Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications

Abstract

Interventional spine and pain procedures cover a far broader spectrum than those for regional anesthesia, reflecting diverse targets and goals. When surveyed, interventional pain and spine physicians attending the American Society of Regional Anesthesia and Pain Medicine (ASRA) 11th Annual Pain Medicine Meeting exhorted that existing ASRA guidelines for regional anesthesia in patients on antiplatelet and anticoagulant medications were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors necessitated separate guidelines for pain and spine procedures. In response, ASRA formed a guidelines committee. After preliminary review of published complication reports and studies, committee members stratified interventional spine and pain procedures according to potential bleeding risk as low-, intermediate-, and high-risk procedures. The ASRA guidelines were deemed largely appropriate for the low- and intermediate-risk categories, but it was agreed that the high-risk targets required an intensive look at issues specific to patient safety and optimal outcomes in pain medicine. The latest evidence was sought through extensive database search strategies and the recommendations were evidence-based when available and pharmacology-driven otherwise. We could not provide strength and grading of these recommendations as there are not enough well-designed large studies concerning interventional pain procedures to support such grading. Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations.

Periprocedural Management of Direct Oral Anticoagulants Should Be Guided by Accurate Laboratory Tests

“…3 We agree that the interruption of DOACs should not be based only on their respective half-life but also on the residual drug concentration. Indeed, a recent multicenter study showed a high interindividual variability of DOACs' plasma concentration.…”

Cervical epidural hematoma following interlaminar epidural steroid injection via the contralateral oblique view in patient taking omega-3 fatty acids

“…While there are other documented case reports of epidural hematoma formation following ILESI in patients that have followed current guidelines for the discontinuation of antiplatelet and anticoagulation medications, there are two factors that we feel make our case unique 1–4. First, even though the ASRA guidelines published by Narouze et al in 2015 were largely followed in this patient, she was later discovered to have regularly taken 2000 mg of fish oil daily and ibuprofen 400 mg as needed 5. In April 2018, Narouze et al published the second edition of the ASRA guidelines for interventional spine and pain procedures.…”

Perioperative considerations and management of patients receiving anticoagulants

“…Recent ASRA and ESRA consensus indicates a 3–4 days interval before performing regional anesthesia procedures and then resuming medications 12–24 h postprocedure. [14]…”

“…[1417] As experience with this agent is limited, along with wide-ranging pharmacokinetics of apixaban therapy, it is warranted to delay postprocedure administration by 6 h.[1419]…”

“…[262728] Cyclooxygenase 2 inhibitors have shown minimal effect on platelet function, consider safe for patients receiving regional anesthesia, and without additive effects in the presence of anticoagulation therapy. [1429]…”