The perioperative efficacy and safety of antifibrinolytics in adult spinal fusion surgery

Study Design. Systematic review and meta-Analysis. Objective. Compare outcomes of adult patients undergoing spinal fusion surgery who receive and do not receive perioperative antifibrinolytics to reduce operative blood loss. Summary of Background Data. The clinical potential for antifibrinolytics such as tranexamic acid and epsilon aminocaproic acid to significantly reduce blood loss during adult spinal fusion surgery remains underexplored. Outcomes for assessment included operative blood loss, and other surgical, clinical, and haematological outcomes. Methods. We followed the recommended Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews. Electronic database searches identified 2041 for screening. Data were extracted and analyzed using meta-Analysis of proportions. Results. A total of 11 randomized controlled trials with a total of 937 adult spinal fusion surgery patients were included for analysis. There were 472 (50%) patients who were treated with antifibrinolytics, with 345 of 472 (73%) and 127 of 472 (27%) receiving tranexamic acid and epsilon aminocaproic acid respectively. The use of antifibrinolytics was associated with significantly lower intraoperative (MD-127.08 mL; P = 0.002) and total blood loss (MD-229.76 mL; P<0.00001), as well as incidence of blood transfusion (OR 0.58; P=0.04). There was no significant difference with antifibrinolytic use in terms of many surgical parameters, including surgery duration (P=0.50), overall complications (P=0.21), and length of stay (P=0.88). Finally, postoperative haemoglobin was significantly greater (MD 0.30 g/dL; P=0.02) following antifibrinolytic use, with other haematological parameters mostly unaffected. Conclusion. Based on the highest level comparative evidence available, the possibility for blood loss reduction in adult spinal fusion surgery with the use of perioperative antifibrinolytics is not unreasonable, as it appears both efficacious and safe. In addition to further, larger investigations to validate the associations found in this study, practical aspects such as cost-benefit analysis, and long-Term follow-up will further enhance our understanding.