Our experience in spinal surgery: a systematic review comparing the single and combined use of Tranexamic acid

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TXA can be used alone or in combination. The study compared the effects of the two administrations, single-use or combined-use, providing a basis for the optimal route of TXA application. Methods Intravenous injection of TXA or topical TXA was used in the experimental group, and combined TXA was used in the control group. A systematic literature search without language restrictions was conducted until November 10, 2023. Statistical analyses were performed using Revman 5.4. Results Four randomized controlled trials (RCTs) and one retrospective cohort study (RCS) were included, involving 682 patients. There were no significant differences in postoperative blood loss (PBL), preoperative haemoglobin (Hb), postoperative Hb, postoperative D-dimer level, operative time, nor complications between the two groups. However, there were statistically significant differences in intraoperative blood loss (IBL), total blood loss (TBL), and preoperative D-dimer levels between the two groups. (IBL: MD=48.63, 95%CI (confidence interval) =[12.61, 84.65], P=0.008, I 2=88%; TBL: MD=140.95, 95%CI= [25.97, 255.93], P=0.02, I 2=75%； Preoperative D-dimmer: MD=-0.15, 95%CI=[-0.19, -0.11], P<0.00001, I 2=0%). Conclusion During spinal surgery, single use of TXA was no better than combined use of TXA in terms of IBL, TBL, and preoperative D-dimer levels. However, the meta-analysis suggests that more high-quality studies need to be included to further compare the results between the two groups to make recommendations for the optimal use of TXA. 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F1000Research 2025, 14 :177 ( https://doi.org/10.12688/f1000research.147477.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Systematic Review Our experience in spinal surgery: a systematic review comparing the single and combined use of Tranexamic acid [version 1; peer review: peer review discontinued] mansi zied https://orcid.org/0000-0002-2595-9934 1,2 , abdelkader tounsi 1,2 , mohsen chamakh 1,2 , [...] wajdi chermiti 1,3 , ali haggui 1,2 , bacem zaidi 1,2 , ahmed mahmoudi 1,2 mansi zied https://orcid.org/0000-0002-2595-9934 1,2 , abdelkader tounsi 1,2 , [...] mohsen chamakh 1,2 , wajdi chermiti 1,3 , ali haggui 1,2 , bacem zaidi 1,2 , ahmed mahmoudi 1,2 PUBLISHED 10 Feb 2025 Author details Author details 1 University of Sousse, Sousse, Sousse, Tunisia 2 Ibn El Jazzar Regional Hospital, Kairouan, Kairouan, Tunisia 3 Sahloul Hospital, Sousse, Sousse, Tunisia mansi zied Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Validation abdelkader tounsi Roles: Data Curation, Investigation, Methodology, Software, Writing – Original Draft Preparation mohsen chamakh Roles: Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing wajdi chermiti Roles: Conceptualization, Formal Analysis, Visualization, Writing – Original Draft Preparation ali haggui Roles: Conceptualization, Formal Analysis, Investigation, Validation, Visualization bacem zaidi Roles: Conceptualization, Investigation, Methodology, Supervision, Writing – Original Draft Preparation ahmed mahmoudi Roles: Formal Analysis, Investigation, Software, Writing – Review & Editing OPEN PEER REVIEW PEER REVIEW DISCONTINUED Abstract Objective Tranexamic acid (TXA) is a chemical compound that can control the amount of bleeding and is often used in spinal surgery. TXA can be used alone or in combination. The study compared the effects of the two administrations, single-use or combined-use, providing a basis for the optimal route of TXA application. Methods Intravenous injection of TXA or topical TXA was used in the experimental group, and combined TXA was used in the control group. A systematic literature search without language restrictions was conducted until November 10, 2023. Statistical analyses were performed using Revman 5.4. Results Four randomized controlled trials (RCTs) and one retrospective cohort study (RCS) were included, involving 682 patients. There were no significant differences in postoperative blood loss (PBL), preoperative haemoglobin (Hb), postoperative Hb, postoperative D-dimer level, operative time, nor complications between the two groups. However, there were statistically significant differences in intraoperative blood loss (IBL), total