How long before a back procedure should aspirin (acetylsalicylic acid) be stopped?

Aspirin Management Before Back Procedures

For spinal surgery, aspirin should be stopped 7 days before the procedure to minimize bleeding risk. 1

Timing of Aspirin Discontinuation by Procedure Type

The timing of aspirin discontinuation varies based on the type of procedure and the patient's thrombotic risk:

• Spinal/Back Procedures: 7 days before surgery 1, 2, 3
• Other high-risk surgeries (neurosurgery, intracranial surgery): 7 days before surgery 1
• Most non-cardiac surgeries: ≤7 days (typically 3-5 days) 1
• Low-risk procedures (minor dental/dermatologic procedures, cataract surgery): Can continue aspirin 1

Special Considerations for Back Procedures

Spine surgeons are particularly concerned about perioperative bleeding with aspirin due to:

• Risk of epidural hematoma formation
• Potential for neurological compromise
• Challenges with hemostasis in the spinal canal

Multiple studies have confirmed increased perioperative risks when aspirin is continued throughout spine surgery or stopped for just 3-7 days preoperatively 3. The irreversible effect of aspirin on platelet function lasts for the entire lifespan of the platelets (7-10 days) 4.

Balancing Thrombotic and Bleeding Risks

For patients with high cardiovascular risk:

• Patients with coronary stents:

  • Delay elective surgery for at least 6 weeks after bare-metal stent placement 5
  • Delay elective surgery for at least 6 months after drug-eluting stent placement 5, 1
  • If surgery cannot be delayed, consider continuing antiplatelet therapy 5

• For patients with secondary prevention of cardiovascular disease:

  • Carefully weigh cardiovascular risk against bleeding risk 1
  • Consider cardiology consultation for high-risk patients

Common Pitfalls and Caveats

1. Not stopping aspirin early enough: Platelets typically regenerate in 10 days, but this can take longer in older patients 3. Stopping aspirin just 3-7 days before spine surgery may still lead to increased bleeding risk.

2. Assuming all surgeries require the same timing: Different procedures have different bleeding risks. The 7-day recommendation is specific to high-risk procedures like spine surgery 1.

3. Overlooking other medications: Other anticoagulants and NSAIDs should also be discontinued at appropriate intervals:

   • Warfarin: stop at least 5 days preoperatively 2
   • Xa inhibitors: Apixaban (stop for 2 days), Rivaroxaban (stop for 3 days) 2
   • Clopidogrel: stop >7-10 days preoperatively 2
   • NSAIDs: varying intervals from 1-10 days depending on the specific medication 2

4. Resumption timing: Aspirin should be resumed within 24 hours after surgery when adequate hemostasis is achieved 1.

The American College of Chest Physicians (ACCP) guidelines recommend stopping aspirin ≤7 days before elective surgery rather than 7-10 days 1, which aligns with the specific recommendation for back procedures to stop aspirin 7 days before surgery.