Journal of Surgery and Transplantation Science

The Role of Tranexamic Acid (TXA) In Spine Surgeries: A Systematic Review

Research Article | Open Access

  • 1. Department of Surgery, Iraq
  • 2. Department of Neuroscience, Saint Georges Hospital, London
+ Show More - Show Less
Corresponding Authors
Ali Basim Almahfoodh, Department Of Surgery, Basrah Teaching Hospital, City-Z1B1D22, Tel: +9647703126734

Almahfoodh AB, Lui DF, Hamdan TA (2021) The Role of Tranexamic Acid (TXA) In Spine Surgeries: A Systematic Review. J Surg Transplant Sci 8(1): 1083.


Tranexamic Acid (TXA)

Tranexamic acid (TXA) was first made in 1962 by Japanese researchers Shosuke and Utako Okamoto. [1]


Tranexamic acid is a synthetic analog of the amino acid lysine. It serves as an antifibrinolytic by reversibly binding four to five lysine receptor sites on plasminogen. This reduces conversion of plasminogen to plasmin, preventing fibrin degradation and preserving the framework of fibrin’s matrix structure. [2]

It can be administered through several routes ,orally, topically, or intravenously, and has a 100% bioavailability [8]

Intravenous administration results in peak levels within minutes. The average half-life (time needed for half the active drug to be eliminated from the body) is two hours following intravenous administration and up to 12 hours following oral administration. [7]

95% of Tranexamic acid is excreted unchanged in the urine and only small amount is metabolized by the Liver.[2]

Dosing Dosing of TXA differs according to the Indication, but regarding it’s usage in Spine Surgeries Previous studies have demonstrated the clinically effective intravenous dose to be 10-15 mg/kg of body weight, with higher dosages providing diminishing benefits.[9]

A topical TXA irrigation is typically poured into the surgical field before wound closure, with dosing protocols ranging from 10 mg/kg (i.e., around 1 g) to 3 g of tTXA in saline solution. [10]


Tranexamic acid is frequently used following major trauma [3]. Tranexamic acid is used to prevent and treat blood loss in a variety of situations, such as dental procedures for hemophiliacs, heavy menstrual bleeding, and surgeries with high risk of blood loss. [4-5] it is also used in orthopedic surgery to reduce blood loss, to the extent of reducing or altogether abolishing the need for perioperative blood collection. It is of proven value in clearing the field of surgery and reducing blood loss when given before or after surgery. Drain and number of transfusions are reduced. [6]


• Allergy to tranexamic acid.

• History of seizures.

• History of venous or arterial thromboembolism or active thromboembolic disease.

• Severe kidney impairment due to accumulation of the medication, so dose adjustment is required in mild or moderate kidney impairment. [11]

Adverse Effects

Side effects are rare. [12] Some include changes in color vision, blood clots, and allergic reactions.[12] Blood clots may include venous thromboembolism (deep vein thrombosis and pulmonary embolism), anaphylaxis. [2] These rare side effects were reported in post marketing experience and frequencies cannot be determined. [2] Despite the mode of action, large studies of the use of tranexamic acid have not shown an increase in the risk of venous or arterial thrombosis. [13]



Massive blood loss occurs frequently and remains a challenge in spinal surgery. [14] Significant intra- and postoperative hemorrhage negatively affects patient outcomes by increasing coagulopathy, postoperative hematoma, and anemia. [15] The need for allogenic blood transfusions can lead to potential transfusion reactions and infections, in addition to increasing long-term mortality rates. [15]There is an economic disadvantage associated with iatrogenic major blood loss relating to the direct costs of the blood products and intraoperative blood salvage technology and indirect costs of prolonged patient hospitalization and complication management.[16]

There are actually increasing numbers of clinical trials and retrospective studies investigating the role of TXA in spine surgeries, using different doses, different methods of administration and on different types Surgeries , THIS Meta -Analysis is directed towards finding the missing points regarding those Studies , and hopefully will guide us towards a more targeted research regarding this topic in the future to help overcome the limitations of TXA use in Spine Surgeries perse and orthopedic practice in general.



