Utility of topical tranexamic acid for adult patients with spinal deformity and contraindications to systemic tranexamic acid: initial experience and report of 2 cases

Restricted access

Tranexamic acid (TXA) is an antifibrinolytic agent with demonstrated efficacy in reducing blood loss when administered systemically. However, in patients with contraindications to systemic or intravenous TXA, topical TXA (tTXA) has been shown to reduce perioperative blood loss, with some studies suggesting equivalence compared to systemic TXA. However, these studies have been conducted in healthy cohorts without contraindications to systemic TXA. In the surgical management of adult spinal deformity (ASD), comorbid disease is commonly encountered and may preclude use of systemic TXA. In this subset of patients with ASD who have contraindications for systemic TXA, use of tTXA has not been reported.

The primary objective of this study was to conduct a systematic review on the use of tTXA in spine surgery and to present the authors’ initial experience with tTXA as a novel hemostatic technique for 2 patients with medically complex ASD. Both patients had contraindications to systemic TXA use and underwent high-risk, long-segment fusion operations for correction of ASD. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to obtain studies related to spine surgery and tTXA from the National Institutes of Health PubMed (www.pubmed.gov) database. Criteria for final selection included a demonstration of quantitative data regarding operative or postoperative blood loss with the use of tTXA, and selection criteria were met by 6 articles.

Topical TXA may offer a potential therapeutic role in reducing intra- and postoperative blood loss following long-segment spinal fusion surgeries, particularly for medically complex patients with contraindications to systemic TXA. It is reasonable to consider the use of tTXA as a salvage technique in complex high-risk patients with contraindications to systemic TXA, although further research is needed to delineate safety, magnitude of benefit, and optimization of dosing.

ABBREVIATIONS AP = anterior-posterior; ASD = adult spinal deformity; DVT = deep venous thrombosis; IV = intravenous; PE = pulmonary embolism; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PSIF = posterior spinal instrumentation and fusion; tTXA = topical tranexamic acid; TXA = tranexamic acid.

Article Information

Correspondence Bhargav D. Desai: University of Virginia, Charlottesville, VA. bd3sb@hscmail.mcc.virginia.edu.

INCLUDE WHEN CITING Published online January 25, 2019; DOI: 10.3171/2018.9.SPINE18204.

Disclosures Dr. Shaffrey has direct stock ownership in NuVasive. He is also both a consultant for and a patent holder with Medtronic, NuVasive, and Zimmer-Biomet. Dr. Smith is a consultant for Zimmer-Biomet, NuVasive, K2M, AlloSource, and Cerapedics. He receives support for a non–study-related clinical or research effort that he oversees from DePuy Synthes. He receives fellowship funding from NREF and AOSpine.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    PRISMA flowchart for literature review. Figure is available in color online only.

  • View in gallery

    Case 1. Extension of cervical thoracic spinal fusion to C1–T10. A: Preoperative anterior-posterior (AP) view. B: Preoperative lateral view. C: Postoperative AP view. D: Postoperative lateral view.

  • View in gallery

    Case 2. Extension of T9–L4 posterior fusion to T4–iliac posterior fusion. A: Preoperative AP view. B: Preoperative lateral view. C: Postoperative AP view. D: Postoperative lateral view.

References

  • 1

    Alshryda SSukeik MSarda PBlenkinsopp JHaddad FSMason JM: A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. Bone Joint J 96-B:100510152014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Buell TJBuchholz ALQuinn JCMullin JPGarces JMazur MD: Extended asymmetrical pedicle subtraction osteotomy for adult spinal deformity: 2-dimensional operative video. Oper Neurosurg (Hagerstown) [epub ahead of print] 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Buell TJTaylor DGChen CJNaik BI: Rotational thromboelastometry-guided transfusion protocol. J Neurosurg Spine 29:1181202018 (Letter)

  • 4

    Cheriyan TMaier SP IIBianco KSlobodyanyuk KRattenni RNLafage V: Efficacy of tranexamic acid on surgical bleeding in spine surgery: a meta-analysis. Spine J 15:7527612015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    El-Sharkawi MSSayed SGad WEl-Meshtawy: Effect of topical versus parentral tranexamic acid on blood loss in spinal deformity surgery. A prospective randomized controlled trial. Global Spine J 6 (1 Suppl):s-0036-15826592017 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 6

    Elwatidy SJamjoom ZElgamal EZakaria ATurkistani AEl-Dawlatly A: Efficacy and safety of prophylactic large dose of tranexamic acid in spine surgery: a prospective, randomized, double-blind, placebo-controlled study. Spine (Phila Pa 1976) 33:257725802008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Eubanks JD: Antifibrinolytics in major orthopaedic surgery. J Am Acad Orthop Surg 18:1321382010

  • 8

    Fu DJChen CGuo LYang L: Use of intravenous tranexamic acid in total knee arthroplasty: a meta-analysis of randomized controlled trials. Chin J Traumatol 16:67762013

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Gilbody JDhotar HSPerruccio AVDavey JR: Topical tranexamic acid reduces transfusion rates in total hip and knee arthroplasty. J Arthroplasty 29:6816842014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Guan JCole CDSchmidt MHDailey AT: Utility of intraoperative rotational thromboelastometry in thoracolumbar deformity surgery. J Neurosurg Spine 27:5285332017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Hunt BJ: The current place of tranexamic acid in the management of bleeding. Anaesthesia 70 (Suppl 1):5053 e182015

