Anticoagulant and Antiplatelet Management for Spinal Procedures: A Prospective, Descriptive Study and Interpretation of Guidelines.
METHODS
Epidural hematoma rarely complicates interventional spine procedures. While anticoagulant and antiplatelet drugs increase bleeding risk, cessation may precipitate serious thromboembolic events. The Spine Intervention Society (SIS) and American Society of Regional Anesthesia and Pain Medicine (ASRA) put forth guidelines that dissent with regard to management of hemostatically active agents during commonly performed spinal injections.


OBJECTIVE
To validate an antiplatelet/anticoagulant management table based on modifications of the SIS 2013 and ASRA 2015 guidelines.


METHODS
Prospective descriptive study.


METHODS
Patients undergoing interventional spine injections from a interventional physiatrist's practice.


METHODS
A Modified SIS 2013-ASRA 2015 Antiplatelet & Anticoagulant (MSAAA) guideline table was devised and adopted. Patients undergoing interventional spine procedures were monitored for bleeding events.


RESULTS
Of 4,253 injection sites, 197 (4.6%) were performed in 74 patients on antiplatelet/anticoagulants. No clinically evident bleeding events were observed in patients on antiplatelet/anticoagulant medications for lumbar transforaminal epidural (N = 90), posterior-approach facet joint (N = 62), lumbar intradiscal (N = 11), lumbar sympathetic (N = 3), and sacroiliac (N = 5) injections or in 26 radiofrequency neurotomy procedures. One in 2,026 (0.05%, 95% confidence interval = 0.00-0.31%) interlaminar epidural injections (cervical, thoracic, lumbar, and caudal) suffered epidural hematoma. This patient was not on an antiplatelet/anticoagulant drug. No patient in 191 cervicothoracic and 723 lumbar transforaminal injections experienced bleeding complications.


CONCLUSIONS
Continuing antiplatelet and anticoagulant medications for intermediate- to low-risk interventional spine procedures may be advisable. The MSAAA table may be a reasonable guideline reference for managing antiplatelet and anticoagulant drugs.
Alabama Ortho Spine & Sports, Birmingham, Alabama.
Bradly S
BS
Goodman
Department of Anesthesia and Perioperative Care, University of California, San Francisco, California.
L McLean
LM
House
Advanced Pain and Anesthesia Consultants, Crown Point, Indiana.
Sridhar
S
Vallabhaneni
Alabama Ortho Spine & Sports, Birmingham, Alabama.
Srinivas
S
Mallempati
Orlando Orthopaedic Center, Orlando, Florida.
Matthew R
MR
Willey
Alabama Pain Physicians, Vestavia Hills, Alabama, USA.
Matthew Thomas
MT
Smith
D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D006406:Hematoma / Q000139:chemically induced* / Q000000981:diagnostic imaging / Q000209:etiology*; D006801:Humans; D007268:Injections, Epidural / Q000009:adverse effects; D008159:Lumbar Vertebrae; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D017410:Practice Guidelines as Topic / Q000592:standards*; D011446:Prospective Studies
D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors
Anticoagulant; Antiplatelet; Epidural (injection space); Facet Joint; Outcome Assessment; Pain Medicine; Transforaminal Epidural Injection