24–48 hour preoperative “surveillance” lower extremity venous Doppler's: Aren’t they worthwhile prior to spine surgery?
- Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, New York - 11501, USA
Nancy E. Epstein
Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, New York - 11501, USA
DOI:10.4103/2152-7806.196763Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Nancy E. Epstein. 24–48 hour preoperative “surveillance” lower extremity venous Doppler's: Aren’t they worthwhile prior to spine surgery?. 26-Dec-2016;7:
How to cite this URL: Nancy E. Epstein. 24–48 hour preoperative “surveillance” lower extremity venous Doppler's: Aren’t they worthwhile prior to spine surgery?. 26-Dec-2016;7:. Available from: http://surgicalneurologyint.com/surgicalint_articles/24-48-hour-preoperative-surveillance-lower-extremity-venous-dopplers-arent-they-worthwhile-prior-to-spine-surgery/
Background:Most previous studies focused on the utility of Doppler surveillance to determine the incidence of deep venous thrombosis (DVT) following spine surgery. Here, we utilized Doppler surveillance to assess the frequency of DVT prior to spine surgery.
Methods:We asked, how often do patients exhibit preoperative DVT? To answer this, for over a 7-month period, bilateral lower extremity venous Doppler's were prospectively obtained 24–48 hours prior to a variety of spinal operations among 45 patients. This did not include an analysis of postoperative venous Doppler's/incidence of pulmonary embolism for these patients.
Results:Of the 45 patients, 3 (6.7%) exhibited preoperative positive/abnormal venous duplex studies (unilaterally) that led to cancellation of spinal surgery. One patient, a 56-year-old female, with a C6-C7 cervical disc, demonstrated a proximal right lower extremity DVT; she required full-dose anticoagulation and her surgery was cancelled. In two cases, a 42-year-old female and a 55-year-old male, exhibited DVT in the right posterior tibial and left peroneal veins respectively; both operations were cancelled, and they were placed on anticoagulants by their internists.
Conclusions:Over a 7-month period, prospective “surveillance Dopplers” of both lower extremities obtained 24–48 hours prior to spinal surgery documented 3 (6.7%) positive studies out of a series of 45 patients. One instance of DVT was proximal (e.g. femoral in local) whereas 2 were distal. These data showed that preoperative surveillance Doppler of both lower extremities was “worthwhile.” However, performing these studies earlier than 24-48 hrs prior to surgery would help avoid last minute cancellations.
Keywords: Deep venous thrombosis, distal, positive studies, preoperative, proximal, spine surgery, surveillance lower extremity Dopplers
The incidence of lower extremity deep venous thrombosis (DVT) prior to spine surgery is not well documented. For years, we have been seeing patients with positive “surveillance” venous Doppler studies of both lower extremities and/or even positive computed tomography angiography-pulmonary embolism (CTA-PE) protocols on days 1 and 2 following spinal surgery. Although we suspected that at least some of these patients had preoperatively undiagnosed DVT and even pulmonary embolism (PE), particularly in those with preoperative neurological deficits (e.g. foot drop), we had no clear documentation for this hypothesis. This prompted the development of a prospective protocol that required all of the author's patients who were to undergo spine surgery (since March 2016 with Rankin Scores of 3 or more indicating varying degrees of paresis) to undergo preoperative bilateral lower extremity “surveillance” Doppler studies 24–48 hours prior to surgery [Tables
6.7% incidence of positive “surveillance” bilateral lower extremity Dopplers prior to spine surgery in patients with Rankin scores of 3 or greater
Of the 45 patients scheduled for spine surgery since March 2016, 3 (6.7%) exhibited preoperative positive unilateral venous duplex studies that led to cancellation of surgery [
Review of risks/benefits of different regiments of prophylaxis for deep venous thrombosis and pulmonary embolism in Neurosurgery (2005)
In a review of the DVT/PE literature regarding spinal surgery, Epstein noted (2005) that approximately 2 million people in the US develop DVT, whereas approximately 100,000 have fatal PE/year [
Efficacy of alternating pneumatic compression stocking prophylaxis alone against deep vein thrombosis in cervical and lumbar spine surgery (2005–2006)
Citing a 2–4% risk of major perioperative hematomas attributed to mini-heparin/low-dose heparin prophylaxis in cranial and 0.7% in spine surgery, Epstein evaluated the efficacy of PCS alone without chemical prophylaxis in cervical and lumbar surgery [
Study confirms value of postoperative computed tomographic angiography-pulmonary embolism protocol in diagnosing pulmonary embolism despite negative lower extremity “surveillance” Dopplers (2011)
Epstein et al. (2011) evaluated the frequency of positive CTA-PE protools despite negative bilateral lower extremity postoperative “surveillance Dopplers) performed in 240 patients undergoing spinal surgery all of whom received PCS prophylaxis alone [
Safety/efficacy of prophylactic inferior vena cava filter placement for two morbidly obese patients prior to lumbar surgery
In 2015, Epstein evaluated the safety/efficacy of preoperative placement of prophylactic IVC filters in two morbidly obese patients [criteria body mass index (BMI) >40 or >35 with 2 major comorbid factors] about to undergo L1-S1 multilevel decompressive lumbar laminectomies [
More recent study confirms value of postoperative bilateral lower extremity “surveillance” Dopplers in patient undergoing spinal surgery
A recent study by Piper et al. documented the value of performing bilateral lower extremity “surveillance” Doppler's of both lower extremities [
“Worthwhile” preoperative surveillance Dopplers of both lower extremities prior to spine surgery: Present study
Utilizing “surveillance preoperative Doppler” of the lower extremities prospectively performed in 45 patients 24–48 hours prior to spinal surgery, we encountered 3 (6.7%) positive studies: One proximal DVT and two distal DVTs [
Recommendations regarding preoperative “surveillance” lower extremity Dopplers prior to lumbar surgery
We would recommend utilizing surveillance venous Dopplers of both lower extremities prior to spine surgery, particularly for those with Rankin scale scores of 3 or greater (e.g., with a paretic leg/focal deficit) deficits. Of Surgical Neurology International Spine to comment further as to whether “surveillance” Doppler would promote the “safety” of spinal surgery in their institutions.
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Conflicts of interest
There are no conflicts of interest.
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3. Epstein NE. Efficacy of pneumatic compression stocking prophylaxis in the prevention of deep venous thrombosis and pulmonary embolism following 139 lumbar laminectomies with instrumented fusions. J Spinal Disord Tech. 2006. 19: 28-31
4. Epstein NE, Staszewski H, Garrison M, Hon M. Pulmonary embolism diagnosed on computed tomography contrast angiography despite negative venous Doppler ultrasound after spinal surgery. J Spinal Disord Tech. 2011. 24: 358-62
5. Epstein NE. Prophylactic inferior vena cava filter placement prior to lumbar surgery in morbidly obese patients: Two-case study and literature review. Surg Neurol Int. 2015. 6: S469-74
6. Piper K, Algattas H, De-Andrea-Lazarus IA, Kimmell KT, Li YM, Walter KA. Risk factors associated with venous thromboembolism in patients undergoing spine surgery. J Neurosurg Spine. 2016. p. 1-7