  • 12

    Ker KBeecher DRoberts I: Topical application of tranexamic acid for the reduction of bleeding. Cochrane Database Syst Rev (7):CD0105622013

  • 13

    Ker KEdwards PPerel PShakur HRoberts I: Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ 344:e30542012

  • 14

    Krohn CDSørensen RLange JERiise RBjørnsen SBrosstad F: Tranexamic acid given into the wound reduces postoperative blood loss by half in major orthopaedic surgery. Eur J Surg Suppl (588):57612003

    • Search Google Scholar
    • Export Citation
  • 15

    Lecker IWang DSWhissell PDAvramescu SMazer CDOrser BA: Tranexamic acid-associated seizures: causes and treatment. Ann Neurol 79:18262016

  • 16

    Li ZJFu XXing DZhang HFZang JCMa XL: Is tranexamic acid effective and safe in spinal surgery? A meta-analysis of randomized controlled trials. Eur Spine J 22:195019572013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Liang JLiu HHuang XXiong WZhao HChua S: Using tranexamic acid soaked absorbable gelatin sponge following complex posterior lumbar spine surgery: a randomized control trial. Clin Neurol Neurosurg 147:1101142016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Lin CQi YJie LLi HBZhao XCQin L: Is combined topical with intravenous tranexamic acid superior than topical, intravenous tranexamic acid alone and control groups for blood loss controlling after total knee arthroplasty: a meta-analysis. Medicine (Baltimore) 95:e53442016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Lin ZXWoolf SK: Safety, efficacy, and cost-effectiveness of tranexamic acid in orthopedic surgery. Orthopedics 39:1191302016

  • 20

    Melvin JSStryker LSSierra RJ: Tranexamic acid in hip and knee arthroplasty. J Am Acad Orthop Surg 23:7327402015

  • 21

    Naik BIDurieux MEKnisely ASharma JBui-Huynh VCYalamuru B: SEER sonorheometry versus rotational thromboelastometry in large volume blood loss spine surgery. Anesth Analg 123:138013892016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Naik BIPajewski TNBogdonoff DIZuo ZClark PTerkawi AS: Rotational thromboelastometry-guided blood product management in major spine surgery. J Neurosurg Spine 23:2392492015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Odabaş ARCetinkaya RSelçuk YKaya HCoşkun U: Tranexamic-acid-induced acute renal cortical necrosis in a patient with haemophilia A. Nephrol Dial Transplant 16:1891902001

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24

    Patel JNSpanyer JMSmith LSHuang JYakkanti MRMalkani AL: Comparison of intravenous versus topical tranexamic acid in total knee arthroplasty: a prospective randomized study. J Arthroplasty 29:152815312014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Raksakietisak MSathitkarnmanee BSrisaen PDuangrat TChinachoti TRushatamukayanunt P: Two doses of tranexamic acid reduce blood transfusion in complex spine surgery: a prospective randomized study. Spine (Phila Pa 1976) 40:E1257E12632015

    • Search Google Scholar
    • Export Citation
  • 26

    Ren ZLi SSheng LZhuang QLi ZXu D: Efficacy and safety of topical use of tranexamic acid in reducing blood loss during primary lumbar spinal surgery: a retrospective case control study. Spine (Phila Pa 1976) 42:177917842017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Saberi HMiri SMPoordel NM: The effects of topically applied tranexamic acid on reduction of post-laminectomy hemorrhage. Tehran Univ Med J 68:5275332010

    • Search Google Scholar
    • Export Citation
  • 28

    Soroceanu AOren JHSmith JSHostin RShaffrey CIMundis GM: Effect of antifibrinolytic therapy on complications, thromboembolic events, blood product utilization, and fusion in adult spinal deformity surgery. Spine (Phila Pa 1976) 41:E879E8862016

    • Search Google Scholar
    • Export Citation
  • 29

    Tse EYCheung WYNg KFLuk KD: Reducing perioperative blood loss and allogeneic blood transfusion in patients undergoing major spine surgery. J Bone Joint Surg Am 93:126812772011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Tuttle JR: Tranexamic acid—a brief review and update. J Blood Disord Med [epub ahead of print] 2016

  • 31

    Vamvakas ECBlajchman MA: Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention. Blood 113:340634172009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Wei ZLiu M: The effectiveness and safety of tranexamic acid in total hip or knee arthroplasty: a meta-analysis of 2720 cases. Transfus Med 25:1511622015

  • 33

    Winter SFSantaguida CWong JFehlings MG: Systemic and topical use of tranexamic acid in spinal surgery: a systematic review. Global Spine J 6:2842952016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Xu DZhuang QLi ZRen ZChen XLi S: A randomized controlled trial on the effects of collagen sponge and topical tranexamic acid in posterior spinal fusion surgeries. J Orthop Surg Res 12:1662017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Yang BLi HWang DHe XZhang CYang P: Systematic review and meta-analysis of perioperative intravenous tranexamic acid use in spinal surgery. PLoS One 8:e554362013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Zhang FWang KLi FNHuang XLi QChen Z: Effectiveness of tranexamic acid in reducing blood loss in spinal surgery: a meta-analysis. BMC Musculoskelet Disord 15:4482014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Zollo RAEaton MPKarcz MPasternak RGlance LG: Blood transfusion in the perioperative period. Best Pract Res Clin Anaesthesiol 26:4754842012

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 259 259 33
Full Text Views 61 61 9
PDF Downloads 82 82 8
EPUB Downloads 0 0 0

PubMed

Google Scholar