AA

Summary

Download as a PDF

Venous thromboembolism following SCI is a source of significant morbidity and mortality. The majority of the research is focused on prophylaxis of venous thromboembolism in this very high-risk population. Guidelines, based on best available evidence for DVT prophylaxis in SCI, include use of sequential compression devices for two weeks and anticoagulant for eight to 12 weeks after injury (Maxwell et al. 2002). There is evidence in the literature that 5000 IU subcutaneously of unfractionated heparin delivered every 12 hours in this population may not be sufficient to provide adequate protection. LMWH with enoxaparin (primary drug studied), appears to be more effective and should be considered the new standard of care, given the added benefit of lower risk of bleeding complications. Physical or mechanical prevention methods, in particular gradient pressure stockings and intermittent pneumatic compression, are designed to reduce the impact of stasis due to prolonged immobilization of the lower extremities and have been shown to have a limited impact. There is an intuitive benefit to combining treatment (i.e. pharmacological with mechanical treatment) although the evidence suggests pharmacological measures are the more important of the two for the purpose of prophylaxis.

Deep venous thrombosis is common in SCI patients not receiving prophylactic treatment.

There is level 2 evidence (from two RCTs and one prospective controlled trial; Merli et al. 1988; Agarwal & Mathur 2009; Frisbie & Sasahara 1981) that 5000 IU of low-dose unfractionated heparin is no more effective than placebo in the prophylaxis of venous thrombosis post SCI.

There is level 1b evidence (from one RCT; Green et al. 1988) that adjusted (higher) dose unfractionated heparin is more effective in prophylaxis of venous thromboembolism than 5000 IU low-dose unfractionated heparin but has a higher incidence of bleeding complications.

There is level 1a evidence (from two RCTs, one prospective controlled trial, one pre-post, and one case series; SCI Thromboprophylaxis Investigators 2003a, 2003b; Green et al. 1990, 1994; Maxwell et al. 2002) that low-molecular-weight heparin, in particular enoxaparin, is more effective in reducing venous thromboembolic events, when compared to the standard subcutaneous heparin prophylaxis. Moreover, the incidence of bleeding complications was less in the LMWH group.

There is level 4 evidence (from one case control study; Hebbeler et al. 2004) that 40 mg daily enoxaparin is no more effective than 30 mg twice daily enoxaparin in reducing the incidence of deep venous thrombosis or bleeding complications when used prophylactically.

There is level 1b evidence (from one RCT and one case control study; Chiou-Tan et al. 2003; Slavik et al. 2007) that enoxaparin is no more effective than dalteparin in reducing the risk of deep venous thrombosis or bleeding complications although enoxaparin is more expensive.

There is level 3 evidence (from one case control study; Marciniak et al. 2012) that enoxaparin is no more effective than tinzaparin in reducing the risk of deep venous thrombosis or bleeding complications.

There is level 4 evidence (from one pre-post study and one case series; Chung et al. 2011; Winemiller et al. 1999) that sequential pneumatic compression devices or gradient elastic stockings were associated with a reduced risk of venous thromboembolism post SCI.

There is level 1b evidence (from one RCT; Becker et al. 1987) that rotating treatment tables reduce the incidence of venous thrombi in acute SCI patients.

There is level 3 evidence (from one case control study and one case series study; Merli et al. 1992; Maxwell et al. 2002) that a comprehensive prophylactic treatment of external pneumatic compression, gradient pressure stockings and low dose unfractionated heparin reduces venous thrombosis post SCI.

There is level 4 evidence (from one pre-post study; Aito et al. 2000) that a comprehensive prophylactic regimen of pharmacological and physical measures is more effective in preventing venous thrombosis post SCI when instituted earlier rather than later.

There is level 1b evidence (from one RCT; Halim et al. 2014) that a comprehensive prophylactic treatment of gradient pressure stockings and low molecular weight heparin is more effective than pressure stockings alone in reducing venous thrombosis post SCI.

There is level 3 evidence (from two case control studies, two case series studies, and one pre-post study; Roberts et al. 2011; Gorman et al. 2009; Kinny et al. 1996; Wilson et al. 1994; Jarrell et al. 1983) that inferior vena cava filters significantly reduce the risk of pulmonary emboli in high-risk SCI patients.

There is level 4 (from one case series study; Tomaio et al. 1998) evidence that subcutaneous enoxaparin is a safe, cost-effective and less labour-intensive compared to intravenous heparin for acute DVTs post SCI.