J Neurol Surg A Cent Eur Neurosurg 2022; 83(01): 046-051
DOI: 10.1055/s-0041-1731751
Original Article

The Efficiency of Simultaneous Systemic and Topical Use of Tranexamic Acid in Spinal Fusion Surgery

Uzay Erdogan
1   Department of Neurosurgery, University of Health Sciences, Bakırköy Prof. Dr. Mazhar Osman Training and Research Hospital for Neurology, Neurosurgery and Psychiatry, Istanbul, Turkey
Seckin Sari
2   Department of Orthopedics, Sportoteam Sport and Spine Center, Istanbul, Turkey
Ahmet Akbas
3   Department of Neurosurgery, Istanbul Taksim Training and Research Hospital, Istanbul, Turkey
› Author Affiliations


Background and Aim Multilevel posterior spinal fusion surgery in adults is associated with significant intra- and postoperative blood loss. Tranexamic acid (TXA) is an antifibrinolytic agent for reducing blood loss and allogenic blood transfusion. The purpose of this study was to evaluate the efficiency of TXA in reducing blood loss and improving hematologic parameters in adult patients undergoing posterior thoracic/lumbar instrumented spinal fusion surgery.

Patients and Methods This is a retrospective observational study comparing the intra- and postoperative hemodynamic findings of two groups treated with and without TXA. The study included 112 adult patients receiving elective posterior thoracic/lumbar instrumented spinal fusion surgery. The patients were evaluated in terms of age, gender, type of surgery, intraoperative blood loss, pre- and postoperative hemoglobin (Hb) and hematocrit values, postoperative systemic anticoagulant use, intra- and postoperative use of blood products, and the volume of the drainage fluid as an indicator of postoperative blood loss. The TXA group received preoperative 10 mg/kg intravenous TXA, another dose of 10 mg/kg/h in isotonic solution during the operation, and local administration of TXA before the closure of the surgical site (1g in patients undergoing surgery in ≤3 segments, and 2g in patients undergoing surgery in ≥4 segment group).

Results Intra- and postoperative blood loss and need for transfusion were significantly lower in the TXA group. Fifty-three of 112 patients required intra- and postoperative transfusion, and postoperative anticoagulants were given to 25/112 patients. The postoperative Hb level was lower, and the difference of pre- and postoperative Hb values was higher in the non-TXA group (not significant).

Conclusion Simultaneous systemic and topical application of TXA is a safe and efficient blood conservation strategy for adult patients undergoing major multilevel spinal surgery.

Publication History

Received: 08 September 2020

Accepted: 29 December 2020

Article published online:
18 November 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Elgafy H, Bransford RJ, McGuire RA, Dettori JR, Fischer D. Blood loss in major spine surgery: are there effective measures to decrease massive hemorrhage in major spine fusion surgery?. Spine 2010; 35 (09) S47-S56
  • 2 Sokolowski MJ, Garvey TA, Perl II J. et al. Prospective study of postoperative lumbar epidural hematoma: incidence and risk factors. Spine 2008; 33 (01) 108-113
  • 3 Urban MK, Beckman J, Gordon M, Urquhart B, Boachie-Adjei O. The efficacy of antifibrinolytics in the reduction of blood loss during complex adult reconstructive spine surgery. Spine 2001; 26 (10) 1152-1156
  • 4 Mosaad AA, Mohamed H, Elsayed MA. et al. A comparative study between prophylactic high dose of tranexamic acid and low does tranexamic acid in reducing perioperative blood loss in spine surgery. Journal of Clinical Anesthesia and Pain Medicine 2017; 1 (01) 3
  • 5 Choi HY, Hyun SJ, Kim KJ, Jahng TA, Kim HJ. Effectiveness and safety of tranexamic acid in spinal deformity surgery. J Korean Neurosurg Soc 2017; 60 (01) 75-81
  • 6 Winter SF, Santaguida C, Wong J, Fehlings MG. Systemic and topical use of tranexamic acid in spinal surgery: a systematic review. Global Spine J 2016; 6 (03) 284-295
  • 7 Andersson L, Nilsson IM, Niléhn JE, Hedner U, Granstrand B, Melander B. Experimental and clinical studies on AMCA, the antifibrinolytically active isomer of p-aminomethyl cyclohexane carboxylic acid. Scand J Haematol 1965; 2 (03) 230-247
  • 8 Kim KT, Kim CK, Kim YC. et al. The effectiveness of low-dose and high-dose tranexamic acid in posterior lumbar interbody fusion: a double-blinded, placebo-controlled randomized study. Eur Spine J 2017; 26 (11) 2851-2857
  • 9 Luo W, Sun RX, Jiang H, Ma XL. The efficacy and safety of topical administration of tranexamic acid in spine surgery: a meta-analysis. J Orthop Surg Res 2018; 13 (01) 96
  • 10 Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology 1983; 58 (03) 277-280
  • 11 Nadler SB, Hidalgo JH, Bloch T. Prediction of blood volume in normal human adults. Surgery 1962; 51 (02) 224-232
  • 12 Smorgick Y, Baker KC, Bachison CC, Herkowitz HN, Montgomery DM, Fischgrund JS. Hidden blood loss during posterior spine fusion surgery. Spine J 2013; 13 (08) 877-881
  • 13 Wong J, Abrishami A, El Beheiry H. et al. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg Am 2010; 92 (15) 2503-2513
  • 14 Henry DA, Carless PA, Moxey AJ. et al. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2011; 3: CD001886
  • 15 Neilipovitz DT. Tranexamic acid for major spinal surgery. Eur Spine J 2004; 13 (Suppl. 01) S62-S65
  • 16 Colomina MJ, Koo M, Basora M, Pizones J, Mora L, Bagó J. Intraoperative tranexamic acid use in major spine surgery in adults: a multicentre, randomized, placebo-controlled trial. Br J Anaesth 2017; 118 (03) 380-390
  • 17 Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ 2012; 344: e3054
  • 18 Walterscheid Z, O'Neill C, Carmouche J. Tranexamic acid in adult elective orthopaedic and complex spinal surgery: a review. Surg Rehabil 2017; 1: 1-4
  • 19 Willner D, Spennati V, Stohl S, Tosti G, Aloisio S, Bilotta F. Spine surgery and blood loss: systematic review of clinical evidence. Anesth Analg 2016; 123 (05) 1307-1315
  • 20 Shi H, Ou Y, Jiang D, Quan Z, Zhao Z, Zhu Y. Tranexamic acid reduces perioperative blood loss of posterior lumbar surgery for stenosis or spondylolisthesis: a randomized trial. Medicine (Baltimore) 2017; 96 (01) e5718
  • 21 Cheriyan T, Maier II SP, Bianco K. et al. Efficacy of tranexamic acid on surgical bleeding in spine surgery: a meta-analysis. Spine J 2015; 15 (04) 752-761
  • 22 Salam A, King C, Orhan O, Mak V. The great deception: tranexamic acid and extensive pulmonary emboli. BMJ Case Rep 2013; 2013: bcr2012007808
  • 23 Parthvi R, Mehra S. Risk of pulmonary embolism due to tranexamic acid: a case study. Am J Ther 2018; 25 (04) e512-e514
  • 24 Zhang L, Li Y, Liu D. 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. Int Orthop 2020; 44 (10) 2079-2087
  • 25 Lecker I, Wang DS, Romaschin AD, Peterson M, Mazer CD, Orser BA. Tranexamic acid concentrations associated with human seizures inhibit glycine receptors. J Clin Invest 2012; 122 (12) 4654-4666