Should aspirin (acetylsalicylic acid) be discontinued before spinal surgery?

Management of Aspirin Before Spinal Surgery

Aspirin should be discontinued 7-10 days before elective spinal surgery to minimize the risk of perioperative bleeding complications. 1, 2

Rationale for Discontinuation

Spinal surgery is considered a high bleeding risk procedure where even small amounts of bleeding can have serious consequences:

• Perioperative bleeding can lead to epidural hematoma formation, which may cause spinal cord compression and potentially irreversible neurological damage
• Increased surgical site bleeding can compromise visualization during surgery
• Postoperative hematoma formation can necessitate reoperation

Timing of Discontinuation

The optimal timing for aspirin discontinuation before spinal surgery is:

• 7-10 days before surgery - This allows adequate time for new platelet production and restoration of normal hemostatic function 1, 2
• This recommendation is consistent with the findings that stopping aspirin between 7-10 days preoperatively results in no increased perioperative bleeding risk 2

Special Considerations

Patients with Cardiovascular Disease

For patients taking aspirin for secondary prevention (previous cardiovascular events):

• The decision requires careful weighing of cardiovascular risk against bleeding risk
• Intracranial and spinal surgery are specifically identified as exceptions to the general rule that aspirin can be continued for most surgeries 3
• A multidisciplinary approach involving cardiology consultation may be warranted to determine the optimal management strategy 4

Emergency Surgery

In urgent/emergent situations where surgery cannot be delayed:

• Discontinue aspirin immediately
• Consider platelet transfusion if significant bleeding occurs intraoperatively 4

Conflicting Evidence

It's important to note that there is some conflicting evidence regarding aspirin continuation during spinal surgery:

• Some studies suggest no significant differences in perioperative blood loss between aspirin continuation and discontinuation groups 5, 6
• However, other studies have documented increased hemorrhagic complications when aspirin is continued or stopped just 3-7 days preoperatively 2

Resumption of Aspirin

For postoperative resumption of aspirin:

• Resume aspirin within 24 hours after surgery if adequate hemostasis has been achieved 4
• For patients with high cardiovascular risk, earlier resumption may be considered if surgical hemostasis is adequate

Common Pitfalls

• Inadequate discontinuation time: Stopping aspirin only 3-5 days before surgery may not allow sufficient time for platelet function recovery
• Failure to recognize other medications with antiplatelet effects: NSAIDs should also be discontinued (timing varies by specific medication) 1
• Overlooking the increased bleeding risk in elderly patients: Older patients may require longer discontinuation periods as platelet regeneration can take longer 2

Given the potential catastrophic consequences of epidural hematoma formation after spinal surgery, the safest approach is to discontinue aspirin 7-10 days before elective spinal procedures, with appropriate planning for patients with significant cardiovascular disease.