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Introduction <p>Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis entails notable bleeding and transfusion risk, yet optimal tranexamic acid dosing remains undefined. We conducted a network meta-analysis (NMA) comparing high dose, low dose, and no-TXA regimens in this setting.</p> Methods <p>We conducted a PROSPERO-registered NMA (CRD420251033929) of RCTs in AIS patients undergoing PSF. PubMed, CINAHL, EMBASE, reference lists, and grey literature were searched for trials comparing high dose (20–50&#xa0;mg/kg load; 10–20&#xa0;mg/kg/h infusion), low dose (10&#xa0;mg/kg load; 1&#xa0;mg/kg/h infusion), or no TXA. Outcomes were pooled using a random-effects model to produce mean differences for continuous data and relative risks for binary data.</p> Results <p>Five RCTs (n = 475) were included. Patients had a frequency‐weighted average (FWA) (SD) age of 15.1 (1.5) years, preoperative Cobb angle of 58.0 (7.9)°, 10.4 (1.3) levels fused, and operative time of 186.9 (62.0) minutes. They were allocated to high‐dose TXA (n = 184), low‐dose TXA (n = 144), or no‐TXA (n = 147) arms. The FWA total EBL was 787.3 (261.5) mL in the high‐dose group, 705.3 (219.0) mL in the low‐dose group, and 1016.3 (492.2) mL in controls. There was no significant difference in EBL between high‐ vs low‐dose TXA (MD −98.3&#xa0;mL [−646.9, 426.2]). In the NMA, high‐dose TXA reduced total EBL by 319&#xa0;mL (95% CI −818 to 133) and low‐dose by 219&#xa0;mL (95% CI −764 to 294) versus no TXA—an 81% probability that no TXA was worst strategy—though neither comparison reached statistical significance. When compared per fused level, High‐ and low‐dose TXA reduced EBL per level by 38.2&#xa0;mL (MD −38.2 [−86.3, 6.1]) and 29.5&#xa0;mL (MD −29.5 [−85.2, 27.3]) versus no TXA, respectively, without statistical significance; however, the no‐TXA arm had an 87% probability of being worst for EBL by level. The FWA EBL per level was 78.9 ± 6.3&#xa0;mL, 78.2 ± 7.2&#xa0;mL, and 116.3 ± 17.8&#xa0;mL for high‐dose, low‐dose, and no‐TXA groups (very low certainty). When compared by operative time, high and lowdose TXA reduced EBL per hour by 81.0&#xa0;mL/h (MD −81.0 [−250.0, 80.5]) and 60.2&#xa0;mL/h (MD −60.2 [−285.0, 160.0]) versus no TXA, respectively, with no statistical significance. FWA EBL per hour was 273.8 ± 112.6&#xa0;mL/h, 315.4 ± 133.6&#xa0;mL/h, and 249.8 ± 150.2&#xa0;mL/h for high dose, low dose, and no TXA (very low certainty). Both TXA arms had no complications vs. one uncontrolled bleed in the no-TXA group (0.7%).</p> Conclusion <p>High and low dose TXA in AIS PSF yielded modest, non-significant reductions in total blood loss and per-level EBL. No thromboembolic, neurologic, or renal complications occurred among, underscoring its safety. These results support a case-by-case approach to TXA use and highlight the need for larger, standardized RCTs to confirm its clinical value.</p>

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The efficacy and safety of high versus low doses of intravenous intraoperative tranexamic acid during spinal fusion in patients with adolescent idiopathic scoliosis: a network meta-analysis of randomized controlled trials

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  • 发表日期：

    2026年1月24日

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  • Omkar S. Anaspure,
  • Anthony N. Baumann,
  • Grayson M. Talaski,
  • Mark Villers,
  • Keith D. Baldwin

摘要

Introduction

Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis entails notable bleeding and transfusion risk, yet optimal tranexamic acid dosing remains undefined. We conducted a network meta-analysis (NMA) comparing high dose, low dose, and no-TXA regimens in this setting.

Methods

We conducted a PROSPERO-registered NMA (CRD420251033929) of RCTs in AIS patients undergoing PSF. PubMed, CINAHL, EMBASE, reference lists, and grey literature were searched for trials comparing high dose (20–50 mg/kg load; 10–20 mg/kg/h infusion), low dose (10 mg/kg load; 1 mg/kg/h infusion), or no TXA. Outcomes were pooled using a random-effects model to produce mean differences for continuous data and relative risks for binary data.

Results

Five RCTs (n = 475) were included. Patients had a frequency‐weighted average (FWA) (SD) age of 15.1 (1.5) years, preoperative Cobb angle of 58.0 (7.9)°, 10.4 (1.3) levels fused, and operative time of 186.9 (62.0) minutes. They were allocated to high‐dose TXA (n = 184), low‐dose TXA (n = 144), or no‐TXA (n = 147) arms. The FWA total EBL was 787.3 (261.5) mL in the high‐dose group, 705.3 (219.0) mL in the low‐dose group, and 1016.3 (492.2) mL in controls. There was no significant difference in EBL between high‐ vs low‐dose TXA (MD −98.3 mL [−646.9, 426.2]). In the NMA, high‐dose TXA reduced total EBL by 319 mL (95% CI −818 to 133) and low‐dose by 219 mL (95% CI −764 to 294) versus no TXA—an 81% probability that no TXA was worst strategy—though neither comparison reached statistical significance. When compared per fused level, High‐ and low‐dose TXA reduced EBL per level by 38.2 mL (MD −38.2 [−86.3, 6.1]) and 29.5 mL (MD −29.5 [−85.2, 27.3]) versus no TXA, respectively, without statistical significance; however, the no‐TXA arm had an 87% probability of being worst for EBL by level. The FWA EBL per level was 78.9 ± 6.3 mL, 78.2 ± 7.2 mL, and 116.3 ± 17.8 mL for high‐dose, low‐dose, and no‐TXA groups (very low certainty). When compared by operative time, high and lowdose TXA reduced EBL per hour by 81.0 mL/h (MD −81.0 [−250.0, 80.5]) and 60.2 mL/h (MD −60.2 [−285.0, 160.0]) versus no TXA, respectively, with no statistical significance. FWA EBL per hour was 273.8 ± 112.6 mL/h, 315.4 ± 133.6 mL/h, and 249.8 ± 150.2 mL/h for high dose, low dose, and no TXA (very low certainty). Both TXA arms had no complications vs. one uncontrolled bleed in the no-TXA group (0.7%).

Conclusion

High and low dose TXA in AIS PSF yielded modest, non-significant reductions in total blood loss and per-level EBL. No thromboembolic, neurologic, or renal complications occurred among, underscoring its safety. These results support a case-by-case approach to TXA use and highlight the need for larger, standardized RCTs to confirm its clinical value.