Efficacy and safety of tranexamic acid in posterior lumbar interbody fusion: a meta-analysis of randomized controlled trials
Luan H, Liu K, Peng C, Tian Q, Song X
Journal of orthopaedic surgery and research. 2023;18(1):14
OBJECTIVE To evaluate the efficacy and safety of tranexamic acid (TXA) in hemostasis in patients undergoing posterior lumbar interbody fusion (PLIF) by meta-analysis. METHODS This study was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42022354812). The databases PubMed, Cochrane Library, Web of Science, and Embase were searched for randomized controlled trial (RCT) papers on the use of TXA in patients with PLIF from database establishment to August 2022. Two researchers screened the literature, extracted data, evaluated the risk of bias of the included studies, recorded the authors, sample size, type of study design, and TXA dose of each study, and extracted the intraoperative blood loss, number of blood transfusions, total blood loss, drainage volume, operation time, and incidence of deep venous thrombosis in each study. Meta-analysis was performed using RevMan 5.4 software provided by Cochrane Library. RESULTS A total of 14 RCTs with a total of 1681 patients were included in this study, including 836 patients in the TXA group and 845 patients in the control group. The intraoperative blood loss [mean difference (MD) = - 125.97, 95% confidence interval (CI) (- 138.56, - 113.37), P < 0.0001] and less total blood loss [MD = - 204.28, 95% CI (- 227.38, - 181.18), P < 0.00001] in TXA group were lower than the control group. Statistical significance was also observed in postoperative drainage volume [MD = - 115.03, 95% CI (- 123.89, - 106.17), P < 0.00001], operation time [MD = - 8.10, 95% CI (- 14.49, - 1.71), P = 0.01], and blood transfusion rate [odds ratio (OR) = 0.30, 95% CI (0.23, 0.39), P < 0.00001]. However, there was no statistical difference observed in the incidence of deep venous thrombosis [OR = 0.83, 95% CI (0.56, 1.21), P = 0.33]. CONCLUSION The application of TXA in PLIF can reduce intraoperative blood loss, total blood loss, drainage volume, the incidence of transfusion events, and operation time without increasing the risk of deep venous thrombosis.
A systematic review and meta-analysis of the effects of tranexamic acid in surgical procedure for intracranial meningioma
Wijaya JH, July J, Quintero-Consuegra M, Chadid DP
Journal of neuro-oncology. 2023
PURPOSE During intracranial meningioma surgery, surgeons experience considerable blood loss. Tranexamic acid (TXA) is used to minimize blood loss in several neurosurgical settings. However, evidence and trials are lacking. Our objective is to establish the most recent evidence on TXA safety and efficacy in intracranial meningioma surgery. METHODOLOGY Based upon Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the authors collected fully published English literature on the administration of tranexamic acid for patients undergoing intracranial meningioma surgery using the keywords ["tranexamic acid" and "meningioma"] and its synonyms from Cochrane Central Database, the WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, and PubMed. The primary outcome of the current study was total blood loss. The secondary outcomes include individuals requiring blood transfusion, anesthesia duration, surgical duration, and complication rate. Each included studies' quality was assessed using the JADAD scale. RESULTS For qualitative and quantitative data synthesis, we included five RCTs (n = 321) with the mean age was 47.5 ± 11.9 years for the intervention group and 47.2 ± 11.9 years for the control group. Our meta-analysis showed that the administration of TXA is associated with decreased total blood loss of standardized mean difference (SMD) of -1.40 (95% CI [-2.49, -0.31]), anesthetic time SMD -0.36 (95% CI [-0.63, -0.09]), and blood transfusion requirements RR 0.58 (95% CI [0.34, 0.99]). CONCLUSIONS The current study showed that TXA was associated with reduced intraoperative blood loss and intra- and postoperative blood transfusion. However, the studies are small. More RCT studies with a greater sample size are favorable.
