No, You Do Not Need to Hold Flexeril or Robaxin Days Before Wrist Surgery
Both Flexeril (cyclobenzaprine) and Robaxin (methocarbamol) should only be held on the day of operation itself, not days in advance 1. The 2021 Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement provides clear guidance that these medications require only same-day discontinuation, not prolonged preoperative cessation.
Specific Recommendations by Medication
Cyclobenzaprine (Flexeril)
- Hold on the day of operation only 1
- The guideline explicitly states "Hold on day of operation" without any mention of extended preoperative discontinuation
- While long-term users may experience mild withdrawal symptoms (malaise, nausea, headache for 2-4 days), these are not life-threatening 1
- If the patient has been on long-term therapy and time permits, consider tapering over 2-3 weeks to prevent withdrawal symptoms, but this is not mandatory for safety 1
Key concern: Cyclobenzaprine can interact with sedatives and anesthetic agents, causing anticholinergic effects (confusion, drowsiness, urinary retention) and norepinephrine potentiation 1. This is why it's held on the day of surgery—to minimize intraoperative drug interactions, not because of bleeding risk or other surgical complications.
Methocarbamol (Robaxin)
- Hold on the day of surgical procedure 1
- Same-day discontinuation is sufficient
- Adverse effects include drowsiness, dizziness, bradycardia, and hypotension 1—concerns during anesthesia, not surgical bleeding
Important nuance: One study actually showed potential benefit with preoperative intravenous methocarbamol in joint arthroplasty, with improved postoperative outcomes 1, 2. However, the oral formulation used chronically should still be held on the day of surgery per consensus guidelines.
Why Not Days in Advance?
Unlike medications that affect coagulation (warfarin, antiplatelet agents) or have long half-lives requiring extended washout periods, muscle relaxants:
- Do not increase surgical bleeding risk
- Have relatively short durations of action
- Are held primarily to avoid intraoperative drug interactions with anesthetics, not surgical complications
- Do not require extended elimination time for wrist surgery safety
Common Pitfalls to Avoid
Confusing muscle relaxants with anticoagulants: Wrist surgery may require holding blood thinners for days, but muscle relaxants are different medications with different perioperative management 3
Abrupt discontinuation in long-term users: If your patient has been taking cyclobenzaprine chronically and you have several weeks before surgery, consider tapering to minimize withdrawal symptoms—but this is for patient comfort, not surgical safety 1
Overlooking anticholinergic burden: In elderly patients or those at high risk for delirium, be aware that cyclobenzaprine has significant anticholinergic effects 4, 5. The decision to hold on surgery day is appropriate, but postoperative resumption should be carefully considered in high-risk populations.
Practical Algorithm
More than 2-3 weeks before surgery:
- Continue medications as prescribed
- If patient is on long-term cyclobenzaprine, consider discussing taper with surgeon (optional, for comfort)
Day before surgery:
- Patient takes their usual dose
- No special instructions needed
Day of surgery:
- Hold both medications
- Inform anesthesia team of chronic use
Postoperatively:
- Resume based on clinical need and patient risk factors for delirium
The evidence is clear and consistent: same-day discontinuation is the standard of care for these muscle relaxants before wrist surgery 1.