How would you manage bleeding risk in a patient undergoing spinal surgery?

Here’s how readers responded to a You Make the Call question about bleeding prevention in a patient undergoing cervical spine surgery.


Disclaimer: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is solely at your own risk.


I am evaluating a 60-year-old man for cervical spine surgery who has a prolonged prothrombin time (PT) and appears to have mild factor VII (FVII) deficiency. He has no problems with minor lacerations (e.g., shaving) and is physically active. The initial abnormality that prompted referral was a baseline PT of 15.2 seconds, international normalized ratio (INR) of 1.3, with normal partial thromboplastin time. Repeat PT was 13.8 seconds, INR 1.2, with the following factor levels: FVII 46 percent, factor II 86 percent, factor V 87 percent, and factor X 87 percent. The FVII deficiency literature suggests that surgical bleeding is rare if FVII is above 10 percent. One discussion suggested that 30 percent should be okay, but I am concerned about this being a critical bleeding site.

I would consider giving tranexamic acid as prophylaxis preoperatively and a dose postoperatively.

Santosh Saraf, MD
University of Illinois Health
Chicago, IL

I do not see any need for any intervention. Proceed with surgery.

Ranga Brahmamdam, MD
TriHealth Cancer Institute

Cincinnati, OH 

Needs perioperative recombinant FVIIa.

Kelty Baker, MD
Houston Methodist
Houston, TX

I would do a mixing study and anti-phospholipid antibody workup, as this could be a presentation of anti-PL syndrome and would make me consider thromboprophylaxis. If mixing corrects the PT, I would not treat but would observe carefully.

Roy Silverstein, MD
Medical College of Wisconsin
Milwaukee, WI

Due to a high-risk surgery on the C-spine, I would recommend administering fresh frozen plasma preoperatively in a loading dose of 15 to 20 mL/kg, followed by 5 mL/kg every 8 to 12 hours, for a few days until wounds heal.

Natalia Neparidze, MD
Yale School of Medicine
New Haven, CT

I would be cautiously optimistic and clear him for surgery, ready to follow and treat, if there is clear evidence. There is more than usual bleed seen with this kind of surgery.

Panju Prithviraj, MD
Port Clinton, OH

With a FVII level of almost 50 percent and a hemostasis that has already proved intact on several occasions, I would advise surgery without any bleed- ing prophylaxis.

Imre Bodó, MD, PhD
Winship Cancer Institute of Emory University
Atlanta, GA

There are several mutations in the FVII gene that cause prolongation of the PT and are associated with low FVII activity that are of limited (if any) clinical significance (e.g., FVII Padua). These mutations a ect the interaction of FVII with rabbit or bovine brain thromboplastin that is frequently used as the activator for the PT and FVII activity assay. The PT and FVII activity are within reference limits when performed using recombinant human tissue factor (Inno- vin). This would also account for the lack of signi cant abnormal bleeding history in this patient. No need for treatment to prevent abnormal bleeding if PT and FVII activity are normal using Innovin as the activator in the PT and FVII assay.

Michael H. Creer, MD
Penn State Health
Hershey, PA

Sounds like he will do ne, based on his previous history. One might want to have factor VIIa available. I would also be concerned about a post-operative DVT/pulmonary embolism, like any other patient having this type of surgery.

Steven Sandler, MD
Advocate Health Care
Skokie, IL

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