Caudal Epidural Injection in Patients on Double Dose Aspirin
Performing a caudal epidural injection while on double dose aspirin is not recommended due to the increased risk of epidural hematoma, which could lead to significant morbidity and mortality. 1
Risk Assessment for Neuraxial Procedures with Aspirin
General Guidelines for Aspirin and Neuraxial Procedures
- While standard dose aspirin is not an absolute contraindication for central neuraxial anesthesia, double dose aspirin presents a higher bleeding risk 1
- The French Working Group on Perioperative Haemostasis (GIHP) states that aspirin monotherapy at standard doses may be continued for central neuraxial anesthesia if the benefit-risk ratio is favorable 1
- However, this recommendation applies to standard dosing, not double dosing
Risk Stratification
Caudal epidural injections are classified as central neuraxial procedures with the following considerations:
- They access the epidural space, where bleeding can lead to spinal cord compression
- Compression of neural structures in this area can result in permanent neurological damage
- The epidural space cannot be easily compressed if bleeding occurs 1
Evidence of Complications
Multiple case reports document epidural hematomas following neuraxial procedures in patients on aspirin:
- An 80-year-old woman developed a spinal epidural hematoma after spinal cord stimulator trial while taking aspirin, requiring emergency neurosurgical intervention 2
- A 73-year-old woman on low-dose aspirin (81 mg/day) developed an epidural hematoma following spinal cord stimulator lead placement 3
- A 79-year-old man on aspirin for secondary prevention developed an epidural hematoma after an interlaminar epidural steroid injection 4
Recommendations Based on Procedure Type
For Central Neuraxial Procedures (including Caudal Epidurals):
- Standard dose aspirin monotherapy may be continued if there are no other abnormalities of hemostasis or anticoagulant therapy 1
- Single-puncture spinal anesthesia is preferable to epidural anesthesia when aspirin is continued 1
- Double dose aspirin represents a higher bleeding risk and should be discontinued before the procedure
For Peripheral Nerve Blocks:
- Low bleeding risk peripheral blocks (e.g., femoral, axillary, popliteal sciatic blocks) can be performed in patients on aspirin therapy 1, 5
- High bleeding risk peripheral blocks (e.g., infraclavicular, para-sacral sciatic, posterior lumbar plexus blocks) may be performed in patients on aspirin monotherapy if the benefit-risk ratio is favorable 1
Management Algorithm for Patients on Double Dose Aspirin Needing Caudal Epidural
Assess indication for double dose aspirin:
- If for secondary prevention after recent myocardial infarction or stent placement, consult with the prescribing cardiologist
- If for primary prevention, consider temporarily reducing to standard dose or discontinuing
Risk mitigation options:
If caudal epidural is absolutely necessary:
- Reduce aspirin to standard dose (81-100 mg daily) at least 3-5 days before the procedure
- Use ultrasound guidance by an experienced operator 1
- Monitor closely for signs of epidural hematoma post-procedure
Post-Procedure Monitoring
If a caudal epidural is performed in a patient on any dose of aspirin, careful monitoring is essential for:
- New or worsening neurological symptoms
- Back pain
- Bladder or bowel dysfunction
- Motor or sensory deficits
Key Considerations
- The risk of epidural hematoma must be weighed against the risk of thrombotic events if aspirin is discontinued
- For patients with recent coronary stents or acute coronary syndrome, discontinuing antiplatelet therapy carries significant risks 1
- In these cases, consider delaying the elective caudal epidural or using alternative pain management approaches
In conclusion, while standard dose aspirin may be continued for neuraxial procedures in selected patients, double dose aspirin significantly increases bleeding risk and should be avoided when performing caudal epidural injections.