin¹, Eric Massicotte¹, Geno Merli¹⁸, James W Middleton¹⁹, Hiroaki Nakashima²⁰, Narihito Nagoshi^{1

21}, Katherine Palmieri⁶, Anoushka Singh¹, Andrea C Skelly¹⁰, Eve C Tsai²², Alexander Vaccaro²³, Jefferson R Wilson^{2

24}, Albert Yee²⁵, James S Harrop²³

Affiliations

¹ Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
² University of Toronto, Toronto, Ontario, Canada.
³ School of Medicine, University College Cork, Cork, Ireland.
⁴ University of Maryland School of Medicine, Baltimore, MD, USA.
⁵ University of Wisconsin, Madison, WI, USA.
⁶ The University of Kansas, Kansas City, KS, USA.
⁷ University of Utah, Salt Lake City, UT, USA.
⁸ Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.
⁹ National Defense Medical College, Saitama, Japan.
¹⁰ Spectrum Research, Inc, Tacoma, WA, USA.
¹¹ University of California at Los Angeles, Los Angeles, CA, USA.
¹² Christopher & Dana Reeve Foundation, Short Hills, NJ, USA.
¹³ Ontario Neurotrauma Foundation, Toronto, Ontario, Canada.
¹⁴ University of Cambridge, Cambridge, UK.
¹⁵ Medical College of Wisconsin, Milwaukee, WI, USA.
¹⁶ University of British Columbia, Vancouver, British Columbia, Canada.
¹⁷ Thomas Jefferson University Hospital, Philadelphia, PA, USA.
¹⁸ Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.
¹⁹ University of Sydney, Sydney, New South Wales, Australia.
²⁰ Nagoya University Graduate School of Medicine, Nagoya, Japan.
²¹ Keio University School of Medicine, Keio, Japan.
²² University of Ottawa, Ottawa, Ontario, Canada.
²³ Thomas Jefferson University, Philadelphia, PA, USA.
²⁴ Li Ka Shing Knowledge Institute, St. Michael s Hospital, Toronto, Ontario, Canada.
²⁵ Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

PMID: 29164026
PMCID: PMC5684841
DOI: 10.1177/2192568217702107

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis

Michael G Fehlings et al. Global Spine J. 2017 Sep.

. 2017 Sep;7(3 Suppl):212S-220S.

doi: 10.1177/2192568217702107. Epub 2017 Sep 5.

Authors

Affiliations

¹ Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
² University of Toronto, Toronto, Ontario, Canada.
³ School of Medicine, University College Cork, Cork, Ireland.
⁴ University of Maryland School of Medicine, Baltimore, MD, USA.
⁵ University of Wisconsin, Madison, WI, USA.
⁶ The University of Kansas, Kansas City, KS, USA.
⁷ University of Utah, Salt Lake City, UT, USA.
⁸ Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.
⁹ National Defense Medical College, Saitama, Japan.
¹⁰ Spectrum Research, Inc, Tacoma, WA, USA.
¹¹ University of California at Los Angeles, Los Angeles, CA, USA.
¹² Christopher & Dana Reeve Foundation, Short Hills, NJ, USA.
¹³ Ontario Neurotrauma Foundation, Toronto, Ontario, Canada.
¹⁴ University of Cambridge, Cambridge, UK.
¹⁵ Medical College of Wisconsin, Milwaukee, WI, USA.
¹⁶ University of British Columbia, Vancouver, British Columbia, Canada.
¹⁷ Thomas Jefferson University Hospital, Philadelphia, PA, USA.
¹⁸ Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.
¹⁹ University of Sydney, Sydney, New South Wales, Australia.
²⁰ Nagoya University Graduate School of Medicine, Nagoya, Japan.
²¹ Keio University School of Medicine, Keio, Japan.
²² University of Ottawa, Ottawa, Ontario, Canada.
²³ Thomas Jefferson University, Philadelphia, PA, USA.
²⁴ Li Ka Shing Knowledge Institute, St. Michael s Hospital, Toronto, Ontario, Canada.
²⁵ Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

PMID: 29164026
PMCID: PMC5684841
DOI: 10.1177/2192568217702107

Abstract

Introduction: The objective of this study is to develop evidence-based guidelines that recommend effective, safe and cost-effective thromboprophylaxis strategies in patients with spinal cord injury (SCI).