The systematic review was written by in guidance of an adapted version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.

Search Strategy

An electronic database search was conducted on PubMed and Cochrane electronic databases. As seen in (Figure 1), the search terms “The Role of Tranexamic Acid in Spine Surgeries” were crucial in our database search in enabling us to find articles relevant to our inclusion criteria (which is detailed below)

Inclusion Criteria:

1-The population of the Study Should be patients undergoing Spine surgeries regardless the Type.

2-Only Tranexamic acid must be used and no other antifibrinolytic agent regardless the method of administration.

3-Studies designed to find the effect of TXA on intra and/or postoperative Bleeding and /or the need for postoperative blood Transfusion.

xclusion Criteria :

1-Meta analysis Designed Studies.

2-Studies and trials in which other Antifibrinolytic agents were used.

Table 1: Studies Investigated.
No Authors Article title Method of Administration Type of spine surgery Result &conclusion
1   A Randomized Controlled Trial of Low-Dose Tranexamic Acid versus Placebo to Reduce Red Blood Cell Transfusion During Complex Multilevel Spine Fusion Surgery(17). IV TXA (10 mg/kg loading dose, then 1 mg/kg/ hr throughout surgery) Complex Multilevel Spine Fusion Surgery Our results support the use of low-dose tranexamic acid during complex multilevel spine fusion surgery to decrease total red blood cell transfusion.
2   A Randomized Controlled Trial of Topical Application of Tranexamic Acid in Patients with Thoracolumbar Spine Trauma Undergoing Long-Segment Instrumented Posterior Spinal Fusion(18). solution containing 1 g of TXA (20 mL) was applied to the site of surgery via a drain tube after the spinal fascia was closed, and then the drain was clamped for 2 hours. Long-Segment Instrume-nted Posterior Spinal Fusion The use of topically administered 1 g TXA in thoracic and lumbar spinal trauma cases effectively decreased postoperative transfusion requirements and minimized postoperative blood loss, as determined by the total drainage volume.
3   Can tranexamic acid reduce blood loss in cervical laminectomy with lateral mass screw fixation and bone grafting: a retrospective observational study(19). IV TXA. cervical laminectomy with lateral mass screw fixation and bone grafting Total blood loss in the TXA group was significantly lower than that of the control group.
4   Clinical Research of Combined Intravenous Administration and Topical Application of Tranexamic Acid to a Surgical Wound During Posterior Lumbar Fusion(20). IV And topical TXA. double-segment posterior lumbar decompression and fusion surgery Combined intravenous and topical administration of TXA seems to be effective and safe in reducing allogenic blood transfusion and blood loss in doublesegment posterior lumbar decompression and fusion surgery
5   Cost-benefit analysis of tranexamic acid and blood transfusion in elective lumbar spine surgery for degenerative pathologies (21). IV TXA. elective lumbar spine surgery for degenerati-ve pathologie-s. TXA use was associated with decreased intraoperative blood loss and significant reductions in total hemostasis costs for patients undergoing surgery on more than 4 levels.
6   Different Effects of Intravenous, Topical, and Combined Application of Tranexamic Acid on Patients with Thoracolumbar Fracture (22). IV , Topical and Combined TXA. thoracolumbar fracture fixation with percutaneous pedicle screw. Preoperative intravenous drip of TXA can remarkably reduce intraoperative HBL and IBL in patients with thoracolumbar fracture fixed with percutaneous pedicle screw.
7   Does Prophylactic Administration of TXA Reduce Mean Operative Time and Postoperative Blood Loss in Posterior Approach Lumbar Spinal Fusion Surgery Performed for Degenerative Spinal Disease?(23). IV TXA. Lumbar Spinal Fusion Surgery Performed for Degenerative Spinal Disease. In the present study, perioperative TXA administration was associated with reduced postoperative drain output and surgical time.
