Direct Oral Anticoagulants in Patients Undergoing Spine Surgery

Objective Despite increasing use of direct oral anticoagulants (DOACs), guidelines for their perioperative use in spine surgery are still lacking. The main goal of our study was to analyze the occurrence of postoperative bleeding events and possible confounders in patients treated with DOACs who undergo spine surgery. Methods Of 2777 patients undergoing spine surgery at our institution, 82 (2.9%) were treated with DOACs. The primary endpoint was postoperative bleeding events. Secondary outcome measures were postoperative thromboembolic events and anemia, hematologic findings, perioperative packed red blood cell substitution, operative time, hospital length of stay, morbidity, and mortality. Subanalysis of possible confounders affecting the rates of bleeding was also performed. Additionally, correlation of bleeding event rates and preoperative and postoperative discontinuation of DOACs was analyzed. Results Overall postoperative bleeding events rate was 4.9% ( n  = 4). Preoperative DOAC discontinuation time of P  = 0.007). Treatment with concomitant blood thinners showed a trend toward higher incidence of bleeding events ( P  = 0.066), whereas pre-existing kidney failure increased significantly rates of postoperative anemia ( P  = 0.014). The rate of postoperative thromboembolic events was 4.9% ( n  = 4); all events occurred with DOAC resumption >72 hours postoperatively. Conclusions Short preoperative discontinuation time of DOACs, even 72 hours may increase risk of thromboembolic events.