Deep-Vein Thrombosis in Spinal Cord Injuries

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Overview

Prolonged immobility (>3 days) puts a patient at greater risk for the development of a deep vein thrombosis (DVT). In cases of spinal cord injuries this increased risk is certainly realized and effective prophylaxis is required. Prophylaxis can be of a mechanical or pharmacological nature. It has been recommended that anticoagulation be delayed for 72 hours following the initial injury to prevent epidural hematoma formation4. Statistics have found that the overall incidence of DVT in patients with spinal cord injury may be as high as 100% when I- fibrinogen is used1. It has also been shown that the overall mortality from this complication is around 9%.

Practice Parameter DVT in Patients with Cervical SCI

Joint Section on Disorders of the Spine and Peripheral Nerve Guidelines2

Practice Parameter DVT in Patients with Cervical SCI – Joint Section on Disorders of the Spine and Peripheral Nerve Guidelines2

Standards

  • Prophylactic treatment in patients with severe motor deficits is recommended
  • Low molecular weight heparin, rotating bed, adjusted dose heparin or combination of modalities is recommended as a prophylactic treatment strategy.
  • Low dose heparin in combination with pneumatic compression stockings or electrical stimulation is recommended as a prophylactic treatment strategy

Guidelines

  • not recommended: low dose heparin used alone
  • not recommended: oral anticoagulation alone

Options

  • Duplex doppler ultrasound, impedance plethysmography & venography are recommended as diagnostic tests
  • Three month duration of prophylactic treatment for DVT and PE is recommended
  • IVC filters are recommended for patients who fail anticoagulation or who are not candidates for anticoagulation and/or mechanical devices

Prediction Rule for Deep Vein Thrombosis

CLINICAL CHARACTERISTICS SCORE
Active cancer (treatment ongoing within previous 6 months or palliative) +1
Paralysis, paresis, or recent plaster immobilization of the lower extremities +1
Recent bed rest of >3 days or major surgery within 3 months requiring anesthesia +1
Localized tenderness of the deep veins of the leg +1
Entire leg swollen +1
Calf swelling of >3 cm larger than asymptomatic side measured 10 cm below tibial tuberosity +1
Pitting edema confined to the symptomatic leg +1
Collateral superficial veins (not varicosed) +1
Previously documented deep vein thrombosis +1
Alternative diagnosis as likely as or more likely than deep vein thrombosis -2


A score of 0 or less indicates low probability, 1 or 2 indicates moderate probability, and 3 or more indicates high probability.
Modified from Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350:1795-1798.

References

1. Hamilton, Mark G., Russell D. Hull, and Graham F. Pineo. "Venous Thromboembolism in Neurosurgery and Neurology Patients." Neurosurgery 34.2 (1994): 280-296.
2. Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons: Chapter 10: Deep venous thrombosis and thromboembolism in patients with cervical spine cord injuries. Neurosurgery 50 Supplement (2): Guidelines for the management of acute cervical spine and spinal cord injuries: S73-80, 2002.
3. Freischlag, Julie A., and Jennifer A. Heller. "Chapter 65, Venous Disease." Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. By David C. Sabiston and Courtney M. Townsend. Philadelphia: Saunders/Elsevier, 2008. 1801-818.
4. Lee, Yu-Po, Cary Templin, Frank Eismont, and Steven R. Garfin. "Chapter 30, Throacic and Upper Lumbar Spine Injuries." Skeletal Trauma: Basic Science, Management, and Reconstruction. By Bruce D. Browner. Philadelphia: Saunders, 2003. 915-77.
5. Greenberg, Mark S. "Deep-Vein Thrombosis in Spinal Cord Injuries." Handbook of Neurosurgery. 7th ed. New York, NY: Thieme, 2010. 937-38
6. Ginsberg, Jeffrey. "Chapter 81, Peripheral Venous Disease." Goldman's Cecil Medicine. By Russell L. Cecil, Lee Goldman, and Andrew I. Schafer. Philadelphia: Elsevier/Saunders/, 2012. 499-506
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