European Spine Journal - 2026-05-05 - Journal Article
Perioperative management of antithrombotic therapy in elderly patients undergoing elective ACDF: implementation and outcomes of a standardized institutional protocol.
Corazzelli G, De Los Rios D, De Rosa G, Fiore F, Corvino S, Leonetti S, Ricciardi F, Di Russo P, Gorgoglione N, Pizzuti V, D'Elia A, Santilli M, Aloj F, Bocchetti A, de Falco R, Cirillo P, Paolini S, Esposito V, Innocenzi G
Topics
Key Takeaway
A substitution-based antithrombotic protocol in 189 elderly ACDF patients produced zero major hemorrhagic or thromboembolic events and equivalent perioperative outcomes across three antithrombotic management groups.
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Summary
This study evaluated a standardized substitution-based perioperative antithrombotic protocol in patients ≥65 years undergoing elective ACDF, stratifying 189 consecutive patients into no-therapy (Group A), primary-prevention (Group B, LMWH bridging), and secondary-prevention (Group C, low-dose aspirin bridge) cohorts. No major hemorrhagic or thromboembolic events occurred in any group, minor complications (Clavien-Dindo I-II) were equivalent across groups, and mJOA and ODI improvement at 3 months was consistent (p>0.3). Non-inferiority TOST analyses confirmed perioperative parameters remained within predefined clinical margins.
Key Limitation
The study is underpowered to detect rare but catastrophic events—specifically epidural hematoma and pulmonary embolism—which are the primary safety concerns driving antithrombotic management decisions in this population.
Original Abstract
OBJECTIVE
Perioperative management of chronic antithrombotic therapy in elderly patients undergoing elective anterior cervical discectomy and fusion (ACDF) remains poorly standardized. This study evaluated the safety and feasibility of an institutional protocol based on temporary substitution rather than interruption of preexisting antithrombotic regimens.
METHODS
We retrospectively analyzed 189 consecutive patients aged ≥ 65 years who underwent elective ACDF between 2019 and 2023. Patients were stratified according to their chronic antithrombotic regimen. Group A included patients with no prior antithrombotic therapy, who received standard postoperative prophylaxis with enoxaparin after drain removal. Group B comprised patients on primary prevention therapy, whose home regimen was discontinued 7 days before surgery and replaced with bridging low-molecular-weight heparin (enoxaparin 40 mg daily) until 15 days postoperatively. Group C included patients on secondary prevention therapy, who suspended their regimen 7 days preoperatively and received low-dose aspirin (100 mg daily) from the preoperative week through postoperative day 15 before resuming their chronic therapy. Primary outcomes were hemoglobin decrease, operative time, and length of stay, while secondary outcomes included complications (Clavien-Dindo classification) and early functional recovery (mJOA, ODI). Non-inferiority analyses using the TOST procedure evaluated whether perioperative outcomes remained within predefined a priori clinical margins across groups.
RESULTS
Baseline characteristics and surgical parameters were comparable among groups. No major hemorrhagic or thromboembolic events occurred. Perioperative parameters and minor complications (Clavien-Dindo I-II) were similar across all groups. Functional improvement at 3 months was consistent (p > 0.3).
CONCLUSION
This substitution-based perioperative protocol proved feasible and clinically safe in elderly ACDF patients. Although underpowered to detect rare events, these findings support prospective studies aimed at further investigating the adoption of standardized replacement strategies in this growing surgical population.