Is there consensus on the perioperative management of Xa inhibitors in patients undergoing elective spine surgery?—A survey of current spine surgeon practices

Background: Factor Xa inhibitors (Xai) are an increasingly common consideration in perioperative anticoagulation management. However, there no existing guidelines established for use in Spine Surgery. This survey study aims to capture current practice trends regarding the perioperative management of Xai among spine surgeons. Methods: An 11-question survey was sent to all surgeon members of 3 spinal surgery societies. Responses were remitted anonymously. Questions characterized the background and experience of the respondent and inquired into their current perioperative Xai and other anticoagulant management. Questions were all single-best option, multiple-choice. Results: A total of 116 surveys were received. Twenty-six (22.4%) were from neurosurgeons and 90 (77.6%) were from orthopedic surgeons. Practiced preoperative Xai hold length tended to be longer than recommended by the respondent’s medical colleagues. Only 65.2% (P≤0.0001) of respondents practiced in agreement with the recommendations of their medical colleagues. Postoperative Xai holds trended toward longer holds than that of other anticoagulants with 37.9% (P=0.0125) of respondents showed differences within their own practice between length of Xai hold and length of other anticoagulant holds. One out of four respondents reported noticing a change in the rate of perioperative bleeding complications among Xai patients. Despite reported increased bleeding issues, only 39% of those who noted this increase in bleeding complications reported they would hold a Xai longer than other anticoagulants. Conclusions: There exists a wide range of recommended and practiced chronic anticoagulant hold lengths. This inconsistency likely highlights conflicting risk aversion among surgeons, between complications which are viewed as medical (i.e., thromboembolism and stroke) vs. surgical (i.e., compressive hematoma). Yet, survey responses suggest the length of Xai hold times did not necessarily reflect the surgeon’s experience with postoperative bleeding complications in Xai patients. These inconsistent practices highlight the need for further research that can establish guidelines for perioperative management of Xai patients undergoing spine surgery.