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Bhiken I. Naik, Thomas N. Pajewski, David I. Bogdonoff, Zhiyi Zuo, Pamela Clark, Abdullah S. Terkawi, Marcel E. Durieux, Christopher I. Shaffrey and Edward C. Nemergut

retrospective review of 423 adult patients, reported major intraoperative blood loss (> 4 L) in 24% of patients undergoing 3-column resection osteotomies. 17 In a study of both pediatric and adult cases, Horlocker et al. demonstrated a 16% incidence of significant intraoperative bleeding, with the range of blood loss varying between 0.9 and 20 L. 8 Rapid, real-time evaluation of the coagulation system is paramount during ongoing major blood loss. Rotational thromboelastometry (ROTEM, TEM International GmbH) is a rapid viscoelastometric method for hemostasis testing in whole

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Shangyi Hui and Qianyu Zhuang

TO THE EDITOR: We read with great interest the article by Naik et al. 5 (Naik BI, Pajewski TN, Bogdonoff DL, et al: Rotational thromboelastometry–guided blood product management in major spine surgery. J Neurosurg Spine 23: 239–249, August 2015), in which the case-control study identified hypofibrinogenemia as an important cause of the coagulopathy in major spine surgeries and indicated that rotational thromboelastometry (ROTEM)–guided transfusion would allow for early identification and treatment of hypofibrinogenemia, thereby reducing the intraoperative