SPINE INJECTION-BLEEDING RISK
SUMMARY
1. Coagulopathy: epidural hematoma risk is rather low (1 in 70,000 to 1 in 190,000)[1][2]. However, severe morbidity such as paraparesis or quadriparesis can be associated with an epidural hematoma.
2. NSAIDs: including aspirin, reduce platelet aggregation, but have not been implicated in increased bleeding risk or complications in lumbar epidural injections[3].
3. Antiplatelet medication: based on labeling precautions, surgical literature, and interventional cardiology and radiology data, it is recommended clopidogrel be discontinued for 7 days and ticlopidine for 14 days before spinal intervention[4][5].
4. Anticoagulants: warfarin is contraindication for spinal interventions & should be discontinued for 4-5 days before any spinal intervention to allow the PT and INR to normalize. Prophylactic LMWH shoulde be withheld for 12 hrs prior to procedure & and can be immediately recommenced after. Theraputic LMWH should be withheld for 24 hrs prior and 24 hrs after.
5. Prophylactic low-dose unfractionated heparin is not a contraindication for spinal procedures[6]. Therapeutic heparin should be discontinued 2-4 hrs before any spinal procedure and a normal APTT documented before; can be recommenced 1 hr after the procedure[7].
Reference(s)
- ↑ Abram SE, O’Connor TC: Complications associated with epidural steroid injections, Reg Anesth 21(2):149-162, 1996.
- ↑ Wulf H: Epidural anaesthesia and spinal haematoma, Can J Anaesth 43(12):1260-1271, 1996.
- ↑ Horlocker TT, Bajwa ZH, Ashraf Z, et al: Risk assessment of hemorrhagic complications associated with nonsteroidal antiinflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection, Anesth Analg 95(6):1691-1697, 2002.
- ↑ Kearon C, Hirsh J: Management of anticoagulation before and after elective surgery, N Engl J Med 336(21):1506-1511, 1997.
- ↑ Layton KF, Kallmes DF, Horlocker TT: Recommendations for anticoagulated patients undergoing image-guided spinal procedures, AJNR Am J Neuroradiol 27(3):468-470, 2006.
- ↑ Vandermeulen EP, Van Aken H, Vermylen J: Anticoagulants and spinal- epidural anesthesia, Anesth Analg 79(6):1165-1177, 1994.
- ↑ Liu SS, Mulroy MF: Neuraxial anesthesia and analgesia in the presence of standard heparin, Reg Anesth Pain Med 23(6 suppl 2):157-163, 1998.