blood loss (TBL), and preoperative D-dimer levels between the two groups. (IBL: MD=48.63, 95%CI (confidence interval) =[12.61, 84.65], P=0.008, I 2 =88%; TBL: MD=140.95, 95%CI= [25.97, 255.93], P=0.02, I 2 =75%； Preoperative D-dimmer: MD=-0.15, 95%CI=[-0.19, -0.11], P<0.00001, I 2 =0%). Conclusion During spinal surgery, single use of TXA was no better than combined use of TXA in terms of IBL, TBL, and preoperative D-dimer levels. However, the meta-analysis suggests that more high-quality studies need to be included to further compare the results between the two groups to make recommendations for the optimal use of TXA. READ ALL READ LESS Keywords Spinal surgery ; Tranexamic acid ; Intravenous ; Topical ; meta-analysis Corresponding Author(s) mansi zied ( [email protected] ) Close Corresponding author: mansi zied Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 zied m et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: zied m, tounsi a, chamakh m et al. Our experience in spinal surgery: a systematic review comparing the single and combined use of Tranexamic acid [version 1; peer review: peer review discontinued] . F1000Research 2025, 14 :177 ( https://doi.org/10.12688/f1000research.147477.1 ) First published: 10 Feb 2025, 14 :177 ( https://doi.org/10.12688/f1000research.147477.1 ) Latest published: 10 Feb 2025, 14 :177 ( https://doi.org/10.12688/f1000research.147477.1 ) Introduction In spinal surgery, the operation time is too long, and the incision is too large, which easily causes massive blood loss and has a great adverse impact on the prognosis of patients. 1 The data showed that the average bleeding volume of instrument lumbar fusion in spinal surgery reached 1517 ml. 2 This massive blood loss can cause cardiopulmonary risks, venous thromboembolism, surgical site infection, and other problems. 3 – 5 There is no doubt that finding effective and safe haemostatic agents is still a challenge to be overcome. 6 Antifibrinolytic drugs are safe and can significantly reduce bleeding. Patients without coagulation defects are the target population for this drug. 7 As a widely used antifibrinolytic drug, (TXA) is effective in controlling blood loss during spinal surgery. 8 The administration methods include intravenous injection, 9 topical medication, and oral administration. 10 Previous studies used intravenous administration of TXA, 11 the experimental data suggested that intravenous administration significantly reduced bleeding in patients. A recent study showed that pouring TXA into the incision has a better haemostatic effect than intravenous injection of TXA. 12 However, it is unclear whether the combined use of TXA has a more significant haemostatic effect than the single use of TXA. Therefore, this meta-analysis sought a better mode of administration in spinal surgery by analysing the efficacy and safety of TXA in the single injection group compared with TXA in the combined injection group in patients undergoing spinal surgery. Methods This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 13 and the AMSTAR (assessing the methodological quality of systematic reviews) guidelines. 14 The author registered this study in Prospero. Search strategy The databases (PubMed, Embase, and Web of Science) were searched until November 10, 2023. The types of studies included were randomized controlled or observational studies. The following terms “Tranexamic acid,” “topical,” “intravenous,” “spinal surgery” were searched for all databases using Boolean operations. Search without language restrictions. Study selection Two reviewers independently carried out the study selection process, and a third reviewer resolved the differences of opinion. Studies were considered to be included if the following criteria were met: (1) patients who underwent spinal surgery. (2) TXA grouping included intravenous injection, topical use, or combined use of TXA. (3) The study included the following indicators: blood loss, haemoglobin levels, D-dimer levels, operative time, and complications. Exclusion criteria: (1) patients who underwent non-spinal surgery were excluded from the study. (2) In the study, the experimental group received TXA injected intravenously or topically, and the control group received TXA in combination. (3) Data could not be extracted. (4) Editorials, reviews, animal studies, etc. Data extraction and management Two reviewers