Anticoagulant and Antiplatelet Management for Spinal Procedures: A Prospective, Descriptive Study and Interpretation of Guidelines

Abstract Setting. 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. Design. Prospective descriptive study. Subjects. 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.