Venous thromboembolism following SCI is a source of significant morbidity and mortality.  Virtually all of the research is focused on prophylaxis of venous thromboembolism in this very high-risk population.  Guidelines based on best evidence for DVT prophylaxis in SCI include use of sequential compression devices for 2 weeks and anticoagulant for 8-12 weeks after injury (Maxwell et al. 2002).  There is evidence in the literature the 5,000 units S/C of unfractionated heparin delivered every 12 hours is this population may not be sufficient to provide adequate protection.  The good news is that low molecular weight heparin with enoxaparin, being the primary drug studied, appears to be more effective and should be considered the new standard of treatment, given the added benefit of lower risk of bleeding complications.  Physical measures in particular gradient pressure stockings and intermittent pneumatic compression are designed to reduce the impact of stasis due to prolonged and immobilized lower extremities and have been shown to have a limited impact. There is an intuitive benefit to combining treatment (i.e. pharmacological with mechanical treatment) although the evidence suggests pharmacological measures are the more important of the two in prophylaxis.

• Deep venous thrombosis is common in SCI patients not receiving prophylaxis.
• There is level 2 evidence (based on one low quality RCT and one non-randomized controlled trial) that 5,000 units s/c of unfractionated heparin is no more effective than placebo in the prophylaxis of venous thrombosis post SCI.
• There is level 1b evidence (based on one RCT) that adjusted (higher) dose s/c heparin is more effective in prophylaxis of venous thromboembolism than 5,000 s/c heparin q12h and has a higher incidence of bleeding complications.
• There is level 1a evidence (based on 2 RCTs) that low molecular weight heparin, in particular enoxaparin, is more effective in reducing venous thromboembolic events, when compared to the standard s/c heparin prophylaxis.  Moreover, the incidence of bleeding complications was less in the LMWH group.
• There was level 4 (limited) evidence that 40 mg Enoxaparin is no more effective than 30 mg of Enoxaparin in reducing the incidence of deep venous thrombosis or bleeding complications when used prophylactically.
• There is level 1b evidence (based on one RCT) that Enoxaparin is no more effective than Dalteparin in reducing the risk of deep venous thrombosis or bleeding complications although Enoxaparin is more expensive.
• There was level 4 (limited) evidence that sequential pneumatic compression devices (SCD) or gradient elastic stockings (GES) were associated with a reduced risk of venous thromboembolism post SCI.
• There is level 1b evidence (based on one small RCT) that rotating treatment tables reduce the incidence of venous thrombi in acute SCI patients.
• There is level 4 (limited) evidence that a comprehensive prophylactic treatment of external pneumatic compression, gradient pressure stockings and low dose heparin reduces venous thrombosis post SCI.
• There is level 4 (limited) evidence that a comprehensive prophylactic regimen of pharmacological and physical measures is more effective in preventing venous thrombosis post SCI when instituted early rather than later.
• There was a trend (supported by one RCT) that pneumatic compression plus antiplatelet agents (ASA and Dipyridamole) was more effective than pneumatic compression alone. Although an RCT, the numbers were small thus the trend was non-significant (p<0.1).
• There is level 3 evidence that inferior vena cava filters significantly reduce the risk of pulmonary emboli in high-risk SCI patients.
• There is limited evidence that Enoxaparin subcutaneously appears to be a safe, cost-effective and less labour-intensive treatment than intravenous heparin for acute DVTs post SCI.