What are the contraindications to a mild procedure in patients with certain health conditions or taking specific medications, such as anticoagulant therapy (e.g. warfarin or aspirin), immunosuppressive drugs (e.g. prednisone), or having conditions like severe cardiovascular disease, uncontrolled hypertension, or active infection?

Contraindications to MILD Procedure

Patients with active bleeding, uncontrolled hypertension, active infection, and those on anticoagulation therapy should not undergo the MILD procedure due to increased risk of procedural complications and adverse outcomes.

Absolute Contraindications

Bleeding Disorders and Anticoagulation

• Active bleeding from any source 1
• Recent central nervous system bleeding or intracranial/spinal lesions at high risk for bleeding 1
• Severe coagulopathy or bleeding diathesis 1
• Thrombocytopenia (platelets <50,000/mcL) 1
• Current anticoagulation therapy with warfarin unless it can be safely discontinued for the appropriate period 2
  • Warfarin should be discontinued at least 5 days before the procedure 1
  • INR should return to normal range before proceeding

Cardiovascular Conditions

• Refractory/unstable angina 1
• High-grade arrhythmias 1
• Decompensated heart failure 1
• Severe aortic dilatation 1
• Active thromboembolic disease 1
• Recent myocardial infarction (within past 6 months) 3
• Recent cerebrovascular accident (stroke) 3
• Severe cardiovascular disease that cannot be medically optimized 1

Infectious Conditions

• Active systemic infection 1
• Active local infection at the procedure site 1
• Septic emboli 1

Other Absolute Contraindications

• Uncontrolled hypertension 1
• Uncontrolled diabetes 1
• End-stage cancer 1
• COPD exacerbation 1
• Immunosuppression (severe) 3

Relative Contraindications

Medication-Related

• Aspirin therapy - Consider discontinuation 7-10 days before procedure if possible 4
• Other antiplatelet agents (e.g., clopidogrel) - Should be discontinued according to their specific washout periods 1
• Immunosuppressive drugs (e.g., prednisone) - May impair healing and increase infection risk 1

Patient Factors

• Inability to lie prone for the duration of the procedure
• Psychiatric illness that prevents cooperation during the procedure 3
• Pregnancy - Due to radiation exposure concerns 2
• History of previous spinal surgery at the target level

Management of Anticoagulation/Antiplatelet Therapy

1. For warfarin:

   • Discontinue at least 5 days before procedure 1
   • Check INR before procedure (should be <1.5)
   • Resume 24 hours after procedure if no bleeding complications

2. For antiplatelet agents:

   • Aspirin: Consider discontinuation 7-10 days before procedure 4
   • Clopidogrel: Discontinue at least 5-7 days before procedure 1
   • P2Y12 inhibitors: Follow specific guidelines for each medication

3. For novel oral anticoagulants (NOACs):

   • Follow specific discontinuation protocols based on renal function and bleeding risk

Pre-Procedure Assessment

1. Laboratory testing:

   • Complete blood count with platelets
   • Coagulation profile (PT/INR, aPTT)
   • Renal function tests

2. Imaging:

   • Recent MRI or CT imaging of the target area
   • Consider cardiac evaluation for patients with cardiovascular risk factors

Special Considerations

• Elderly patients may have increased risk of complications and should be carefully evaluated
• Patients with multiple comorbidities require comprehensive risk assessment
• History of prior spinal procedures may increase technical difficulty and complication risk

Resuming Medications Post-Procedure

• Anticoagulation can typically be resumed 24-48 hours after the procedure if no bleeding complications
• Antiplatelet therapy can usually be resumed 24 hours after the procedure
• Immunosuppressive medications should be managed in consultation with the prescribing physician

By carefully screening patients for these contraindications, providers can minimize procedural risks and improve outcomes for patients undergoing the MILD procedure.