Tranexamic acid use in meningioma surgery - A systematic review and meta-analysis
Clynch AL, Gillespie CS, Richardson GE, Mustafa MA, Islim AI, Keshwara SM, Bakhsh A, Kumar S, Zakaria R, Millward CP, et al
Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2023;110:53-60
Tranexamic Acid (TXA) has been used in medical and surgical practice to reduce haemorrhage. The aim of this review was to evaluate the effect of TXA use on intraoperative and postoperative outcomes of meningioma surgery. A systematic review and meta-analysis was conducted in accordance with the PRISMA statement and registered in PROSPERO (CRD42021292157). Six databases were searched up to November 2021 for phase 2-4 control trials or cohort studies, in the English language, examining TXA use during meningioma surgery. Studies ran outside of dedicated neurosurgical departments or centres were excluded. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Random effects meta-analysis were performed to delineate differences in operative and postoperative outcomes. Four studies (281 patients) were included. TXA use significantly reduced intraoperative blood loss (mean difference 315.7 mls [95% confidence interval [CI] -532.8, -98.5]). Factors not affected by TXA use were transfusion requirement (odds ratio = 0.52; 95% CI 0.27, 0.98), operation time (mean difference = -0.2 h; 95% CI -0.8, 0.4), postoperative seizures (Odds Ratio [OR] = 0.88; 95% CI 0.31, 2.53), hospital stay (mean difference = -1.2; 95% CI -3.4, 0.9) and disability after surgery (OR = 0.50; 95% CI 0.23, 1.06). The key limitations of this review were the small sample size, limited data for secondary outcomes and a lack of standardised method for measuring blood loss. TXA use reduces blood loss in meningioma surgery, but not transfusion requirement or postoperative complications. Larger trials are required to investigate the impact of TXA on patient-reported postoperative outcomes.
Efficacy and Safety Profile of Tranexamic Acid in Traumatic Thoracolumbar Fracture Management: A Systematic Review and Meta-Analysis
Vasu ST, Raheja L, Parmar K, Ramachandran S
International journal of spine surgery. 2022
OBJECTIVE In this article, the authors systematically evaluated the efficacy and safety of tranexamic acid (TXA) in surgeries for spinal trauma. METHODS Potentially relevant academic articles were identified from the Cochrane Library, MEDLINE, PubMed, and Google Scholar. Secondary sources were identified from the references of the included literature. RevMan software was used to analyze the pooled data. RESULTS A total of 7 randomized controlled trials (RCTs) and 2 non-RCTs were included in the review. There were significant differences in total blood loss (standard mean difference [SMD] = -2.54 [95% CI, -3.72, -1.37], P = 0.0001), intraoperative blood loss (SMD = -0.96 [95% CI, -1.28, -0.64], P < 0.00001), postoperative blood loss (SMD = -1.42 [95% CI, -1.72, -1.11], P < 0.00001), and length of hospital stay (SMD = -3.73 [95% CI, -4.41, -3.06], P = 0.00001). No significant differences were found regarding transfusion requirement, operative duration, deep vein thrombosis, and pulmonary embolism between the 2 groups. CONCLUSIONS The present meta-analysis indicates that the use of TXA in spinal surgery decreases blood loss and duration of hospital stay while not increasing the risk of side effects such as deep vein thrombosis and pulmonary embolism. CLINICAL RELEVANCE The study aims to provide clinicians who operate on spine trauma with information on the use of tranexamic acid to decrease blood loss and related complications.
