Perioperative Management of Elective Spine Surgery in Splenectomized Patients

Preoperative Assessment and Optimization

• The American Society of Hematology recommends that all splenectomized patients must have documented immunization against encapsulated bacteria at least 2-4 weeks before elective surgery 1, 2, 3
• Required vaccines include polyvalent pneumococcal, meningococcal C conjugate, and Haemophilus influenzae type B (Hib) 1
• Patients who received rituximab or other B-cell depleting therapies may require revaccination once B-cell recovery occurs 1

Infection Risk Assessment

• The American College of Surgeons states that splenectomized patients face lifelong risk of overwhelming post-splenectomy infection (OPSI) with mortality rates approaching 50% for pneumococcal sepsis 1
• Any active infection is an absolute contraindication to elective spine surgery 2

Thrombotic Risk Evaluation

• The American Society of Hematology notes that post-splenectomy patients have significantly elevated thrombotic risk affecting both portal and systemic venous systems 4, 5
• Review complete blood count with particular attention to platelet count—thrombocytosis increases thrombotic complications 4, 5

Perioperative Infection Prophylaxis

• The Centers for Disease Control and Prevention recommend that patients have home supply of antibiotics (penicillin VK, erythromycin, or levofloxacin) for any post-discharge febrile illness 1
• Educate patients that any fever >38°C (101°F) requires immediate emergency department evaluation 1

Thromboembolism Prevention

• The American College of Chest Physicians recommends initiating mechanical prophylaxis (sequential compression devices) immediately and continuing throughout hospitalization 6, 7
• Administer perioperative low molecular weight heparin (LMWH) to all splenectomized patients undergoing spine surgery 6, 7

Intraoperative Considerations

• The American Society of Anesthesiologists suggests using multimodal analgesia including epidural anesthesia when feasible to reduce opioid requirements and facilitate early mobilization 3
• Maintain low tidal volumes with adequate PEEP to prevent atelectasis 3

Postoperative Management

• The Society of Critical Care Medicine recommends implementing aggressive pulmonary hygiene protocol including incentive spirometry, deep breathing exercises, and early mobilization 3
• Monitor closely for signs of infection including fever, tachycardia, hypotension, or altered mental status 1

Special Populations

• The American Society of Hematology notes that patients with myeloproliferative disorders have 5-10% perioperative mortality risk and 50% complication rate if splenectomy was performed for myelofibrosis 4, 5
• The American Academy of Pediatrics recommends that pediatric patients with sickle cell disease require additional SCD-specific perioperative protocols including potential transfusion 2, 8

Discharge Planning

• The Centers for Disease Control and Prevention recommend ensuring patient has adequate supply of prophylactic antibiotics at home 1
• Provide clear written instructions about fever management and when to seek emergency care 1