extracted the data, and divergence was resolved by a third reviewer. We extracted data from several aspects: (1) article information (first author and publication date). (2) Research characteristics (study type, number of surgeries, and operation mode) and (3) study object information (age, sex, and BMI). All results will be summarized into a table for display ( Table 1 ). Table 1. Baseline data sheet. Study Group Age (years) Gender M/F BMI (kg/m 2 ) Dong 2021 Intravenous 14.0 ± 2.0 12/25 20.8 ± 2.6 Combined 14.4 ± 1.9 11/29 19.7 ± 2.9 Weissmann 2020 Intravenous 14.59 ± 2.07 4/33 NA Topical 14.70 ± 3.71 7/16 Combined 15.57 ± 2.91 21/65 Wang 2019 Intravenous 45.43 ± 8.18 34/27 21.26 ± 2.26 Topical 45.72 ± 9.96 37/24 21.37 ± 2.17 Combined 45.47 ± 11.24 33/26 21.58 ± 2.43 Li 2020 Intravenous 66.67 ± 3.27 24/46 23.95 ± 3.25 Topical 65.61 ± 4.81 25/45 22.24 ± 2.78 Combined 65.28 ± 3.18 27/43 24.15 ± 2.54 Ronnakrit 2022 Intravenous 59± 13 19/13 22.4 ± 3 Combined 57 ± 11 23/10 22.29 ± 3 The Cochrane tool was used to assess the bias risk in RCTs. 15 The Newcastle-Ottawa Scale (NOS) was used to assess RCS quality. 16 The strategy adopted was to conduct a meta-analysis of the included studies and summarize their risk of bias. In cases where I 2 >50% indicated highly heterogeneous studies, sensitivity was necessary to determine heterogeneous sources. We used different effect models and eliminated the literature individually to perform a sensitivity analysis. Included indicators Four RCTs and one RCS were included in this study. Blood loss, Hb and D-dimer levels, operative time, and complications were analysed in the single and combined groups. Bleeding was divided into three subgroups: IBL, PBL, and TBL. Haemoglobin levels were divided into preoperative and postoperative Hb levels. D-dimer levels are divided into preoperative and postoperative D-dimer levels. Heterogeneity and publication bias Statistical heterogeneity was evaluated using the chi-square test and I 2 test. I 2 ≤ 50% indicates that the heterogeneity is not obvious; otherwise, it is obvious. 17 In the former case, the fixed effects model was selected, whereas in the latter case, the random effects model was applied. To explore publication bias, we used funnel plots for visual evaluation. The Begg test and Egger test were used for quantitative publication bias, and P<0.05 indicates significant publication bias. 18 The number of included studies may have affected the test ability of the funnel plot. An insufficient number of studies and statistical heterogeneity may have caused asymmetry in the funnel plots. Statistical analysis Data were analyzed using Review Manager (latest version) 19 and Stata software ( https://www.stata.com/ ) (latest version). The weighted mean difference (WMD) and 95% confidence interval (CI) expressed differences in the results of the continuous variables. The outcomes of the binary variables were expressed as the risk ratio (RR) and 95% CI. Results Study selection The databases (PubMed, Embase, Web of Science) were searched using search terms, including mesh terms, emtree, and free words, and preliminarily determined 75 studies. After deduplication and article summary reading, the contents of all 37 studies were read. After exclusion according to the established criteria, five studies 20 – 24 were finally selected and included in the summary analysis ( Figure 1 ). Figure 1. Flow diagram. Flow diagram based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Study characteristics Four RCTs and one RCS were included, the research characteristics are summarized in Table 1 . The operative methods of the three RCTs were lumbar fusion and one RCT was percutaneous pedicle screw fixation. Spinal cord decompression was used. Weissmann’s, Wang’s, and Li’s studies included intravenous, topical, and combined groups. Therefore, there were two kinds of comparisons between single use of TXA and combined use of TXA in each study ( Table 1 and Table 2 ), respectively. Table 2. Operation methods and usage of tranexamic acid. Study Surgical methods Group ivTXA Administration dose tTXA Administration dose Combined TXA Administration dose Dong 2021 Posterior spinal fusion with segmental instrumentation Intravenous Combined 1 g TXA + 20 mg/kg+ NA 1 g TXA + 10 mg/kg/h (Intravenous) + 2 g TXA (topical) Weissmann 2020 Posterior lumbar interbody fusion Intravenous topical Combined 