Letter to the editor regarding chemical prophylaxis and venous thromboembolism following elective spinal surgery: a systematic review and meta-analysis

I found the article by R. Rahmani et al. to be highly intriguing during my reading [[1]Rahmani R Eaddy S Stegelmann SD Skrobot G Andreshak T. Chemical prophylaxis and venous thromboembolism following elective spinal surgery: A systematic review and meta-analysis.North American Spine Society Journal (NASSJ). 2023; 100295Google Scholar]. In this valuable systematic review, 19 articles were analyzed to establish the general occurrence rates of deep venous thrombosis (DVT), pulmonary embolism (PE), and spinal epidural hematomas (SEH) following elective spine surgery and to assess the impact of chemical thromboprophylaxis on these rates. We want to line out two concerns. In the abstract of the present study, it is clearly mentioned that the known cases of cancer were excluded. Also, in the Baseline patient characteristics section of the results, it is noted that Indications for spine surgeries among included studies varied from degenerative disc disease to spinal canal stenosis and disc herniation, and there is no mention of tumor surgeries. The absence of tumor surgeries in this study's section on exclusion criteria creates a discrepancy with the information presented in these sentences. However, in Table 2 of the study conducted by Cunningham et al., which summarizes features of postoperative spinal epidural hematoma cases, it is obviously stated that patient number 2 and patient number 16 underwent surgeries for excision of T1/3 intradural tumor and L3/4 decompression for intradural tumor respectively [[2]Cunningham JE Swamy G Thomas KC. Does preoperative DVT chemoprophylaxis in spinal surgery affect the incidence of thromboembolic complications and spinal epidural hematomas?.Clinical Spine Surgery. 2011; 24: E31-EE4Google Scholar]. In six studies, encompassing the studies revealed by Pirkle et al., H. M. T. Fawi et al., S. Hamidi et al., Macki et al., Ryan P. McLynn et al., Cloney et al., Thota et al., and Thomas M. Zervos et al. the exclusion of patients with tumors is precisely outlined as one of the of exclusion criteria [3Cloney MB Hopkins B Dhillon E El Tecle N Koski TR Dahdaleh NS. Chemoprophylactic Anticoagulation Following Lumbar Surgery Significantly Reduces Thromboembolic Events After Instrumented Fusions, Not Decompressions.Spine. 2023; 48: 172-179Crossref Scopus (3) Google Scholar, 4Fawi H Saba K Cunningham A Masud S Lewis M Hossain M et al.Venous thromboembolism in adult elective spinal surgery: a tertiary centre review of 2181 patients.The Bone & Joint Journal. 2017; 99: 1204-1209Crossref Scopus (14) Google Scholar, 5Hamidi S Riazi M. Incidence of venous thromboembolic complications in instrumental spinal surgeries with preoperative chemoprophylaxis.Journal of Korean Neurosurgical Society. 2015; 57: 114-118Crossref PubMed Scopus (0) Google Scholar, 6Macki M Haddad Y Suryadevara R Dabaja AL Chedid M Chang V Investigators P. Prophylactic low-molecular-weight heparin versus unfractionated heparin in spine surgery (PLUSS): a pilot matched cohort study.Neurosurgery. 2021; 89: 1097-1103Crossref PubMed Scopus (0) Google Scholar, 7McLynn RP Diaz-Collado PJ Ottesen TD Ondeck NT Cui JJ Bovonratwet P et al.Risk factors and pharmacologic prophylaxis for venous thromboembolism in elective spine surgery.The Spine Journal. 2018; 18: 970-978Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 8Pirkle S Cook DJ Kaskovich S Bhattacharjee S Ho A Shi LL Lee MJ. Comparing bleeding and thrombotic rates in spine surgery: An analysis of 119 888 patients.Global Spine Journal. 2021; 11: 161-166Crossref Scopus (3) Google Scholar, 9Thota DR Bagley CA Al Tamimi M Nakonezny PA Van Hal M Anticoagulation in elective spine cases: rates of hematomas versus thromboembolic disease.Spine. 2021; 46: 901-906Crossref Scopus (3) Google Scholar, 10Zervos TM Bazydlo M Tundo K Macki M Rock J. Risk factors associated with symptomatic deep vein thrombosis following elective spine surgery: a case–control study.World Neurosurgery. 2020; 144: e460-e4e5Crossref Scopus (6) Google Scholar]. Also, in another study by Weber and colleagues, no spinal tumor was among the elective spine surgery cases [[11]Weber B Seal A McGirr J Fielding K. Case series of elective instrumented posterior lumbar spinal fusions demonstrating a low incidence of venous thromboembolism.ANZ Journal of Surgery. 