Aspirin Discontinuation Before Lumbar Epidural Procedures
Aspirin should be discontinued 7 days prior to a lumbar epidural procedure to minimize bleeding risk and potential complications such as epidural hematoma. 1
Evidence-Based Recommendations
The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Thrombosis and Haemostasis (GFHT) provide clear guidance on this matter:
- Central neuraxial procedures like epidurals are considered high-risk procedures for bleeding
- Aspirin should be discontinued one week prior to surgical procedures 1
- For epidural procedures specifically, aspirin should be discontinued if the benefit-risk ratio is favorable 1
Risk Stratification for Neuraxial Procedures
Neuraxial procedures can be categorized by bleeding risk:
High-Risk Procedures (including lumbar epidural)
- Epidural anesthesia/analgesia
- Spinal anesthesia
- Deep peripheral nerve blocks
Risk Factors That Increase Bleeding Complications
- Anatomic pathology (spinal stenosis)
- Multiple needle attempts
- Visible bleeding during the procedure
- Concomitant use of other anticoagulants
Timing of Discontinuation
The recommended timing for discontinuation of antiplatelet medications before high-risk procedures:
| Medication | Discontinuation Time |
|---|---|
| Aspirin | 7 days |
| Clopidogrel | 5 days |
| Prasugrel | 7 days |
| Ticagrelor | 5 days |
Special Considerations
Patients with Coronary Stents
For patients with coronary stents or high cardiovascular risk:
- Consider postponing elective procedures until completion of dual antiplatelet therapy
- Consult with cardiology before discontinuing antiplatelet therapy
- For patients with bare-metal stents, defer elective procedures for at least 6 weeks after placement 2
- For patients with drug-eluting stents, defer elective procedures for at least 6 months after placement 2
Resumption of Aspirin
- Aspirin should be restarted 24 hours after the procedure if adequate hemostasis is achieved 1
- For patients at high cardiovascular risk, earlier resumption may be considered based on individual risk assessment
Case Reports and Complications
There have been documented cases of epidural hematoma following interventional pain procedures in patients taking aspirin:
- A 73-year-old woman developed an epidural hematoma 24 hours after spinal cord stimulator lead placement while on aspirin 81 mg/day 3
- Another report suggested a link between aspirin use (250 mg/day) and acute spinal epidural hematoma 4
Algorithm for Decision-Making
- Assess bleeding risk of procedure: Lumbar epidural = high risk
- Assess thrombotic risk of patient:
- Low risk: Discontinue aspirin 7 days before procedure
- High risk (recent stent, recent MI): Consider delaying procedure or consult cardiology
- Monitor for complications: Watch for severe back pain or neurological deficits after procedure
- Resumption timing: Resume aspirin 24 hours after procedure if no bleeding complications
Warning Signs of Epidural Hematoma
- Severe back pain at injection site
- Rapid neurological deterioration
- Progressive motor or sensory deficits
- If suspected, obtain immediate MRI and consider surgical decompression
Remember that the diagnosis of epidural hematoma requires prompt recognition and surgical intervention to avoid permanent neurological damage 5.