Spine Journal - 2026-09-01 - Journal Article
Timing of thromboprophylaxis in acute spinal cord injury patients: a TQIP study in 15,960 patients.
Abbas A, Koucheki R, Toor J, Fowler R, Nathens AB, Yee A, Lewis S, Wilson JR, Witiw CD, Fehlings MG, Whyne C, Badhiwala J
Topics
Key Takeaway
Initiating pharmacologic thromboprophylaxis within 48 hours of surgery (postoperative day 1) in acute SCI patients reduced in-hospital VTE from 5.9% to 4.7% (OR 1.26) and mortality from 4.9% to 4.0% (OR 1.28) without increasing return to OR for spine-related procedures.
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Summary
This TQIP database study (2017–2022) evaluated whether early (<48 hours postoperative) versus late (≥48 hours) pharmacologic thromboprophylaxis affects VTE, mortality, and surgical bleeding risk in acute SCI patients who underwent surgical decompression within 24 hours. Restricted cubic spline analysis identified 48 hours post-surgery as the inflection point for rising VTE risk, and propensity-matched comparison confirmed early initiation reduced VTE (4.7% vs 5.9%, OR 1.26), mortality (4.0% vs 4.9%, OR 1.28), and overall return to OR (2.2% vs 2.9%, OR 1.38). Return to OR specifically for same-level spine procedures did not differ significantly (0.7% vs 1.0%, OR 1.4, p=0.07), suggesting early anticoagulation does not meaningfully increase surgical site hemorrhage risk.
Key Limitation
TQIP does not capture thromboprophylaxis agent, dose, or route, so it is impossible to determine whether findings apply equally to LMWH, UFH, or other agents, or whether dosing protocols confound the timing effect.
Original Abstract
BACKGROUND CONTEXT
Optimal timing of pharmacologic thromboprophylaxis in patients with acute traumatic spinal cord injury (SCI) is unclear. Most guideline recommendations are consensus-based and lacking in primary large-scale data. This study evaluated an ideal timeframe for delivery of thromboprophylaxis in acute SCI.
PURPOSE
Determine the ideal timeframe for initiation of chemical thromboprophylaxis in the setting of acute SCI.
STUDY DESIGN/SETTING
Retrospective cohort study. North American trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program (2017-2022).
PATIENT SAMPLE
Adults (≥16 years) with acute SCI secondary to blunt trauma who underwent surgical decompression within 24 hours.
OUTCOME MEASURES
Primary: in-hospital venous thromboembolism. Secondary: in-hospital return to the operating room, death during admission and length of stay.
METHODS
Restricted cubic splines identified an inflection point defining early versus late thromboprophylaxis initiation, which was used for propensity score-matched comparisons. Covariates for propensity matching included patient, injury, treatment, and hospital characteristics. Effect size was calculated using risk difference (RDs) and odds ratio (OR) for dichotomous outcomes and mean difference (MD) for linear outcomes with associated 95% confidence interval (CI).
RESULTS
Total of 15,960 patients across 511 trauma centers were included. Spline analysis indicated increasing risk after 24-48 hours from surgery. In propensity-matched cohorts for postoperative day 1 (ie, early <48 hours; late ≥48 hours) (N=6,867 per group), early thromboprophylaxis was associated with lower VTE rates (4.7% vs 5.9%; p=.002; OR 1.26 [95% CI: 1.09, 1.46]), fewer returns to operating room overall (2.2% vs 2.9%; p=.004; OR 1.38 [95% CI 1.11, 1.71]), no difference in return to operating room for same-level spine procedure (0.7% vs 1.0%; p=.07; OR 1.4 [95% CI 0.98, 2.02]), lower mortality (4.0% vs 4.9%; p=.003; OR 1.28 [95% CI: 1.09, 1.51]), and shorter length of stay (15.8 vs 16.9 days; p<.001; MD 1.06 days [95% CI: 0.47, 1.65]).
CONCLUSIONS
Thromboprophylaxis by postoperative day 1 after was associated with a decreased risk of venous thromboembolism, decreased returns to the operating room, no increased return to the operating room for related spine procedure, decreased risk of death, and decreased length of stay. Administration of thromboprophylaxis by postoperative day 1 for acute SCI patients may represent a new clinical standard for optimal patient outcomes.