Intracranial Hemorrhage following Spinal Surgery: A Systematic Review of a Rare Complication
Al-Saadi T, Al-Kindi Y, Allawati M, Al-Saadi H
Surgery journal (New York, N.Y.). 2022;8(1):e98-e107
Introduction Intracranial hemorrhage (ICH) is a potentially severe complication of spinal surgeries. The occurrence of such complications causes deterioration of the patient's clinical status and delayed discharge from the hospital. Although no specific etiological factors were identified for this complication, but multiple risk factors might play role in its development, they include the use of anticoagulants, presence of uncontrolled hypertension, and perioperative patient positioning. Aim A systematic review of the literature to investigate the prevalence of different types of intracranial hemorrhages in patients who underwent spinal surgeries. Methods A literature review was conducted using multiple research databases. Data were extracted using multiple variables that were formulated incongruent with the study aim and then further analyzed. Results A total of 79 studies were included in our analysis after applying the exclusion criteria and removing of repeated studies, 109 patients were identified where they were diagnosed with intracranial hemorrhage after spine surgery with a mean age of 54 years. The most common type of hemorrhage was cerebellar hemorrhage (56.0%) followed by SDH and intraparenchymal hemorrhage; 23.9 and 17.4%, respectively. The most common spine surgery was laminectomy (70.6%), followed by fixation and fusion (50.5%), excision of spinal lesions was done in 20.2% of the patient, and discectomy (14.7%). Conclusion The data in this study showed that out of 112 patients with ICH, cerebellar hemorrhage was the most common type. ICH post-spine surgery is a rare complication and the real etiologies behind this complication are still unknown, cerebrospinal fluid drain and durotomy were suggested.
Optimal administration strategies of tranexamic acid to minimize blood loss during spinal surgery: results of a Bayesian network meta-analysis
Cao Z, Li Q, Guo J, Li Y, Wu J
Annals of medicine. 2022;54(1):2053-2063
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BACKGROUND Tranexamic acid (TXA) has been widely used for bleeding reduction in spinal surgery. Available evidence is insufficient to inform clinical decisions making and there remains a lack of comprehensive comparisons of dose regimens and delivery routes. This study is aimed to assess and compare different strategies regarding the involvement of TXA in spinal surgery for the optimal pathway of efficacy and safety. MATERIALS AND METHODS Cochrane Library, PubMed, Embase, Scopus and CNKI were searched for the period from January 1990 to October 2021. A random-effect model was built in the Bayesian network meta-analysis. The surface under the cumulative ranking analysis (SUCRA) and clustering rank analysis was performed for ranking the effects. RESULTS The current network meta-analysis incorporated data from 33 studies with 3302 patients. Combination administration showed superior effects on reducing intraoperative bleeding (SUCRA 78.78%, MD -129.67, 95% CI [(-222.33, -40.58)]) than placebo, and was ranked as top in reducing postoperative bleeding (SUCRA 86.91%, MD -169.92, 95% CI [(-262.71, -83.52)]), changes in haemoglobin (SUCRA 97.21%, MD -1.28, 95% CI [(-1.84, -0.73)]), and perioperative blood transfusion (SUCRA 93.23%, RR 0.10, 95% CI [(0.03, 0.25)]) simultaneously, and was shown as the best effectiveness and safety (cluster-rank value for IBL and VTE: 4057.99 and for TRF and VTE: 4802.26). CONCLUSIONS Intravenous (IV) plus topical administration of TXA appears optimal in the reduction of perioperative bleeding and blood transfusion, while the local infiltration administration is not effective for blood conservation. Further studies are required to verify the current findings.
Patients undergoing spinal surgery (33 studies, n= 3,302).
Tranexamic acid (TXA).
Various comparators: low-dose intravenous (IV), high-dose IV, low-dose topical, high-dose topical, combined use (IV plus topical), oral, local infiltration, multiple IV use before and after surgery, and placebo.
The surface under the cumulative ranking analysis (SUCRA) and clustering rank analysis was performed for ranking the effects. Combination administration showed superior effects on reducing intraoperative bleeding (SUCRA 78.78%, weighted mean difference (MD) -129.67) than placebo, and was ranked as top in reducing postoperative bleeding (SUCRA 86.91%, MD -169.92), changes in haemoglobin (SUCRA 97.21%, MD -1.28), and perioperative blood transfusion (SUCRA 93.23%) simultaneously, and was shown as the best effectiveness and safety.
