Comparative Effectiveness of Intravenous, Oral, and Topical Tranexamic Acid in Elective Spine Surgery: A Systematic Review and Network Meta-Analysis
In brief
Combined tranexamic acid was linked to 2.5 fewer hospital days after spine surgery
In a network meta-analysis of 25 randomized trials, combined intravenous and topical tranexamic acid ranked highest for reducing hospital stay, with an estimated 2.5 fewer days than control, and also ranked well for blood loss and drainage. No route showed a detected increase in complications, but the evidence was not strong enough to establish that combined treatment is definitively superior or safe.
- Journal
- Global spine journal (Q1)
- Published
- 29 October 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Bara M Hammadeh, Cameron J Sabet, Ahmad Al-Qunbar, Leen Sabbah, AlBaraa K Mohammad, Zaid Hasan, et al.
- PMID
- 42954965
- DOI
- 10.1177/21925682261503531
Why clinicians should know about it
- Picked for Spine Surgery (paper of the day, 31 October 2026): Randomized-trial synthesis informs perioperative blood management in spine surgery
Abstract
Study DesignSystematic review and Bayesian network meta-analysis.ObjectiveTo compare the efficacy and safety of intravenous (IV), oral, topical, and combined IV+topical tranexamic acid (TXA) in reducing perioperative bleeding and transfusion requirements in elective spine surgery, and to identify the optimal administration route.MethodsWe searched Ovid MEDLINE, Ovid Embase, and CENTRAL from inception to February 20, 2026, for RCTs evaluating TXA routes in elective spine procedures. A Bayesian random-effects network meta-analysis was performed. Primary outcomes were length of stay (LOS), blood loss, and drainage volume; secondary outcomes included hemoglobin levels, operative time, complications, transfusion requirements, and coagulation parameters. Treatment rankings were estimated using Surface Under the Cumulative Ranking Curve (SUCRA). Trial sequential analysis (TSA) assessed evidence robustness.ResultsTwenty-five randomized controlled trials were included. Combined IV+topical TXA ranked highest for reducing LOS (SUCRA 97.1%; mean difference -2.46 days vs. control, 95% CrI -4.15 to -0.81), intraoperative blood loss (SUCRA 83.9%; MD -122.8 mL, 95% CrI -202.2 to -43.6), postoperative day 1 hemoglobin preservation (SUCRA 96.5%; MD +0.99 g/dL, 95% CrI 0.43-1.57), and drainage volume (SUCRA 83.4%; MD -191.3 mL, 95% CrI -311.6 to -74.8). Oral TXA ranked first for total blood loss (SUCRA 83.8%; MD -421.2 mL, 95% CrI -691.9 to -156.6), closely followed by combined IV+topical TXA (SUCRA 82.2%). No route significantly increased complications or adversely affected coagulation. TSA suggested insufficient evidence for definitive conclusions on several outcomes.ConclusionsCombined IV+topical TXA ranked highest for reducing hospital stay, intraoperative blood loss, and drainage volume in elective spine surgery, and no route was associated with a detected increase in reported complications. These findings suggest that combined IV+topical TXA is a promising option; however, TSA indicated that the available evidence is insufficient to establish definitive route superiority or safety, and further high-quality trials are needed.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.