Management of Deep Vein Thrombosis in Spinal Cord Injury

¹ The Division of Internal Medicine, Department of Rehabilitation Medicine, and the Regional Spinal Cord Injury Center of the Delaware Valley, Thomas Jefferson University Hospital, Philadelphia.

From the preceding data, we can draw some clinical conclusions on the acute and prolonged management of DVT in acute spinal cord-injured patients.

Continuous infusion heparin either by the traditional regimen, the Hull et al dosing method of high and low risk patients, or the Cruickshank et al nomogram, have all been shown to be safe and efficacious in the treatment of DVT. The former 2 methods are the most frequently used in the management of acute thrombosis. The use of adjusted subcutaneous dose heparin is an alternative strategy that has been proven effective for the treatment of DVT. More studies with this method are necessary to standardize the dosing and generalize it to other populations. This latter heparin regimen would offer significant advantages in the care of spinal cord injured-patients. It eliminates the need for intravenous access and infusion pumps which interfere in the rehabilitation program.

The use of caval interruption should be reserved for those patients meeting the designated criteria for placement. All patients must have caval assessment prior to interruption to evaluate the anatomy, patency, and placement site for the filter. The Greenfield and Bird's Nest filters are the primary caval interruption devices used today. This form of therapy is a prophylaxis for pulmonary embolism during high risk situations. This is a valuable modality in the armamentarium of treatment for thromboembolic disease.

Warfarin is the long-term prophylaxis for recurrence of DVT. It can be initiated on day 1 or 3 of the initial heparin therapy at an initial dose of 10 mg with daily adjustment to maintain an INR of 2 to 3. Therapy is continued for a full 3 to 6 months. The factors which influence the risk of bleeding are the intensity of anticoagulation, age, and use of aspirin. The SCI patients receiving warfarin should be observed for thigh hemorrhage during the rehabilitation process. Adjusted-dose heparin is an alternative method which can be used as a prophylaxis for recurrence. It has been demonstrated to be as effective as warfarin therapy.

Acute spinal cord-injured patients are a high risk population for the development of DVT. The appropriate interventions listed above should be selected as indicated for the management of the spinal cord-injured patient with acute DVF.