Comparative Effectiveness of Intravenous, Oral, and Topical Tranexamic Acid in Elective Spine Surgery: A Systematic Review and Network Meta-Analysis

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.