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Chapter Summary
• Context: Spine surgery, particularly in complex deformities, multi-level reconstructions, oncologic resections, and revision procedures, can involve substantial intraoperative blood loss. Hemorrhage obscures surgical visibility, increases operating time, and causes hypovolemia, hypothermia, acidemia, and dilutional or consumption coagulopathy. Massive bleeding and allogeneic blood transfusions are independently associated with increased surgical site infections, pulmonary complications, extended ICU stays, and transfusion-related immunomodulation (TRIM). Intraoperative bleeding control cannot be approached as a reactive response to hemorrhage; it requires an integrated, proactive Patient Blood Management (PBM) framework spanning preoperative optimization, surgical positioning, precise intraoperative hemostasis, pharmacological antifibrinolytics, viscoelastic coagulation testing, and restrictive transfusion protocols.
• Chapter Objective: To present comprehensive strategies for intraoperative bleeding control and patient blood management in spine surgery. The reader will learn to evaluate preoperative bleeding risk, optimize prone positioning to reduce venous congestion, apply topical and systemic hemostatics (tranexamic acid), utilize viscoelastic coagulation testing (TEG/ROTEM), and implement rational, context-driven transfusion protocols.
• Preoperative Risk Assessment and OptimizationIdentifying preoperative anemia, nutritional deficiencies, and coagulopathies is essential. Anticoagulants and antiplatelet agents must be managed according to standardized suspension intervals. Preoperative iron supplementation and erythropoietin are indicated for elective patients with iron-deficiency anemia.
• Surgical Positioning and Venous DecompressionProper prone positioning on chest and pelvic bolsters ensures the abdomen hangs completely free without pressure. This prevents inferior vena cava compression, decompressing Batson's valveless epidural venous plexus and significantly reducing diffuse venous bleeding throughout the exposure.
• Pharmacological and Topical HemostasisIntravenous tranexamic acid (TXA) reduces blood loss and transfusion requirements in adult and pediatric deformity surgery with proven safety. Topical hemostatics (gelatin sponges, microfibrillar collagen, oxidized cellulose, thrombin, and fibrin sealants) provide adjunct hemostasis on decorticated bone beds and epidural spaces.
• Coagulation Monitoring and Viscoelastic TestingPoint-of-care viscoelastic testing (Thromboelastography - TEG / Rotational Thromboelastometry - ROTEM) rapidly evaluates clot formation kinetics, firmness, and fibrinolysis in real time. Viscoelastic guidance allows targeted administration of specific blood products (fibrinogen concentrate, cryoprecipitate, platelets) rather than empirical transfusion.
• Patient Blood Management (PBM) and TransfusionPBM rests on three pillars: optimizing erythropoiesis, minimizing intraoperative blood loss (cell salvage, meticulous bipolar/hemostatic technique), and applying restrictive transfusion triggers (Hb < 7.0-8.0 g/dL based on hemodynamics and tissue perfusion). Red blood cell salvage and autologous reinfusion are highly effective in major fusion surgery.
• Clinical Application: In major deformity or tumor surgeries, bleeding management begins weeks prior with anemia treatment and anticoagulant management. In the operating room, ensure proper prone positioning with zero abdominal pressure. Initiate weight-based intravenous tranexamic acid prior to incision. Deploy intraoperative cell salvage. In the presence of significant diffuse bleeding, use ROTEM/TEG to determine whether hypofibrinogenemia, thrombocytopenia, or hyperfibrinolysis is responsible. Avoid empirical plasma transfusions, targeting specific factor deficiencies, and maintain normothermia and physiological pH to support native coagulation enzymes.
