What are the guidelines for managing anticoagulation (Anti-Coagulant) therapy in patients undergoing intraspinal surgery, particularly with medications like warfarin, rivaroxaban (Xarelto), apixaban (Eliquis), aspirin, and clopidogrel (Plavix)?

From the Guidelines

For patients undergoing intraspinal surgery, anticoagulation therapy should be temporarily discontinued to minimize bleeding risks, with the most recent guidelines suggesting warfarin be stopped 5 days before surgery and direct oral anticoagulants (DOACs) like rivaroxaban and apixaban be discontinued 48-72 hours before surgery, as recommended by the 2018 European Heart Rhythm Association practical guide 1. The management of anticoagulation therapy in patients undergoing intraspinal surgery is crucial to balance the risks of thrombosis and bleeding.

• Warfarin should be stopped 5 days before surgery with INR confirmation of <1.5 prior to proceeding, as suggested by the american heart association/american college of cardiology foundation guide to warfarin therapy 1.
• Direct oral anticoagulants (DOACs) like rivaroxaban (Xarelto) and apixaban (Eliquis) should be discontinued 48-72 hours before surgery, with longer intervals for patients with renal impairment, as recommended by the 2018 European Heart Rhythm Association practical guide 1.
• Aspirin should be stopped 7-10 days preoperatively, while clopidogrel (Plavix) requires discontinuation 5-7 days before surgery, as suggested by the perioperative management of antiplatelet agents in patients with coronary stents: recommendations of a french task force 1.
• Bridging therapy with low molecular weight heparin may be necessary for high-risk patients (mechanical heart valves, recent thromboembolism) when stopping warfarin, typically using enoxaparin 1 mg/kg twice daily or 1.5 mg/kg once daily, with the last dose given 24 hours before surgery, as recommended by how i treat anticoagulated patients undergoing an elective procedure or surgery 1. Postoperatively, anticoagulants can generally be resumed 24-72 hours after surgery, with earlier resumption (24 hours) for low bleeding risk cases and later (48-72 hours) for higher bleeding risk procedures, as suggested by the 2018 European Heart Rhythm Association practical guide 1. DOACs reach therapeutic levels within hours of administration, while warfarin requires 5-7 days to reach therapeutic effect, as noted in the american heart association/american college of cardiology foundation guide to warfarin therapy 1. These guidelines balance thrombotic and hemorrhagic risks, as intraspinal procedures carry significant bleeding complication potential that could result in spinal hematoma, cord compression, and permanent neurological damage.

From the FDA Drug Label

5.3 Spinal/Epidural Anesthesia or Puncture

• The risk of spinal or epidural hematoma is increased by the use of XARELTO in patients with spinal/epidural anesthesia or puncture.
• When spinal anesthesia or puncture is employed, patients should be carefully monitored for neurological impairment.
• Use of low-molecular-weight heparin with XARELTO may increase the risk of bleeding, so this combination should be used with caution.

The guidelines for managing anticoagulation therapy in patients undergoing intraspinal surgery with medications like warfarin, rivaroxaban (Xarelto), apixaban (Eliquis), aspirin, and clopidogrel (Plavix) suggest that patients should be carefully monitored for neurological impairment due to the increased risk of spinal or epidural hematoma.

• Discontinuation of anticoagulant therapy before surgery may be necessary to reduce this risk.
• However, the exact management strategy may depend on the specific clinical situation and the patient's individual risk factors. 2

From the Research

Guidelines for Managing Anticoagulation Therapy

The management of anticoagulation therapy in patients undergoing intraspinal surgery is crucial to prevent perioperative bleeding complications and thromboembolic events. The following guidelines are based on the available evidence:

• Warfarin: Stop at least 5 days preoperatively 3, 4
• Xa inhibitors:
  • Apixaban (Eliquis): Stop for 2 days preoperatively 3
  • Rivaroxaban (Xarelto): Stop for 3 days preoperatively 3
• Anti-platelet agents:
  • Aspirin: Stop 7-10 days preoperatively for doses >1 g/d, 1-3 days for doses 81-500 mg 3, 5, 4
  • Clopidogrel (Plavix): Stop 5-7 days preoperatively 3, 4
• Non-steroidal anti-inflammatory drugs (NSAIDs): Stop for varying intervals ranging from 1-10 days prior to spine surgery, depending on the specific medication 3

Risk of Bleeding Complications

The risk of bleeding complications in patients undergoing intraspinal surgery while on anticoagulation therapy is a concern. However, the available evidence suggests that:

• Bleeding complications are rare, with a reported incidence of 0.0-4.3% across several types of anticoagulants 6
• Postoperative hematoma is reported in only 10 of 2507 patients 6
• The risk of major bleeding is low, ranging from 0.0% to 4.3% across several types of anticoagulants 6

Risk of Thromboembolic Events

The risk of thromboembolic events in patients undergoing intraspinal surgery is also a concern. However, the available evidence suggests that:

• Venous thromboembolism is uncommon after elective spine surgery, with a reported incidence of 2.3-6.0% 7, 6
• Trauma patients are at increased risk of thromboembolic events, and chemical prophylaxis should be considered 6
• Preoperative anticoagulation can reduce the risk of pulmonary embolism without increasing bleeding complications 7