The Use of Antiplatelet Agents in Elective Spine Surgery: A Systematic Review and Meta-analysis

Introduction: The number of patients on antiplatelet medications undergoing elective spine surgery is rising. While these medications may increase perioperative bleeding risk, discontinuing them raises the risk of thromboembolic events. No clear guidelines exist for perioperative management of antiplatelet therapy (APT) in elective spine surgery. This systematic review and meta-analysis assesses the safety of continuing versus discontinuing antiplatelet therapy during elective thoracolumbar spine surgery.

Methods: A PRISMA guided literature search through September 2023 was conducted including studies reporting the use of antiplatelet agents. Data extracted included the timing of discontinuation (if applicable), perioperative complications such as hemorrhagic (spinal epidural hematoma (SEH)) and thromboembolic events (deep venous thrombosis and pulmonary embolism), estimated blood loss (EBL), and reoperation rates.

Results: Nine studies met inclusion criteria. Group 1 compared patients who continued APT during surgery versus those who did not take any antiplatelets (six studies). Group 2 compared patients who discontinued APT preoperatively with those not on antiplatelets (three studies). In Group 1, patients continuing APT had a statistically significant but clinically insignificant increase in EBL (SMD = 0.22 mL, p < 0.001). There was no significant increase in spinal epidural hematoma (RR = 4.61, p = 0.346) or thrombotic events (RR = 1.55, p = 0.754) in this group. In Group 2, patients who discontinued APT had significantly lower EBL (SMD = -0.08 mL, p = 0.016) compared to those not on antiplatelets, but the difference was clinically insignificant. However, discontinuing antiplatelets preoperatively led to a higher risk of SEH (RR = 2.08, p = 0.027) and thrombotic events (RR = 15.55, p = 0.002) compared to patients who did not take antiplatelets.

Conclusion : Continuing APT during elective thoracolumbar spine surgery is associated with a non-clinically significant increase in blood loss and does not significantly increase the risk of hemorrhagic or thromboembolic events. Discontinuing APT, however, increases the risk of both thromboembolic and hemorrhagic complications. These results support considering continued APT in selected patients, though further research is needed to guide definitive management strategies.