• Davide Marco Croci, Martina Dalolio, Raphael Guzman, Luigi Mariani, Stefan Schaeren, Maria Kamenova, and Jehuda Soleman.
• Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland; Department of Spine Surgery, University Hospital of Basel, Basel, Switzerland. Electronic address: davidemarco.croci@usb.ch.
• World Neurosurg. 2019 May 1; 125: e1034-e1041.

ObjectiveDespite increasing use of direct oral anticoagulants (DOACs), guidelines for their perioperative use in spine surgery are still lacking. The main goal of our study was to analyze the occurrence of postoperative bleeding events and possible confounders in patients treated with DOACs who undergo spine surgery.MethodsOf 2777 patients undergoing spine surgery at our institution, 82 (2.9%) were treated with DOACs. The primary endpoint was postoperative bleeding events. Secondary outcome measures were postoperative thromboembolic events and anemia, hematologic findings, perioperative packed red blood cell substitution, operative time, hospital length of stay, morbidity, and mortality. Subanalysis of possible confounders affecting the rates of bleeding was also performed. Additionally, correlation of bleeding event rates and preoperative and postoperative discontinuation of DOACs was analyzed.ResultsOverall postoperative bleeding events rate was 4.9% (n = 4). Preoperative DOAC discontinuation time of <24 hours increased significantly the rate of perioperative packed red blood cell substitution (P = 0.007). Treatment with concomitant blood thinners showed a trend toward higher incidence of bleeding events (P = 0.066), whereas pre-existing kidney failure increased significantly rates of postoperative anemia (P = 0.014). The rate of postoperative thromboembolic events was 4.9% (n = 4); all events occurred with DOAC resumption >72 hours postoperatively.ConclusionsShort preoperative discontinuation time of DOACs, even <24 hours, may be justified, considering an increased risk of perioperative packed red blood cell substitution. Care should be taken with patients treated with concomitant blood thinners and patients with pre-existing kidney disease. Postoperative DOAC resumption >72 hours may increase risk of thromboembolic events.Copyright © 2019 Elsevier Inc. All rights reserved.

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