Is TXA beneficial in open spine surgery? And its effects vary by dosage, age, sites, and locations: A meta-analysis of randomized controlled trials
Liu ZG, Yang F, Zhu YH, Liu GC, Zhu QS, Zhang BY
World neurosurgery. 2022
BACKGROUND The role of tranexamic acid (TXA) in controlling blood loss during spine surgery remains unclear. With the publication of a new randomized-controlled trial (RCT), we conducted a meta-analysis to determine the safety and Efficacy of TXA in spine surgery. METHODS PubMed, Embase, Web of Science, and Cochrane databases were searched for relevant studies through 2022. Only randomized controlled trials were eligible for this study. The extracted data were analyzed using Revman 5.3 software for meta-analysis. RESULTS Twenty randomized controlled trials including 1497 patients undergoing spine surgery were included in this systematic evaluation. Compared with the control group, TXA significantly reduced total blood loss [mean difference (MD) - 218.96, 95% confidence interval（CI） - 309.77 to - 128.14, p < 0.00001], perioperative blood loss [MD - 90.54, 95%（CI） - 139.33 to - 41.75, p =0.0003], postoperative drainage [MD - 102.60, 95%（CI） - 139.51 to - 65.70, p < 0.00001]，reduced hospital stay [MD - 1.42, 95%（CI） - 2.71 to - 0.14, p=0.03], reduced total blood transfusion volume [MD - 551.06, 95%（CI） - 755.90 to - 346.22, p < 0.00001] and INR [MD -0.03, 95%（CI） -0.04 to-0.02, p < 0.00001]. CONCLUSION Based on the meta-analysis of 20 RCTs, we demonstrated that TXA reduces blood loss in open spine surgery, decreases transfusion rates, and shortens hospital stays. The TXA administration during the perioperative period does not increase the incidence of postoperative complications.
Point-of-care platelet function testing for guided transfusion in neurosurgical management of intracranial hemorrhage: a systematic review
Xu FWX, Lim NA, Sim MA, Lean LL, Loh NW, Ng KT, Chua VTY, Chew STH, Ti LK
European journal of medical research. 2022;27(1):191
Given the rising prevalence of antiplatelet therapy, rapid preoperative identification of patients with bleeding diathesis is necessary for the guidance of blood product administration. This is especially relevant in neurosurgery for intracranial hemorrhage (ICH), where indiscriminate transfusions may lead to further hemorrhagic or thromboembolic injury. Point-of-care (POC) testing of platelet function is a promising solution to this dilemma, as it has been proven effective in cardiac surgery. However, to date, POC platelet function testing in neurosurgery has not been extensively evaluated. This systematic review appraises the use of POC platelet function test (PFT) in emergency neurosurgery in terms of its impact on patient outcomes.A comprehensive search was conducted on four electronic databases (Pubmed, MEDLINE, Embase, and Cochrane) for relevant English language articles from their respective inceptions until 1 June 2022. We included all randomized controlled trials and cohort studies that met the following inclusion criteria: (i) involved adult patients undergoing neurosurgery for ICH; (ii) evaluated platelet function via POC PFT; (iii) reported a change in perioperative blood loss; and/or (iv) reported data on treatment-related adverse events and mortality. Assessment of study quality was conducted using the Newcastle Ottawa Quality Assessment Scale for Cohort Studies and Case-Control Studies, and the JBI Critical Appraisal Checklist for Case Series.The search yielded 2,835 studies, of which seven observational studies comprising 849 patients met the inclusion criteria for this review. Overall, there is evidence that the use of POC PFT to assess bleeding risk reduced bleeding events, thromboembolic adverse outcomes, and the length of hospitalization. However, there is currently insufficient evidence to suggest that using POC PFT improves blood product use, functional outcomes or mortality.
