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Multicenter Study
. 2024 Dec 4;106(23):2205-2214.
doi: 10.2106/JBJS.23.01323. Epub 2024 Oct 3.

High-Dose TXA Is Associated with Less Blood Loss Than Low-Dose TXA without Increased Complications in Patients with Complex Adult Spinal Deformity

Andrew H Kim  1 , Kevin C Mo  1 , Andrew B Harris  1 , Renaud Lafage  2 , Brian J Neuman  1 , Richard A Hostin  3 , Alexandra Soroceanu  4 , Han Jo Kim  2 , Eric O Klineberg  5 , Jeffrey L Gum  6 , Munish C Gupta  7 , D Kojo Hamilton  8 , Frank Schwab  9 , Doug Burton  10 , Alan Daniels  11 , Peter G Passias  12 , Robert A Hart  13 , Breton G Line  14 , Christopher Ames  15 , Virginie Lafage  9 , Christopher I Shaffrey  16 , Justin S Smith  17 , Shay Bess  14 , Lawrence Lenke  18 , Khaled M Kebaish  1 ; on behalf of the International Spine Study Group
Collaborators, Affiliations
Multicenter Study

High-Dose TXA Is Associated with Less Blood Loss Than Low-Dose TXA without Increased Complications in Patients with Complex Adult Spinal Deformity

Andrew H Kim et al. J Bone Joint Surg Am. .

Abstract

Background: Tranexamic acid (TXA) is commonly utilized to reduce blood loss in adult spinal deformity (ASD) surgery. Despite its widespread use, there is a lack of consensus regarding the optimal dosing regimen. The aim of this study was to assess differences in blood loss and complications between high, medium, and low-dose TXA regimens among patients undergoing surgery for complex ASD.

Methods: A multicenter database was retrospectively analyzed to identify 265 patients with complex ASD. Patients were separated into 3 groups by TXA regimen: (1) low dose (<20-mg/kg loading dose with ≤2-mg/kg/hr maintenance dose), (2) medium dose (20 to 50-mg/kg loading dose with 2 to 5-mg/kg/hr maintenance dose), and (3) high dose (>50-mg/kg loading dose with ≥5-mg/kg/hr maintenance dose). The measured outcomes included blood loss, complications, and red blood cell (RBC) units transfused intraoperatively and perioperatively. The multivariable analysis controlled for TXA dosing regimen, levels fused, operating room time, preoperative hemoglobin, 3-column osteotomy, and posterior interbody fusion.

Results: The cohort was predominantly White (91.3%) and female (69.1%) and had a mean age of 61.6 years. Of the 265 patients, 54 (20.4%) received low-dose, 131 (49.4%) received medium-dose, and 80 (30.2%) received high-dose TXA. The median blood loss was 1,200 mL (interquartile range [IQR], 750 to 2,000). The median RBC units transfused intraoperatively was 1.0 (IQR, 0.0 to 2.0), and the median RBC units transfused perioperatively was 2.0 (IQR, 1.0 to 4.0). Compared with the high-dose group, the low-dose group had increased blood loss (by 513.0 mL; p = 0.022) as well as increased RBC units transfused intraoperatively (by 0.6 units; p < 0.001) and perioperatively (by 0.3 units; p = 0.024). The medium-dose group had increased blood loss (by 491.8 mL; p = 0.006) as well as increased RBC units transfused intraoperatively (by 0.7 units; p < 0.001) and perioperatively (by 0.5 units; p < 0.001) compared with the high-dose group.

Conclusions: Patients with ASD who received high-dose intraoperative TXA had fewer RBC transfusions intraoperatively, fewer RBC transfusions perioperatively, and less blood loss than those who received low or medium-dose TXA, with no differences in the rates of seizure or thromboembolic complications.

Level of evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

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Conflict of interest statement

Disclosure: This publication was made possible by the Johns Hopkins Institute for Clinical and Translational Research (ICTR), which is funded in part through a grant (UL1TR003098) from the National Center for Advancing Translational Sciences (NCATS), which is a component of the National Institutes of Health (NIH), and the NIH Roadmap for Medical Research. V. Lafage received grant funding from the International Spine Study Group pertaining to the submitted manuscript (paid directly to the institution). J. Smith received grant funding from DePuy Synthes and ISSG pertaining to the submitted manuscript (paid directly to the institution). S. Bess received grant funding from Medtronic, Stryker, Globus, Carlsmed, and SI-BONE pertaining to the submitted manuscript (paid directly to the institution). L. Lenke received funding from Scoliosis Research Society pertaining to the submitted manuscript (paid directly to the institution) and nonfinancial assistance from the Harms Study Group (paid directly to the institution). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I227 ).

References

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    1. Worley N, Marascalchi B, Jalai CM, Yang S, Diebo B, Vira S, Boniello A, Lafage V, Passias PG. Predictors of inpatient morbidity and mortality in adult spinal deformity surgery. Eur Spine J. 2016 Mar;25(3):819-27.
    1. Raphael BG, Lackner H, Engler GL. Disseminated intravascular coagulation during surgery for scoliosis. Clin Orthop Relat Res. 1982 Jan-Feb;(162):41-6.
    1. De la Garza-Ramos R, Nakhla J, Gelfand Y, Echt M, Scoco AN, Kinon MD, Yassari R. Predicting critical care unit-level complications after long-segment fusion procedures for adult spinal deformity. J Spine Surg. 2018 Mar;4(1):55-61.
    1. Mayer PJ, Gehlsen JA. Coagulopathies associated with major spinal surgery. Clin Orthop Relat Res. 1989 Aug;(245):83-8.

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