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Topical Tranexamic Acid: An Effective Hemostatic Agent for Complex Spine Surgeries

Key findings

  • This systematic review and meta-analysis compared the clinical outcomes of 258 patients who received topical tranexamic acid (tTXA) vs. 351 patients who received intravenous TXA (ivTXA) or saline/placebo undergoing complex spine surgeries
  • The use of tTXA significantly reduced operative time, postoperative blood loss, postoperative drain output, transfusion requirement and length of hospital stay, and preserve postoperative hemoglobin level compared with the control group (ivTXA/placebo)
  • However, tTXA did not significantly reduce intraoperative blood loss or postoperative thromboembolic or seizure complications
  • A subgroup analysis demonstrated that low-dose tTXA (250 mg–500 mg) more effectively reduced postoperative blood loss than high-dose regimens (1 g–3 g) by 168 mL vs. 122 mL, respectively (P=0.001)

Complex spine surgeries are often associated with significant amount of perioperative blood loss. Utilization of anti-fibrinolytics to promote surgical hemostasis has been increasingly common to reduce the risk of perioperative blood loss. Intravenous tranexamic acid (ivTXA), an antifibrinolytic, has been demonstrated to promote surgical hemostasis during spine surgeries. However, complications such as convulsive seizures and systematic thrombogenicity have limited the use of ivTXA. Therefore, it's important to understand the potential application of tTXA as a therapeutic alternative to ivTXA.

Nida Fatima, MD, research fellow in neurosurgery, Ganesh M. Shankar, MD, PhD, assistant professor and neurosurgeon, and John H. Shin, MD, director of Spinal Deformity & Spine Oncology Surgery in the Department of Neurosurgery at Massachusetts General Hospital, and colleagues theorized that topical TXA (tTXA) would decrease the risk of postoperative complications because of minimal systemic absorption.

In a systematic review and meta-analysis, they showed that although tTXA decreases postoperative blood loss and transfusion rates compared with ivTXA/saline, it does not decrease postoperative complication rates and intraoperative blood loss. Their results appeared in Neurosurgical Review.

Study Methods

The team found relevant clinical trials published in any language between January 1, 1970, and August 30, 2019, which included seven randomized controlled trials and one non-randomized controlled trial.

609 patients undergoing complex spine surgeries were represented: 258 (42%) who received tTXA and 351 (58%) who received ivTXA or saline. In all included studies, tTXA was administered at the completion of surgery just prior to wound closure.

Primary Analyses

Results for the tTXA group were superior to those of the control group in terms of:

  • Average postoperative hemoglobin (12 ± 0.3 vs. 10.9 ± 0.4 g/dL; P=0.0008)
  • Average postoperative blood loss (233.9 ± 151.4 vs. 384.1 ± 154.9 mL; P<0.00001)
  • Average postoperative drain output (181.2 ± 48.3 vs. 388.7 ± 62.7 mL; P<0.00001)
  • Average operative time (120.6 ± 18.4 vs. 120.8 ± 25.2 minutes; P=0.001)
  • Average length of stay (5.5 ± 3.6 vs. 7.2 ± 4.9 days; P<0.00001)
  • Number of postoperative transfusions (reduced by 61% with tTXA; P=0.007)

The tTXA group did not differ from the control group with regard to:

  • Average intraoperative blood loss (461.2 ± 453.2 vs. 480.1 ± 477.4 mL; P=0.13)
  • Reduction of postoperative thromboembolism or seizures (OR, 2.12; P=0.23)

Subgroup Analysis

Low-dose tTXA (250 mg–500 mg, delivered as gel foam or direct irrigation of the wound) was more effective than a high dose (1 g–3 g) in reducing postoperative blood loss (-167.7 mL vs. -122.2 mL; P=0.001).

Looking Ahead

Considering the continuous bleeding that occurs during spinal deformity surgery, it may be practical to use tTXA as a topical irrigant during spinal deformity surgery. Further clinical trials are necessary to understand the impact of tTXA during complex spine surgeries with focus upon clinical as well as cost-effectiveness.

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