The Safety and Effectiveness of Tranexamic Acid in Lumbar Interbody Fusion Surgery: An Updated Meta-analysis of Randomized Controlled Trials
Lin GX, Chen CM, Zhu MT, Zheng L
World neurosurgery. 2022;166:198-211
OBJECTIVE Several previous meta-analyses have been published, followed by additional randomized clinical trials investigating the effects of tranexamic acid (TXA) in patients undergoing posterior lumbar interbody fusion (PLIF) surgery. As a result, the purpose of this research is to present an updated quantitative analysis of the existing literature and to further explicate its effectiveness. METHODS PubMed, Embase, Web of Science, and Cochrane Library databases were searched for randomized controlled trials (RCTs) comparing the application of TXA and placebo in patients undergoing PLIF surgery from their establishment to December 31, 2021. Data on clinical outcomes, perioperative outcomes, and complications were collected. The summary statistics for continuous and dichotomous variables were derived as weighted mean difference (WMD) and relative risk (RR), respectively. RESULTS A total of 12 studies enrolling 1088 participants were included in this meta-analysis. The combined results revealed that TXA can decrease intraoperative blood loss (WMD: -84.83, P < 0.0001), total blood loss (WMD: -189.93, P < 0.00001), hidden blood loss (WMD: -134.69, P = 0.002), postoperative drainage (WMD: -100.71, P < 0.00001), postoperative hemoglobin loss (WMD: 6.21, P < 0.00001), operative time (WMD: -3.80, P = 0.007), hospital stay (WMD: -1.86, P = 0.001), and transfusion rates (RR: 0.41, P < 0.00001) in PLIF without increasing the risk of thromboembolic events (RR: 0.80, P = 0.43). CONCLUSIONS TXA can considerably decrease surgical blood loss, postoperative drainage, reduce operative times, hospital stays, and transfusion rates. Furthermore, the TXA group had lower postoperative hemoglobin drop values than the placebo group.
The efficacy of platelet-rich plasma applicated in spinal fusion surgery: A meta-analysis
Yu H, Zhou Z, Yu B, Sun T, Tang Q, Jia Y
Frontiers in surgery. 2022;9:924753
OBJECTIVE The purpose of this meta-analysis is to evaluate the effect of the application of platelet-rich plasma (PRP) in spinal fusion surgery on the fusion rate of the spine. METHODS A comprehensive search of the PubMed, Embase, Cochrane Library, and Science Direct databases was conducted to identify randomized control trials (RCTs) or observational cohort studies that evaluated the efficacy and safety of PRP in spinal fusion. Data on final fusion rate, changes in the visual analog scale (VAS), estimated blood loss (EBL), and operative time was collected from the eligible studies for meta-analysis. Patients were divided into PRP and non-PRP groups according to whether PRP was used during the spinal fusion procedure. RESULTS According to the selection criteria, 4 randomized controlled trials and 8 cohort studies with 833 patients and 918 levels were included. The outcomes indicated that PRP application is associated with a lower fusion rat (OR = 0.62, 95% CI: (0.43, 0.89), P = 0.009) at final follow-up (>24 months). Subgroup analysis showed a lower rate of spinal fusion in the PRP group compared to the non-PRP group (OR = 0.35, 95% CI: (0.21, 0.58), P < 0.001) when spinal fusion was assessed using only anterior-posterior radiographs. When the bone graft material was a combination of autologous bone + artificial bone, the spinal fusion rate was lower in the PRP group than in the non-PRP group (OR = 0.34, 95% CI: (0.16, 0.71), P = 0.004). The PRP and non-PRP groups showed no significant differences in VAS changes at the 24th postoperative month (WMD = 0.36, 95% CI: (-0.37, 1.09), P = 0.33); Application of PRP does not reduce the estimated blood loss (WMD = -86.03, 95% CI: (-188.23, 16.17), P = 0.10). In terms of operation time, using PRP does not prolong operation time (WMD = -3.74, 95% CI: (-20.53, 13.04), P = 0.66). CONCLUSION Compared with bone graft fusion alone, PRP cannot increase the rate of spinal fusion. Inappropriate methods of spinal fusion assessment or mixing PRP with artificial/allograft bone may have been responsible for the lower rate of spinal fusion in the PRP group. SYSTEMATIC REVIEW REGISTRATION doi: 10.37766/inplasy2022.5.0055.