Topical Application of Tranexamic Acid to Reduce Blood Loss During Spine Surgery

U.S. service members have seen an increasing severity and complexity of injuries during the Global War on Terrorism due to unconventional tactics by insurgent forces and use of high-energy improvised explosive devices. The treatment of these patients is complicated, often requiring a multidisciplinary team with various medical specialties coordinating and optimizing care. There have been unique challenges in the polytrauma combat casualty, and we have extrapolated the surgical treatment of high-energy spinal column injuries from civilian trauma following high-speed motor vehicle crashes or falls from significant heights. For patients undergoing complex spinal trauma fixation, a significant concern is acute blood loss both during and after surgery, as there continues to be significant bleeding from the surgical wound. There are many strategies employed to decrease intra-operative blood loss, including meticulous surgical technique and control of bleeding arteries and veins using electrocautery, and some surgeons have employed the use of intravenous medications to decrease bleeding during dental surgery, open heart surgery, total joint replacement surgery, and spinal deformity surgery. Numerous studies on the use of tranexamic acid (TXA) delivered intravenously have found significantly decreased perioperative blood loss and the rate of blood transfusions. TXA is a synthetic medication and works to inhibit the breakdown of blood clot formation. However, there has been some concern with the use of this medication as an intravenous medication due to the wide distribution of the medication throughout the body and the potential to promote harmful blood clots throughout the body, rather than to just control bleeding and reduce clot breakdown at the surgical site. However, there have been numerous studies evaluating the risk of this complication, and none have found a higher risk of blood clots in the body or extremities (deep vein thrombosis [DV]; pulmonary embolism [PE]). Given this concern, some surgeons have investigated the use of topical TXA, which has been proposed as a safer, target-directed route of administration to reduce post-operative bleeding from the local, surgical field. Direct topical application of TXA is thought to decrease microvascular bleeding at the site of raw tissue surfaces following surgical dissection. The use of topical TXA was recently studied following total knee replacement and was found to significantly decrease post-operative blood loss and the rate of blood transfusion. This study also found minimal systemic absorption after topical application and did not find an increased rate of DVTs in the legs or pulmonary embolism between the treatment group and placebo group.

Reducing perioperative blood loss is critically important in the treatment of multiply injured combat casualties, and major blood loss during complex spine trauma surgery is a significant concern. Similar to previous studies in dental, cardiac, and total knee arthroplasty procedures, the use of topical TXA during complex combat-related spine trauma surgery can be a cost-effective and simple route of administration to reduce blood loss, with no significant systemic effects. Patients would be expected to benefit immediately by decreasing blood loss and the need for blood transfusion post-operatively, thereby exposing them to less risk of transfusion reactions or disease transmission. This may also potentially decrease the rate of surgical site infection because patients have been found to have a significantly increased risk for surgical site infection after blood transfusion due to changes in the immune system and by also decreasing the amount of blood that collects under the surgical wound, which serves as excellent medium for bacterial growth. This proposed intervention is innovative and novel, and it can be incorporated into routine clinical practice with immediate beneficial impacts on the care of our Warfighters by (1) decreasing the necessity for blood transfusions, (2) reducing surgical site infections, which are a significant burden on the patient, and (3) significantly decreasing the cost of perioperative care of combat and civilian-related spine trauma.