2016; 86: 796-800Crossref Scopus (16) Google Scholar]. On the other hand, surgeries for tumors were not mentioned in the exclusion criteria of nine other studies [12Fourman MS Shaw JD Nwasike CO Boakye LA Dombrowski ME Vaudreuil NJ et al.Use of fondaparinux following elective lumbar spine surgery is associated with a reduction in symptomatic venous thromboembolism.Global Spine Journal. 2020; 10: 844-850Crossref PubMed Scopus (0) Google Scholar, 13Kiguchi MM Schobel H TenEyck E Earls B Pan-Chen S Freedman E et al.The risks and benefits of early venous thromboembolism prophylaxis after elective spinal surgery: A single-centre experience.Journal of Perioperative Practice. 2022; 32: 286-294Crossref Scopus (3) Google Scholar, 14Li X Jiao G Li J Ji W Hao Z Gong F Chen Y Combined Use of tranexamic acid and rivaroxaban in posterior/transforaminal lumbar interbody fusion surgeries safely reduces blood loss and incidence of thrombosis: evidence from a prospective, randomized, double-blind, placebo-controlled study.Global Spine Journal. 2023; 13: 1229-1237Crossref Scopus (5) Google Scholar, 15Nicol M Sun Y Craig N Wardlaw D. Incidence of thromboembolic complications in lumbar spinal surgery in 1,111 patients.European Spine Journal. 2009; 18: 1548-1552Crossref PubMed Scopus (0) Google Scholar, 16Nikouei F Chehrassan M Shakeri M Mahdavi SM Ameri E Eslami A et al.Effect of aspirin in preventing deep vein thrombosis (DVT) after lumbar canal spinal stenosis surgeries: a double-blind parallel randomized clinical trial.Current Orthopaedic Practice. 2022; 10: 1097Google Scholar, 17Shapiro JA Stillwagon MR Padovano AG Moll S Lim MR An Evidence-Based Algorithm for Determining Venous Thromboembolism Prophylaxis After Degenerative Spinal Surgery.International Journal of Spine Surgery. 2020; 14: 599-606Crossref Scopus (1) Google Scholar, 18Yang S-D Liu H Sun Y-P Yang D-L Shen Y Feng S-Q et al.Prevalence and risk factors of deep vein thrombosis in patients after spine surgery: a retrospective case-cohort study.Scientific reports. 2015; 5: 11834Crossref Scopus (47) Google Scholar, 19Zhang L Li Y Liu D Xiao X Guan T Yue H et al.Combined use of tranexamic acid and rivaroxaban in posterior lumbar interbody fusion safely reduces blood loss and transfusion rates without increasing the risk of thrombosis—a prospective, stratified, randomized, controlled trial.International Orthopaedics. 2020; 44: 2079-2087Crossref PubMed Scopus (0) Google Scholar, 20Megan F Jashvant P Liu J Wilson LA Memtsoudis SG. Venous thromboembolism and prophylaxis therapy after elective spine surgery: a population-based study.Canadian Journal of Anesthesia. 2021; 68: 345-357Crossref Scopus (3) Google Scholar]. Additionally, upon conducting a thorough literature review, we identified some studies that showed spinal tumors and their surgeries carry a high risk of hemorrhage and VTE [21Finkelstein J Zaveri G Wai E Vidmar M Kreder H Chow E. A population-based study of surgery for spinal metastases: survival rates and complications.The Journal of Bone & Joint Surgery British Volume. 2003; 85: 1045-1050Crossref PubMed Scopus (0) Google Scholar, 22Pennington Z Ehresman J Schilling A Feghali J Hersh AM Hung B et al.Influence of tranexamic acid use on venous thromboembolism risk in patients undergoing surgery for spine tumors.Journal of Neurosurgery: Spine. 2021; 35: 663-673Crossref Scopus (9) Google Scholar, 23Yoshioka K Murakami H Demura S Kato S Hayashi H Inoue K et al.Comparative study of the prevalence of venous thromboembolism after elective spinal surgery.Orthopedics. 2013; 36: e223-e2e8Crossref Scopus (34) Google Scholar]. In general, it should be highlighted that the lack of direct separate references to the types of surgeries performed in each of the included studies is the main drawback of this study. Another probable weakness that needs to be noticed is the consideration of DVT and PE under the title of venous thromboembolism (VTE). Given the difference between the pooled incidence of DVT (3.3) and PE (0.4), this study would benefit from an isolated analysis of these two complications. None

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