Postoperative Management of Direct Oral Anticoagulants After Elective Spine Surgery

Study design: Retrospective monocentric study. Objectives: To determine a safe interval for the resumption of DOACs based on the risk of postoperative surgical reoperation in the month following spine surgery. Summary of Background Data: More patients scheduled for spine surgeries are being treated with direct oral anticoagulants (DOACs). Scientific society guidelines recommend the resumption of DOACs 2–3 days postoperatively. However, spine surgeries could be associated with an increased risk of complications warranting urgent surgical revision. Early resumption of DOACs imposes a 3–5-day delay before any possible intervention, raising challenges for the surgeon. Methods: All patients who had spine surgery between 2006 and 2020 were included. Data on the occurrence of reoperation, age, sex, duration of surgery, surgeon’s experience, year, and type of surgery were collected. The main outcome was the occurrence of reoperation and the time to reoperation. Results: In total, 2540 patients, who underwent 3109 spine surgeries, were included. There were 260 reoperations that occurred in the month following the index surgery, of which 230 (7.39%) were due to complications requiring urgent revision surgery. More than 80% of the revision surgeries occurred within the 15 days following the index surgery, with half occurring after postoperative day 5. A longer duration of the surgery, nighttime surgery, and the type of surgery (multilevel fusions, surgery for surgical site infection) were associated with a significantly increased risk of revision within the month following the surgery. Conclusions: Although the resumption of DOACs 2–3 days postoperatively is safe in terms of bleeding risk, we believe that this interval is short considering the risk of revision during the first month after surgery. Timing of DOACs’ resumption should be tailored to the patient’s comorbidities and to the surgical characteristics; it should sometimes involve a multidisciplinary discussion.