Diagnosis, prevalence, and management of thromboembolism in patients with spinal cord injury

Background: Deep vein thrombosis and pulmonary embolism (thromboembolism) are frequent causes of morbidity and mortality in patients with spinal cord injury. Diagnosis: Strong clinical suspicion and confirmation with objective studies such as color-flow Doppler ultrasonography and helical CT. Management: In most patients, anticoagulation therapy with low-molecular-weight heparin (LMWH) is initiated when thrombosis is suspected, and continued if it is confirmed. Warfarin is started concomitantly, and the LMWH is discontinued when the International Normalized Ratio exceeds 2.0 for at least 48 hours. Duration of Treatment: At least 6 months; whether low-dose warfarin should be continued for an indefinite period is still under study. Vena Cava Filters: Indicated for patients who cannot tolerate anticoagulants because of active or imminent bleeding. Whether filters are ever indicated for prophylaxis is controversial; both benefits and risks have been emphasized. Retrievable filters may be preferable, but their safety and efficacy have not been established. The Future: A variety of new anticoagulants-including fondaparinux, idraparinux, and ximelagatran-currently are in clinical trials and may replace current agents because of improved efficacy, safety, and ease of administration.