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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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Jian Guan, Chad D. Cole, Meic H. Schmidt and Andrew T. Dailey

perioperatively. 3 , 4 Rotational thromboelastometry (ROTEM; TEM International GmbH) is a form of viscoelastic testing that allows rapid analysis of multiple coagulation parameters. 6 Although significant questions remain regarding the interpretation and standardization of ROTEM, 10 trauma and transplant surgeons have begun to use this technology in clinical practice to guide transfusion and improve outcomes. 15 , 16 , 21 Investigations into the use of ROTEM for spine surgery (in general) and for deformity surgery (in particular) remain extremely limited. In this study, we

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Thomas J. Buell, Davis G. Taylor, Ching-Jen Chen, Lauren K. Dunn, Jeffrey P. Mullin, Marcus D. Mazur, Chun-Po Yen, Mark E. Shaffrey, Christopher I. Shaffrey, Justin S. Smith and Bhiken I. Naik

have been shown to have prolonged hospitalization, increased readmission and reoperation rates, and higher surgery-related costs. 12 , 22 , 29 , 34 Because of these various complications, there have been significant efforts to reduce the need for perioperative blood product transfusion. 7 , 14 , 16 , 23 , 24 , 28 , 47 Utilization of rotational thromboelastometry (ROTEM) for rapid intraoperative evaluation of the coagulation system may allow early detection and management of coagulopathy and thereby reduce blood loss and perioperative transfusion requirements. 21

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Thomas J. Buell, Davis G. Taylor, Ching-Jen Chen and Bhiken I. Naik

TO THE EDITOR: We read with great interest the outstanding article by Guan and colleagues 2 ( Guan J, Cole CD, Schmidt MH, et al: Utility of intraoperative rotational thromboelastometry in thoracolumbar deformity surgery. J Neurosurg Spine 27:528–533, November 2017 ). This timely study showed intraoperative rotational thromboelastometry (ROTEM)-guided transfusion for posterior thoracolumbar deformity surgery (≥ 7 levels) significantly reduced total blood product transfusion requirements. However, we were left with unresolved questions. We request clarification

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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

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Svetlana Kvint, James Schuster and Monisha A. Kumar

V iscoelastic hemostatic assays (VHAs), such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM), are global assessments of coagulation based on the physical and kinetic properties of clot formation. 52 VHAs allow for rapid, point-of-care testing and identify all phases of hemostasis, from initial fibrin formation to clot lysis. VHAs provide a real-time analysis of hemostasis with information on the kinetics of clot formation and clot stability from the occurrence of the initial thrombin burst to fibrinolysis. Through measurement of the

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Bhargav D. Desai, Davis G. Taylor, Ching-Jen Chen, Thomas J. Buell, Jeffrey P. Mullin, Bhiken I. Naik, Justin S. Smith and Christopher I. Shaffrey

replacement . Bone Joint J 96- B : 1005 – 1015 , 2014 10.1302/0301-620X.96B8.33745 25086114 2 Buell TJ , Buchholz AL , Quinn JC , Mullin JP , Garces J , Mazur MD , : Extended asymmetrical pedicle subtraction osteotomy for adult spinal deformity: 2-dimensional operative video . Oper Neurosurg (Hagerstown) [epub ahead of print], 2018 29920605 3 Buell TJ , Taylor DG , Chen CJ , Naik BI : Rotational thromboelastometry-guided transfusion protocol . J Neurosurg Spine 29 : 118 – 120 , 2018 (Letter) 10.3171/2018.1.SPINE1845 29701562 4

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Christopher I. Shaffrey, Justin S. Smith, Christopher P. Ames, Mitsuru Yagi, Ahmet Alanay and Yoon Ha

DI , Zuo Z , Clark P , Terkawi AS , : Rotational thromboelastometry-guided blood product management in major spine surgery . J Neurosurg Spine 23 : 239 – 249 , 2015 26053893 10.3171/2014.12.SPINE14620 5 Paulus MC , Kalantar SB , Radcliff K : Cost and value of spinal deformity surgery . Spine (Phila Pa 1976) 39 : 388 – 393 , 2014 10.1097/BRS.0000000000000150 24573071 6 Robin GC , Span Y , Steinberg R , Makin M , Menczel J : Scoliosis in the elderly: a follow-up study . Spine (Phila Pa 1976) 7 : 355 – 359 , 1982 6215719

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Jian Guan, Michael Karsy, Andrea A. Brock, William T. Couldwell, John R. W. Kestle, Randy L. Jensen, Andrew T. Dailey, Erica F. Bisson and Richard H. Schmidt

length of stay in patients undergoing craniotomy for tumor, which may partially explain this association. 2 The finding that laboratory costs for our cohort were significantly higher after the policy change was also unexpected, although we believe that this is more likely related to the introduction of new technologies to our hospital system (e.g., rotational thromboelastometry). 8 Case mix prior to the policy change and after the policy change was not significantly different in our cohort, as previously reported. 9 The total number of cases performed before the