TXA in Spinal Fusion

This study is to assess whether tranexamic acid (a drug that is used to coagulate the blood and reduce bleeding) use in lumbar spinal fusion can reduce blood loss and postoperative delirium compared to placebo. Thusly reducing need for transfusion, shorting the hospital stay and improving outcomes. For this the study will randomize patients who are receiving elective lumbar interbody fusion (PLIF or TLIF) of 2 or more levels for degenerative disc disease (DDD) into 2 groups. Group 1 would receive tranexamic acid during the surgery while group 2 will receive placebo. Blood loss during the surgery and postoperatively (while the patient has a drain) will be monitored along with the amount of transfusions needed, postoperative cognitive status (including delirium), postoperative markers of systemic inflammation, and and the duration of hospital stay. Delirium occurrence and severity will be assessed daily for the first 5 days after surgery or at discharge, whichever comes first. Cognitive status (neuropsychological tests) will be assessed at post-discharge follow up visits and compared to preoperative status.

The drug or placebo are only given during the surgery. The patient population includes elective cases of patient undergoing lumbar spinal fusion of 2 or more levels. Spinal fusions are known to be associated with blood loss, especially when the surgeries are long and more levels need to be fused.

Inclusion criteria

• Age 18-90 years
• American Spinal Injury Association (ASA) Impairment Scale anesthesia risk of I to IV
• Patients undergoing 2 or more levels of posterior lumbar interbody fusion for DDD. This includes PLIF or TLIF.
• Patients have failed conservative management, which include physical therapy (PT) or occupational therapy (OT) and/or injections.

Exclusion criteria

• ASA class V
• Patient unable to consent
• Patient with chronic kidney disease stage III or above: baseline plasma creatinine>1.5mg/dL
• Patient with known liver failure
• Patients on anticoagulation or dual antiplatelets (presence of vascular stents).
• Patients with artificial valves.
• Patients with allergy to TXA
• Patients with platelet count < 150 000,
• Patients with PT>15s
• Patients with Activated Partial Thromboplastin Time (APPT) >38s
• History of stroke or (an) unprovoked thromboembolic event(s).
• History of intracranial bleeding,
• Pregnancy
• known defective color vision
• history of venous or arterial thromboembolism or active thromboembolic disease
• Patients with severe pulmonary or cardiac disease.
• Patients who refuse transfusion of blood products
• Patients with chronic anemia with Hg<8
• Patients undergoing lumbar fusion for disease other than DDD (neoplasm)
• Patients undergoing lumbar fusion by anterior or lateral approach.
• Minimally invasive TLIF are excluded.
• Emergent cases.
• Women on hormonal contraception
• Retinal vein or artery occlusion
• Hypercoagulability
• Seizure disorder
• Current use of tretinoin
• Current use of chlorpromazine
• Breast feeding