Comparative Effectiveness of Intravenous, Oral, and Topical Tranexamic Acid in Elective Spine Surgery: A Systematic Review and Network Meta-Analysis
Global Spine Journal · 29 Oct 2026
† Impact is the editorial-priority score. All scores are out of 100. Clinical is a stored clinical-importance score from the earlier method; it has not been recalculated.
Why it matters
TXA is used routinely to limit bleeding in spine fusion, and this review suggests IV TXA, alone or with topical TXA, is the most reliable way to give it, while showing that safety data on thromboembolic events remain thin.
The evidence
This network meta-analysis pooled 25 randomised trials of elective spine surgery, mostly adult lumbar fusions for degenerative disease plus some adolescent scoliosis cases, to compare intravenous, oral, topical, and combined IV plus topical tranexamic acid (TXA) with each other and with no TXA. Combined IV plus topical TXA ranked best for most bleeding outcomes. For example, it cut intraoperative blood loss by about 123 mL versus control (95% CrI -202 to -44), but it did not clearly beat IV TXA alone (difference about 14 mL, CrI crossing zero). No route changed operative time or complication rates, and the complication data came from only five trials.
Intraoperative blood loss: Mean difference -122.79 (95% CI -202.22 to -43.579; other). The interval favours the first group; the size of the benefit needs clinical interpretation.
Why this rigour score?
Network meta-analysisDesign starting point: 53
Raised the score
- Placebo or sham control+5.1
- Pools randomised trials+5.1
Lowered the score
- No correction for multiple comparisons−3.4
Score capped at 64. A critical methodological failure for a review.
Methods at a glance
Recorded assessment- Comprehensive literature searchMet
- Risk of bias assessedMet
- Bias considered in synthesisNot met
- Publication bias assessedMet
- Study exclusions justifiedMet
- Prospective registrationNot reported
Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.
See the full score breakdown
- Study design starting point
- 53
- Placebo or sham control
- +5.1
- No correction for multiple comparisons
- −3.4
- Pools randomised trials
- +5.1
- Comprehensive literature search
- +3.4
- Risk of bias assessed in the included studies
- +3.4
- Excluded studies listed and justified
- +1.7
- Publication bias assessed
- +2.5
- Methodological cap
- −6.8
- Final rigour score rounded
- 64 / 100
Study design sets the starting point and a ceiling of 90. Recorded methods then adjust the score. Points are shown to one decimal place; the final score uses unrounded values.
Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.
For journal club
1.Given that adding topical TXA to IV TXA did not significantly lower intraoperative blood loss compared with IV TXA alone, when, if ever, would you add a topical dose for a patient undergoing a one- or two-level lumbar fusion?
2.With complication data drawn from only five trials, how would you counsel and select patients with a history of venous thromboembolism or coronary stents before giving TXA for elective spine surgery?
Original publication title
Comparative Effectiveness of Intravenous, Oral, and Topical Tranexamic Acid in Elective Spine Surgery: A Systematic Review and Network Meta-Analysis