Methods: A systematic review of the literature was conducted to address key questions relating to thromboprophylaxis in SCI. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest."

Results: Based on conclusions from the systematic review and expert panel opinion, the following recommendations were developed: (1) "We suggest that anticoagulant thromboprophylaxis be offered routinely to reduce the risk of thromboembolic events in the acute period after SCI;" (2) "We suggest that anticoagulant thromboprophylaxis, consisting of either subcutaneous low-molecular-weight heparin or fixed, low-dose unfractionated heparin (UFH) be offered to reduce the risk of thromboembolic events in the acute period after SCI. Given the potential for increased bleeding events with the use of adjusted-dose UFH, we suggest against this option;" (3) "We suggest commencing anticoagulant thromboprophylaxis within the first 72 hours after injury, if possible, in order to minimize the risk of venous thromboembolic complications during the period of acute hospitalization."

Conclusions: These guidelines should be implemented into clinical practice in patients with SCI to promote standardization of care, decrease heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.

Keywords: acute spinal cord injury; anticoagulant; anticoagulant thromboprophylaxis; guideline; spinal cord injury; thromboprophylaxis; traumatic spinal cord injury.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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References

1. Teasell RW, Hsieh JT, Aubut JA, et al. Venous thromboembolism after spinal cord injury. Arch Phys Med Rehabil. 2009;90:232–245. doi:10.1016/j.apmr.2008.09.557. - PMC - PubMed
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1. Gerlach R, Raabe A, Beck J, Woszczyk A, Seifert V. Postoperative nadroparin administration for prophylaxis of thromboembolic events is not associated with an increased risk of hemorrhage after spinal surgery. Eur Spine J. 2004;13:9–13. doi:10.1007/s00586-003-0642-8. - PMC - PubMed
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[1] Teasell RW, Hsieh JT, Aubut JA, et al. Venous thromboembolism after spinal cord injury. Arch Phys Med Rehabil. 2009;90:232–245. doi:10.1016/j.apmr.2008.09.557. - PMC - PubMed

[2] Teasell RW, Hsieh JT, Aubut JA, et al. Venous thromboembolism after spinal cord injury. Arch Phys Med Rehabil. 2009;90:232–245. doi:10.1016/j.apmr.2008.09.557. - PMC - PubMed

[3] Miranda AR, Hassouna HI. Mechanisms of thrombosis in spinal cord injury. Hematol Oncol Clin North Am. 2000;14:401–416. - PubMed

[4] Miranda AR, Hassouna HI. Mechanisms of thrombosis in spinal cord injury. Hematol Oncol Clin North Am. 2000;14:401–416. - PubMed

[5] Cheng JS, Arnold PM, Anderson PA, Fischer D, Dettori JR. Anticoagulation risk in spine surgery. Spine (Phila Pa 1976). 2010;35(9 suppl):S117–S124. doi:10.1097/BRS.0b013e3181d833d4. - PubMed

[6] Cheng JS, Arnold PM, Anderson PA, Fischer D, Dettori JR. Anticoagulation risk in spine surgery. Spine (Phila Pa 1976). 2010;35(9 suppl):S117–S124. doi:10.1097/BRS.0b013e3181d833d4. - PubMed

[7] Gerlach R, Raabe A, Beck J, Woszczyk A, Seifert V. Postoperative nadroparin administration for prophylaxis of thromboembolic events is not associated with an increased risk of hemorrhage after spinal surgery. Eur Spine J. 2004;13:9–13. doi:10.1007/s00586-003-0642-8. - PMC - PubMed

[8] Gerlach R, Raabe A, Beck J, Woszczyk A, Seifert V. Postoperative nadroparin administration for prophylaxis of thromboembolic events is not associated with an increased risk of hemorrhage after spinal surgery. Eur Spine J. 2004;13:9–13. doi:10.1007/s00586-003-0642-8. - PMC - PubMed

[9] Shiffman RN, Michel G. Toward improved guideline quality: using the COGS statement with GEM. Stud Health Technol Inform. 2004;107:159–163. - PubMed

[10] Shiffman RN, Michel G. Toward improved guideline quality: using the COGS statement with GEM. Stud Health Technol Inform. 2004;107:159–163. - PubMed

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A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis

Affiliations

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis

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