20 mg/kg+ 1 mg/kg/h 6g TXA 1 mg/kg/h (intravenous) + 6 g TXA (topical) Wang 2019 Percutaneous pedicle screw fixation Intravenous topical Combined 15 mg/kg 3g TXA 15 mg/kg (intravenous) + 3 g TXA (topical) Li 2020 Lumbar fusion Intravenous topical Combined 15 mg/kg 2g TXA 15 mg/kg TXA (intravenous) + 1 g TXA (topical) Ronnakrit 2022 Cord decompression Intravenous Combined 1 g TXA NA + 2 g TXA (topical) The analysis results are summarized in Table 3 . Table 3. Results of the meta-analysis of outcome measures. Outcome and subgroup Number of studies Patients S:C RR/MD (95% CI) p Value Heterogeneity p value (I 2 ) Blood loss IBL (ml) 8 394:288 48.63[12.61,84.65] 0.008 <0.00001 (88%) PBL (ml) 3 92:119 38.83[-56.21,-133.88] 0.42 0.39 (0%) TBL (ml) 7 354:248 140.95[25.97,255.93] 0.02 0.0005 (75%) Hb level (g/L) Preoperative Hb level (g/L) 3 180:110 2.00 [−1.80, 5.79] 0.30 0.29 (19%) Postoperative Hb level (g/L) 3 180:110 -0.19[-3.04, 2.66] 0.90 0.59 (0%) D-dimer Preoperative D-dimer 3 162:99 -0.15[-0.19, -0.11] < 0.00001 0.85 (0%) Postoperative D-dimer 3 162:99 0.02 [−0.30, 0.34] 0.90 0.010 (67%) Operative time (min) 6 254:218 -0.24 [−10.23, 9.75] 0.96 0.12 (42%) Complications 3 180:110 1.23 [0.58, 2.59] 0.59 0.85 (0%) Blood loss The forest plot shows the results of the single group on blood loss compared with the combined group. There were three subgroups of blood loss. Eight studies (n=682) provided IBL data, three studies (n=211) provided PBL data and seven studies (n=602) provided TBL data. Pooled results showed that the combined use of TXA significantly reduced IBL and TBL compared to single TXA administration. (IBL: MD=48.63, 95%CI=[12.61, 84.65], P=0.008, I 2 =88%; PBL: MD=38.83, 95%CI=[-56.21, 133.88], P=0.42, I 2 =0%; TBL: MD=140.95, 95%CI= [25.97, 255.93], P=0.02, I 2 =75%) ( Figure 2 ). Figure 2. Summary of bias risk. +: low risk of bias; -: high risk of bias; ?: bias unclear. Hb and D-dimer The forest plot (4a) compares Hb levels. The Hb level was divided into two subgroups. Three studies (n=290) provided preoperative and postoperative Hb results. The summary analysis results showed no significant difference in Hb levels between the two groups before and after surgery (Preoperative Hb: MD=2.00, 95%CI = [-1.80,5.79], P=0.30, I 2 =19%; postoperative Hb: MD=-0.19, 95%CI= [-3.04,2.66], P=0.90, I 2 =0%). The forest plot (4b) compares D-dimer levels. D-dimer levels were divided into preoperative and postoperative D-dimer levels. We extracted D-dimer level data from three studies (n=261). No significant difference was detected in D-dimer levels between the two groups postoperatively. However, there was a significant difference in D-dimer levels between the two groups before surgery (preoperative D-dimer: MD=-0.15, 95%CI=[-0.19, -0.11], P<0.00001, I 2 =0%). Postoperative D-dimmer: MD=0.16, 95%CI=[−0.49, 0.81], P=0.63, I 2 =72%) ( Figure 3 ). Figure 3. Forest plot of blood loss (IBL: intraoperative blood loss; PBL: postoperative blood loss; TBL: Total blood loss). Operative time Six studies assessed the operative time (n=472). The results in Figure 4 show that the indicator did not vary between single and combined treatments. (MD=-0.24, 95%CI=[-10.23, 9.75], P=0.96, I 2 =42%) ( Figure 4 ). Figure 4. (a) Forest plot of Hb level. (b) Forest of D-dimmer level. (Hb: hemoglobin). Complication Three studies evaluated complications (n=290). As shown in Figure 5 , the results did not vary between single and combined treatments. (RR=1.23, 95%CI=[0.58, 2.59], P=0.59, I 2 =0%) ( Figure 5 ). Figure 5. Forest plot of operative time. Bias risk The Cochrane tool was used to assess the quality of the four RCTs. 25 NOS was adopted to assess the quality of the RCS. 16 In the four RCTs, the risk of selection bias was very low and the randomization and allocation processes were clearly reported. However, none of the four RCTs reported detection or other biases ( Figure 6 ). The score of RCS is six, 0-4 points are considered high bias, 4-6 points are considered as medium bias, and 6-9 points are considered as low bias ( Table 4 ). Figure 6. (a) Forest plot of drainage volume. (b) Forest plot of LOH. (c) Forest plot of blood transfusion rate. Table 4. NOS Scoring Table. First author Quality evaluation Case definition Representativeness Selection of Controls Definition of Controls Comparability Ascertainment of exposure Same method? Non Response rate Weissmann 