Efficacy and Safety of High-dose Tranexamic Acid Protocol in Adult Spinal Deformity – Analysis of 100 Consecutive Cases

Background/Introduction: Adult spinal deformity (ASD) surgery is a massive undertaking that may involve a significant amount of blood loss, especially when various osteotomy techniques are utilized. Antifibrinolytic agents such as tranexamic acid (TXA) have been used in an attempt to reduce intraoperative blood loss. However, there is no universally accepted dosing protocol for TXA in spine surgery. Moreover, there are very few reports in the literature regarding highdose TXA use in ASD, possibly due to concerns for thromboembolic or seizure risks. This study aims to investigate the safety profile and efficacy of using a high-dose (50mg/kg loading, 5mg/kg/hr infusion) TXA protocol during ASD surgery. Materials/Methods: Consecutive patients undergoing spinal deformity correction over a 14-month period (September 1st 2015 – November 1st 2016) at a single institution were identified. Inclusion criteria were adults (age >= 18 years) who underwent posterior spinal fusion surgery of at least 5 levels. Our standard TXA protocol is 50 mg/kg intravenous loading dose followed by a 5 mg/kg/hr infusion until skin closure. Patient demographics, estimated blood time (EBL), post operative blood transfusion, and other procedure specific information were recorded and analyzed. Results: A total of 100 adult patients were included in the study. Operative procedures were performed by a single surgeon. The mean age was 46.5 years, and 71% of patients were female. Average BMI was 24.7. The average fusion length was 14 levels. 46/100 patients had a primary surgical procedure while the rest were revisions. 61/100 of patients had pelvic fixation. Posterior column osteotomies were performed on 80/100 patients; pedicle subtraction osteotomy (PSO) was performed in 8 patients; and vertebral column resections (VCRs) were performed in 15 patients. Mean intraoperative blood loss among all patients was 1296cc. There was one PE was treated with a heparin drip, and two DVTs which developed in rehab which were treated with oral anticoagulation. There were no MIs, seizures, strokes, or renal complications. Discussion/Conclusion: This study demonstrates that high dose TXA is effective and safe to use in well-selected ASD patients and lays the foundation for further studies on this important topic.