Efficacy of different types of chemoprophylaxis for venous thromboembolism in elective spine surgery: A network meta-analysis of randomized controlled trials.

Abstract

The purpose of this study was to comprehensively examine the high-level evidence regarding the efficacy and safety of chemoprophylaxis for venous thromboembolism (VTE) for adults in elective spine surgery. A pre-registered network meta-analysis (NMA) (PROSPERO: CRD420251026334) used four databases searched through April 2025 to identify randomized controlled trials (RCTs) that examined various types of VTE chemoprophylaxis for adults in elective spine surgery. Exclusion criteria were non-randomized studies and non-elective spine surgery. This study utilized a random-effects Bayesian NMA model using risk ratio (RR) with 95% confidence intervals and surface under the cumulative ranking curve (SUCRA) for comparisons. Certainty of evidence, risk of bias, and network model transitivity were also assessed. Twelve RCTs were included. Patients (n = 3159; mean age = 54.5 years; mean operative time = 169.0 min) were stratified into one of eight subgroups: direct oral anticoagulant (DOAC; n = 715), low-molecular-weight heparin (LMWH) (n = 814), heparin (n = 117), aspirin (n = 91), tranexamic acid (TXA; n = 363), TXA and DOAC (n = 387), warfarin (n = 35), or no chemoprophylaxis (n = 637) based on the chemoprophylaxis method received. For effectiveness, all chemoprophylactic groups demonstrated an absolute decrease in VTE and DVT incidence compared to the no chemoprophylaxis group; however, no group had a high probability (≥75%) of being the best or worst treatment, indicating no clear evidence of superiority. For safety, all subgroups demonstrated a similar incidence of significant bleeding events and epidural hematoma with no group having a high probability (≥75%) of being the best or worst treatment, indicating no clear evidence of superiority. Rates of epidural hematoma ranged from 0 to 0.56% in all studies. Certainty of evidence was "moderate" for VTE effectiveness and "low" for chemoprophylactic safety. Various types of VTE chemoprophylaxis in elective spine surgery may be clinically equivocal for effectiveness and safety, with no method demonstrating a high probability of superiority. VTE chemoprophylaxis should be used on a case-by-case basis factoring in individual patient variables.