How long should aspirin and Plavix be discontinued before a cervical epidural?

Antiplatelet Medication Discontinuation Before Cervical Epidural Injections

For patients on dual antiplatelet therapy with aspirin and Plavix (clopidogrel), aspirin should be discontinued 5 days before a cervical epidural injection, and Plavix should be discontinued 5 days before the procedure.

Specific Recommendations for Antiplatelet Discontinuation

Aspirin

• Discontinue 5 days before cervical epidural injection 1
• While some studies suggest shorter discontinuation periods (4-5 days) may be possible 2, the French Working Group on Perioperative Haemostasis (GIHP) strongly recommends a 5-day washout period for aspirin before high-risk neuraxial procedures 1

Plavix (Clopidogrel)

• Discontinue 5 days before cervical epidural injection 1, 3
• The FDA label for clopidogrel specifically states to "discontinue 5 days prior to elective surgery that has a major risk of bleeding" 3

Risk Stratification and Rationale

Epidural Procedures: High Bleeding Risk

• Cervical epidural injections are classified as high-risk neuraxial procedures 1
• Epidural hematoma is a rare but potentially devastating complication that can lead to permanent neurological damage 4
• The insertion of an epidural needle carries similar risks to catheter insertion and removal, requiring complete absence of antiplatelet effect 1, 5

Thrombotic Risk Considerations

• For patients with recent coronary stents:
  • If possible, elective procedures should be postponed until completion of the full course of dual antiplatelet therapy (DAPT) 1
  • For bare metal stents: defer procedure for at least 6 weeks after placement 5
  • For drug-eluting stents: defer procedure for at least 6 months after placement 5

Perioperative Management Algorithm

1. Assess thrombotic risk:

   • Recent coronary stent placement (within 6 months)
   • Recent myocardial infarction
   • Recent stroke
   • High ASCVD risk

2. If high thrombotic risk:

   • Consider postponing the cervical epidural if clinically appropriate
   • Consult with cardiology for patients with recent stent placement
   • Consider alternative pain management approaches

3. If procedure cannot be postponed:

   • Discontinue Plavix (clopidogrel) 5 days before procedure 1, 3
   • Discontinue aspirin 5 days before procedure 1
   • For very high thrombotic risk patients (e.g., stent within 1 month), consider hospitalization and bridging with intravenous antiplatelet agents 1

4. Post-procedure management:

   • Resume antiplatelet therapy 24-72 hours after the procedure if no bleeding complications 1, 5
   • Resume with the same P2Y12 inhibitor as used preoperatively 1

Common Pitfalls to Avoid

• Inadequate discontinuation time: Failing to stop antiplatelet medications for the recommended period increases the risk of epidural hematoma 4
• Overlooking patient disclosure: Patients may not disclose over-the-counter aspirin use 4
• Premature discontinuation in high-risk patients: Stopping antiplatelet therapy too early in patients with recent stents can lead to stent thrombosis 1, 6
• Delayed resumption: Antiplatelet medications should be resumed within 24-72 hours after the procedure to minimize thrombotic risk 1
• Ignoring other risk factors: Advanced age, renal impairment, and concomitant anticoagulants further increase bleeding risk 4

By following these evidence-based recommendations, you can minimize both the risk of bleeding complications from the cervical epidural procedure and the risk of thrombotic events from antiplatelet discontinuation.