Perioperative management of antithrombotic therapy in elderly patients undergoing elective ACDF: implementation and outcomes of a standardized institutional protocol

Objective: Perioperative management of chronic antithrombotic therapy in elderly patients undergoing elective anterior cervical discectomy and fusion (ACDF) remains poorly standardized. This study evaluated the safety and feasibility of an institutional protocol based on temporary substitution rather than interruption of preexisting antithrombotic regimens. Methods: We retrospectively analyzed 189 consecutive patients aged ≥ 65 years who underwent elective ACDF between 2019 and 2023. Patients were stratified according to their chronic antithrombotic regimen. Group A included patients with no prior antithrombotic therapy, who received standard postoperative prophylaxis with enoxaparin after drain removal. Group B comprised patients on primary prevention therapy, whose home regimen was discontinued 7 days before surgery and replaced with bridging low-molecular-weight heparin (enoxaparin 40 mg daily) until 15 days postoperatively. Group C included patients on secondary prevention therapy, who suspended their regimen 7 days preoperatively and received low-dose aspirin (100 mg daily) from the preoperative week through postoperative day 15 before resuming their chronic therapy. Primary outcomes were hemoglobin decrease, operative time, and length of stay, while secondary outcomes included complications (Clavien–Dindo classification) and early functional recovery (mJOA, ODI). Non-inferiority analyses using the TOST procedure evaluated whether perioperative outcomes remained within predefined a priori clinical margins across groups. Results: Baseline characteristics and surgical parameters were comparable among groups. No major hemorrhagic or thromboembolic events occurred. Perioperative parameters and minor complications (Clavien–Dindo I–II) were similar across all groups. Functional improvement at 3 months was consistent (p > 0.3). Conclusion: This substitution-based perioperative protocol proved feasible and clinically safe in elderly ACDF patients. Although underpowered to detect rare events, these findings support prospective studies aimed at further investigating the adoption of standardized replacement strategies in this growing surgical population.