6 1 1 1 0 1 1 1 0 Publication bias To analyse publication bias, we plotted a funnel plot of bleeding ( Figure 7 ). The P-values of the Begg and Egger tests were both less than 0.05, which proved that there was no significant publication bias in the study. Figure 7. Funnel plot of bleeding: no significant publication biais in the study. Sensitivity analysis In cases where I 2 >50% indicated highly heterogeneous studies, sensitivity was necessary to determine heterogeneous sources. Our pooled analysis showed that IBL, TBL, postoperative D-dimer level, and operative time were highly heterogeneous. We attempted to analyse the sources of heterogeneity, which may be due to the following reasons:(1) different spinal surgery methods, (2) different injection doses, and (3) too few included studies. After sensitivity analysis, we found that heterogeneity was still > 50%; therefore, additional valuable studies may need to be included in the study analysis. Discussion The antifibrinolytic drug tranexamic acid inhibits fibrinolysis. 26 Tranexamic acid is often used to reduce intraoperative bleeding in orthopaedics, general surgery, and obstetric surgery. 27 Currently, the administration routes of tranexamic acid include the most common intravenous injection, 9 topical administration, 10 and oral administration. 28 The administration regimen of TXA is usually intravenous injection before incision, followed by continuous infusion during the operation. 29 In several studies, intravenous TXA was compared with placebo (0.9% sodium chloride solution) in randomized controlled trials. A significant reduction in intraoperative bleeding was observed in the intravenous group. 30 , 31 In addition, a meta-analysis of 581 patients from nine studies demonstrated that the intravenous group experienced less bleeding during spinal surgery than the placebo group. 32 The Xiong et al. This study compared the efficacy of intravenous injections of TXA with placebo. According to the results, both high- and low-dose groups could effectively reduce the different kinds of bleeding and blood transfusion rates in adolescents with spinal deformities, and the postoperative Hb levels of the two groups were similar. 33 However, intravenous administration of TXA may pose risks to patients, including thrombosis and myocardial infarction. 8 , 27 Therefore, randomized controlled trials using TXA usually exclude patients with haemorrhagic disease or a hypercoagulable state. 21 – 24 However, according to Yang et al., the incidence of adverse events did not differ between intravenous and placebo groups. 32 The possibility of thrombosis caused by intravenous TXA necessitates the search for a safer application strategy, resulting in the emergence of topical use. 10 For topical administration, gelatine sponges were immersed in a mixture of TXA and saline before the incision was closed and placed horizontally in the surgical area 5 minutes later. The results of a 2017 study showed that compared with placebo (0.9% sodium chloride solution), the total perioperative blood loss decreased, and complications were not more common among the topical group. 34 A meta-analysis of total knee replacement in 2017 compared topical and intravenous treatment. 35 Blood loss and Hb levels did not differ between the intravenous and placebo groups, and there was no indication that complications increased. Xiong et al. compared the outcome indicators of intravenous and topical groups in spinal non-malformation surgery; blood loss and transfusion rates did not vary by treatment. 35 However, this meta-analysis was restricted to non-malformed spinal surgery. Recently, many studies have compared the combined use of TXA with the single use of TXA to observe its efficacy, but their results seem contradictory. 14 , 20 – 23 To understand the use of TXA in two ways in unrestricted spinal surgeries, we conducted a meta-analysis that included all spine surgeries. Follow-up studies should include more studies to supplement the existing research results. Outcome indicators included IBL, PBL, TBL, Hb and D-dimer levels, operative time, and complications. Forest plots of a previous study 20 showed no statistical difference in BL between the single and combined treatments. However, our meta-analysis found statistically significant differences in the two types of blood loss (IBL and TBL) between the two groups. This suggests that TXA, when administered in combination, reduces bleeding more than when administered alone. 