Anterior approach lumbar fusions cause a marked increase in thromboembolic events: Causal inferences from a propensity-matched analysis of 1147 patients

Anterior approach lumbar fusions are thought to be associated with increased venous thromboembolic event (VTE) rates [1], [2], [3], [4], [5]. However, the risk of VTE associated with anterior approach surgery is not well characterized, with reported VTE rates after anterior approach fusions varying between 0 % and 14 % [3], [6], [7]. Existing literature on VTE risk for anterior approach surgery is heterogenous with respect to the specific procedures performed, the incidence of VTE observed, and the demographic and clinical confounders assessed [1], [2], [3], [7]. A recent, comprehensive meta-analysis of VTE risk factors among spine surgery patients noted no significant difference in VTE rates between anterior and posterior approaches [8]. However, unlike the breadth of studies available examining other VTE risk factors, only 2 high-quality studies were identified that directly compared anterior- and posterior-approach fusions, each of which used large national datasets, but came to opposing conclusions [9], [10]. Another comparable recent meta-analysis found no increased VTE risk with anterior approach fusions, but also noted a high degree of data heterogeneity, limiting the interpretation of its results [8], [11].

Given the limitations of the existing literature, the risk of VTE due to anterior approach lumbar fusion is not well described. Moreover, commonly used statistical methods cannot determine how much of an increase in VTE risk, if any, is attributable to anterior approach fusion. Propensity score analysis allows non-equivalent groups to be balanced in non-randomized studies, thereby allowing for accurate causal inference [12], [13], [14], [15]. Here, we used propensity score methods to identify and quantify any increase in VTE caused by undergoing anterior lumbar fusion as compared to posterior lumbar fusion.

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