Anticoagulants and Spine Interventions FactFinder

Committed to providing helpful information to members about key patient safety issues, the Patient Safety Committee has developed a FactFinder series. FactFinders will explore and debunk myths surrounding patient safety issues. The intent of this FactFinder is to address the use of anticoagulants in patients undergoing interventional spine procedures.

Much of the content of this FactFinder has been excerpted from the 2nd edition of the International Spine Intervention Society Practice Guidelines 1, in press at the time of this publication.

 

Myth: Anticoagulants must be ceased, or their doses reduced substantially, prior to performing any interventional spine procedures.

Fact: The physician must weigh the risks of performing the specific procedure on the anticoagulated patient with the risks incurred by ceasing or reducing the anticoagulant.

In the past, physicians planning to perform minimally-invasive, spinal diagnostic or treatment procedures on patients who were taking anticoagulants were advised to cease those medications before the procedure. This advice required that the physician identify the anticoagulant drug, tell the patient to cease taking it at an appropriate time before the procedure in order to normalize coagulation and then check the coagulation status of the patient before they have the procedure. Ostensibly, the concern was that spinal complications, attributable to the passage of a needle or electrode through a blood vessel, could occur in patients who remained anticoagulated. Data that have recently become available provide a basis for reconsidering this advice. There is also evidence that ceasing or reducing anticoagulant therapy carries its own risks 2.

The question is whether to cease anticoagulants or not. The considerations include the theoretical risk of complications, the epidemiology of the actual risks, the nature of possible complications, the nature of the medications being used and the need for the intended procedure.

Table 1 summarizes recommendations relative to use of anticoagulants for various spinal interventions. These recommendations pertain to procedures performed in accordance with specific techniques described in the ISIS guidelines. The physician performing the procedure must be appropriately trained and qualified, and have a deep understanding of the procedure to be undertaken, along with the nature and treatment of the condition for which the patient is taking anticoagulants. Additionally, any change in the patient’s regimen of medications should be undertaken in consultation with the physician responsible for their prescription, in case there are insights, considerations or precautions of which the patient or the physician about to perform the procedure is unaware.

Recommendations Regarding Use of Anticoagulants for

Interventional Spine Procedures

 

*Relative contraindication means:

Physicians should exercise discretion not only on whether or not to cease anticoagulants, but also whether or not the presumed therapeutic benefit of the procedure justifies the risk of ceasing anticoagulants.


All patients who undergo spinal diagnostic or treatment procedures while on anticoagulants should be diligently monitored for the possible development of paraspinal or epidural hematoma, and action should be taken to recognize and treat potential complications early.

Extra care should be exercised in monitoring an anticoagulated patient in whom vascular penetration is demonstrated during the conduct of a procedure.

References

1. International Spine Intervention Society. Anticoagulants. In: Bogduk N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd edn. International Spine Intervention Society, San Francisco, 2013. (In Press)

2. Linn AJ, DeSilva C, Peeters-Asdourian C. Thrombo-embolic stroke: a rare complication associated with peri-procedural management of an epidural steroid injection. Pain Physician 2009; 12: 159-162.

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Additional References - Cited in the ISIS Practice Guidelines, 2nd edn.

1. Gogarten W, Vandermeulen E, van Aken H, Kozek S, Llau JV, Samama CM. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anesthesiology. Eur J Anesthesiol 2010; 27:999-1015.

2. Endres S, Bogduk N, Schlimgen M, Shufelt A, Endres B. Efficacy/safety of performing fluoroscopically guided spinal interventions in conjunction with anticoagulation therapy. Pain Med 2011; 12:1442.

3. Endres S. Efficacy/safety of performing fluoroscopically guided spinal interventions in conjunction with anticoagulation therapy. Paper presented at the 19th Annual Scientific Meeting of the International Spine Intervention Society, Chicago, August 10-13, 2011.

4. Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, Brown DL, Heit JA, Mulroy MF, Rosenquist RW, Tryba M, Yuan CS. Regional anesthesia in the patient receiving antithrombotic of thrombolytic therapy. American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35:64-101.

5. Breivik H, Bang U, Jalonen J, Vigfússon G, Alahuhta S, Lagerjranser M. Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2010; 54:16-41.

6. Horlocker TT, Wedel DJ, Schroeder DR, Rose SH, Elliott BA, McGregor DG, Wong GY. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg 1995; 80:303-309.

7. Horlocker TT, Bajwa ZH, Ashraf Z, Khan S, Wilson JL, Sami N, Peeters-Asdourian C, Powers CA, Schroeder DR, Decker PA, Warfield CA. Risk assessment of hemorrhagic complications associated with nonsteroidal antiinflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection. Anesth Analg 2002; 95:1691-1697.

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