8   Does Tranexamic Acid Reduce Perioperative Bleeding in Short Segment Pedicle Screw Fixation in Thoracolumbar Spine Fractures?(24). 10 mg/kg of TXA 30 minutes intravenously before skin incision and 3 hours post-operative and oral medication for three days Short Segment Pedicle Screw Fixation in Thoracolumbar Spine Fractures. Administration of TXA before surgery significantly reduces perioperative bleeding in patients undergoing short segment pedicle screw fixation for thoracolumbar spine fractures.
9   Double-blind, randomized controlled trial of tranexamic acid in minor lumbar spine surgery: no effect on operative time, intraoperative blood loss, or complications(25). IV TXA (10 mg/kg). minor lumbar decompressive surgery. Tranexamic acid did not have a statistically significant effect on operative time, intraoperative blood loss, or complications.
10   Effectiveness and Safety of Tranexamic Acid in Spinal Deformity Surgery(26). IV TXA. spinal deformity surgery TXA use can effectively reduce the amount of intraoperative bleeding and transfusion requirements in spinal deformity surgery.
11   Efficacy and safety of prophylactic large dose of tranexamic acid in spine surgery: a prospective, randomized, doubleblind, placebo-controlled study(27). Patients received either TA or placebo as a loading dose of 2 g (for adults) or 30 mg/kg (for children), followed immediately by continuous infusion of 100 mg/h (for adults) or 1 mg/ kg/h (for children) during surgery and for 5 hours after the operation. Eighteen patients had multilevel anterior cervical discectomies with or without internal fixation, 22 patients had decompressive surgery (12 laminectomies and 10 intersegmental decompressions) for multisegment spinal stenosis, 15 patients had laminectomy with posterior spinal fixation, and remaining 9 patients had laminectomy and excision of spinal tumor. Prophylactic use of large doses of TA provides an effective, safe, and cheap method for reducing blood loss during and after spinal operations.
12   Efficacy and Safety of Topical Use of Tranexamic Acid in Reducing Blood Loss During Primary Lumbar Spinal Surgery: A Retrospective Case Control Study(28). Wound surface was soaked with TXA (1 g in 100 mL saline solution) for 5 minutes before wound closure. Posterior lumbar spinal fusion surgery Topical TXA can significantly reduce postoperative blood loss, accelerate removal of drainage tube, shorten the duration of hospital stay, while not increasing the complication incidence in patients undergoing posterior lumbar spinal 13fusion surgery.
13   Efficacy of prophylactic low dose of tranexamic acid in spinal fixation surgery: a randomized clinical trial (29). TXA (10 mg/kg) at the initiation of induction of anesthesia during 10 min followed by intravenous infusion of 1 mg/kg/h. Spinal fixation surgeries. The administration of a prophylactic low dose of TXA did not have a significant effect in the management of intraoperative blood loss and transfusion requirements in patients undergoing spinal fixation surgery
14   Efficacy of tranexamic acid in reducing blood loss in posterior lumbar spine surgery for degenerative spinal stenosis with instability: a retrospective case control study(30). patients received 1 g tranexamic acid intravenous, preoperative and six hours and twelve hours postoperative. posterior lumbar spine surgery for degenerative spinal stenosis with instability. This study suggests a less blood loss when administering tranexamic acid in posterior lumbar spine surgery as demonstrated by the higher postoperative hemoglobin concentration and the less blood loss.


Almahfoodh AB, Lui DF, Hamdan TA (2021) The Role of Tranexamic Acid (TXA) In Spine Surgeries: A Systematic Review. J Surg Transplant Sci 8(1): 1083

Received : 21 May 2021
Accepted : 24 Jun 2021
Published : 26 Jun 2021
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
TEST Journal of Dentistry
ISSN : 1234-5678
Launched : 2014
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X