36 The Hb level for patients with total knee replacement 37 decreased better than that for those receiving topical treatment. In terms of operative time and complications, the forest plot results of this study were the same as those of a previous meta-analysis. 24 D-dimer is a specific degradation product of fibrin monomers hydrolysed by plasmin in vivo and is used as an important indicator of coagulation function. 25 A significant difference in postoperative D-dimer between the single and combined treatments could not be detected. However, the difference in D-dimer levels before surgery was significant and could not reflect the change in blood coagulation function. As a common and effective method, TXA can control bleeding during spinal surgery. Both the single use of TXA and combined use of TXA seem to effectively control intraoperative bleeding. However, the mechanism through which TXA can be used remains unclear. These results suggest that combined treatment seems to be a better solution if we consider reducing bleeding. This provides a reference for the best clinical-use scheme. According to RCTs conducted by Dong et al., four cases of complications in patients in the intravenous group and five cases of complications with combined treatment were found. According to Li et al., seven cases of wound leakage were found in the intravenous group, two cases of deep vein embolism (DVT), five cases of wound leakage were found in the topical group, one case of DVT, and four cases of wound leakage were found in the combined group. There is a need for more valuable studies to assess adverse events, as the number of included studies was small. However, this meta-analysis has several limitations. First, few studies were originally included, including only four RCTs and one RCS, three of which contained two experimental comparisons. 20 – 22 Second, the quality of the included research was not high enough, and more suitable RCTs or observational studies need to be included in subsequent analyses. Third, the drug administration schemes included in this study were different, and the optimal dose could not be determined. Finally, the surgical teams in this study were obtained from different countries, and the surgical methods were also different. Conclusion The results of this meta-analysis showed that there was no significant difference in PBL, preoperative Hb level, postoperative Hb level, postoperative D-dimer level, operative time, or complications between the single and combined groups. However, significant differences in IBL, TBL, and preoperative D-dimer levels were observed between the two groups. In the future, we will consider including more appropriate RCTs to further improve the analytical results and enhance the credibility of the conclusions. Data availability Underlying data No data are associated with this article. 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PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 10 Feb 2025 ADD YOUR COMMENT Comment Author details Author details 1 University of Sousse, Sousse, Sousse, Tunisia 2 Ibn El Jazzar Regional Hospital, Kairouan, Kairouan, Tunisia 3 Sahloul Hospital, Sousse, Sousse, Tunisia mansi zied Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Validation abdelkader tounsi Roles: Data Curation, Investigation, Methodology, Software, Writing – Original Draft Preparation mohsen chamakh Roles: Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing wajdi chermiti Roles: Conceptualization, Formal Analysis, Visualization, Writing – Original Draft Preparation ali haggui Roles: Conceptualization, Formal Analysis, Investigation, Validation, Visualization bacem zaidi Roles: Conceptualization, Investigation, Methodology, Supervision, Writing – Original Draft Preparation ahmed mahmoudi Roles: Formal Analysis, Investigation, Software, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 10 Feb 2025, 14:177 https://doi.org/10.12688/f1000research.147477.1 Copyright © 2025 zied m et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article zied m, tounsi a, chamakh m et al. Our experience in spinal surgery: a systematic review comparing the single and combined use of Tranexamic acid [version 1; peer review: peer review discontinued] . 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