What are the recommendations for aspirin (acetylsalicylic acid) therapy prior to a caudal epidural steroid injection?

Recommendations for Aspirin Prior to Caudal Epidural Steroid Injection

Aspirin should be discontinued 3-5 days prior to a caudal epidural steroid injection for procedures with high bleeding risk, though it may be continued for patients with high cardiovascular risk where the thrombotic risk outweighs bleeding concerns.

Risk Assessment and Decision Framework

Bleeding Risk Considerations

• Caudal epidural steroid injections are considered intermediate-risk neuraxial procedures
• Aspirin inhibits platelet function through irreversible cyclooxygenase-1 (COX-1) inhibition 1
• Complete recovery of platelet function requires 5-10 days after aspirin discontinuation 1
• A three-day washout of aspirin leads to improvement in platelet function that is often sufficient for most procedures 1
• For high bleeding risk procedures (such as neurosurgery), a full 5-day washout is recommended 1

Thrombotic Risk Considerations

• Patients on aspirin for secondary prevention (previous myocardial infarction, stroke, or stent placement) have higher thrombotic risk 2
• Discontinuing aspirin in high cardiovascular risk patients may lead to serious thrombotic events 3
• The European Society of Cardiology recommends lifelong aspirin for patients who have undergone CABG 1

Specific Recommendations Based on Patient Profile

Low Thrombotic Risk Patients

• Discontinue aspirin 3-5 days before the procedure 1
• Resume aspirin within 24 hours after the procedure if no bleeding complications 2

High Thrombotic Risk Patients (Recent stent, ACS, history of stent thrombosis)

• Consider continuing aspirin throughout the procedure 2
• Evidence suggests caudal epidural injections specifically may be safely performed while on aspirin 3
• If aspirin must be discontinued, limit to shortest possible duration (3 days) 1

Evidence Analysis

The recommendations show some variability in the literature:

1. A 2018 retrospective study found no complications in 392 caudal epidural steroid injections performed while patients remained on antithrombotic medications, suggesting this approach may be safe 3

2. However, case reports exist of epidural hematomas following epidural injections in patients on aspirin 4, highlighting that risk is not zero

3. The French Working Group on Perioperative Haemostasis recommends that aspirin should not be given for three days before procedures with significant bleeding risk 1

4. For high-risk procedures like neurosurgery, a full 5-day washout is recommended 1

Practical Approach

1. Assess bleeding vs. thrombotic risk:

   • High thrombotic risk: Recent coronary stent (<3 months for bare metal, <6 months for drug-eluting), recent ACS, history of stent thrombosis
   • High bleeding risk: Advanced age, history of bleeding disorders, concurrent anticoagulation

2. Decision algorithm:

   • Low thrombotic risk → Discontinue aspirin 3-5 days before procedure
   • High thrombotic risk → Consider continuing aspirin or limit discontinuation to 3 days
   • For procedures with very high bleeding risk (interlaminar approach) → Full 5-day discontinuation regardless of thrombotic risk

3. Post-procedure management:

   • Resume aspirin within 24 hours if no bleeding complications 2
   • Monitor for signs of epidural hematoma (progressive neurological deficits, severe back pain)

Important Caveats

• The caudal approach has a lower risk of epidural hematoma compared to interlaminar approaches 3
• Ultrasound guidance reduces the risk of vascular puncture 1
• Patients who discontinue aspirin for >48 hours and have been desensitized for aspirin-exacerbated respiratory disease may require repeat desensitization 1
• Single-needle technique is preferred to minimize vascular trauma 1

Remember that while guidelines provide general recommendations, individual patient factors must be carefully weighed when making this decision.