How long should a patient stop taking aspirin (acetylsalicylic acid) before undergoing a cervical epidural procedure?

Aspirin Discontinuation Guidelines Before Cervical Epidural Procedures

Aspirin should be discontinued at least 7 days before undergoing a cervical epidural procedure to minimize bleeding risk and prevent potential complications such as epidural hematoma. 1

Rationale for Aspirin Discontinuation

• Aspirin irreversibly inhibits platelet function for the entire lifespan of platelets (7-10 days), making timing of discontinuation critical for invasive procedures 1
• While some guidelines suggest a 3-day washout period, this may not be sufficient for high-risk procedures like cervical epidurals that involve the neuraxial space 2
• For procedures with high bleeding risk, such as neuraxial interventions, a complete correction of platelet function is necessary in all patients, requiring a 5-7 day washout period 1
• Epidural procedures are classified as moderate to high-risk interventions that warrant appropriate antiplatelet medication management 2

Evidence-Based Recommendations

• The American Society of Interventional Pain Physicians (ASIPP) recommends discontinuing low-dose aspirin for at least 3 days before high and moderate-risk procedures 3
• The Association of Anaesthetists of Great Britain & Ireland recommends stopping aspirin at least 3 days before moderate to high-risk procedures like epidurals 2
• For procedures with high bleeding risk (including neuraxial procedures), the French Working Group on Perioperative Haemostasis recommends a 5-day aspirin washout period 1
• Central neuraxial anesthesia may be performed in patients on aspirin monotherapy if the benefit-risk ratio is favorable, but a longer discontinuation period is preferred for optimal safety 1

Risk Factors and Complications

• Epidural hematoma is a rare but potentially devastating complication of accessing the epidural space 4
• A case report documented an epidural hematoma following spinal cord stimulator lead placement in a patient taking low-dose aspirin (81 mg/day), suggesting that even low-dose aspirin can increase bleeding risk 4
• Antiplatelet medication use is associated with 2.21 times higher odds of procedural complications within 7 days after cervical epidural injections 5
• Multiple attempts during the procedure and bleeding observed during the procedure increase the risk for epidural hematoma formation 3

Special Considerations

• For patients with high cardiovascular risk (recent myocardial infarction or cardiac stent placement), the continuation of aspirin may be considered after careful risk-benefit assessment 1
• Patients with drug-eluting stents at high risk of thrombosis may need to postpone elective procedures until 6 months to 1 year after stent placement 6
• If thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during cessation of aspirin, and discontinued 24 hours before the epidural procedure 3
• Shared decision-making between the patient and treating physicians should consider all appropriate risks associated with continuation or discontinuation of aspirin therapy 3

Resumption of Aspirin Therapy

• Aspirin can typically be resumed 12-24 hours after the procedure when adequate hemostasis has been achieved 6
• If thromboembolic risk is high, antithrombotic therapy may be resumed 12 hours after the interventional procedure 3
• For patients with aspirin-exacerbated respiratory disease who have undergone desensitization, gaps in aspirin doses >48 hours may lead to loss of tolerance 1

Conclusion

When planning a cervical epidural procedure, the safest approach is to discontinue aspirin 7 days before the procedure to allow complete recovery of platelet function and minimize bleeding risk. This timeframe provides the best balance between preventing procedural complications while maintaining patient safety.