What are the contraindications to spinal procedures?

Contraindications to Spinal Procedures

Spinal procedures including neuraxial anesthesia, lumbar puncture, and epidural catheter placement are absolutely contraindicated in patients with active systemic or spinal infection, uncorrectable bleeding diathesis, recent central nervous system bleeding, intracranial or spinal lesions at high risk for bleeding, and recent spinal anesthesia/lumbar puncture. 1

Absolute Contraindications

Infectious Contraindications

• Active systemic infection, particularly spinal infection, prohibits any spinal procedure due to risk of seeding infection into the central nervous system 1

Hematologic Contraindications

• Uncorrectable bleeding diathesis represents an absolute contraindication to spinal procedures 1
• Active major bleeding requiring more than 2 units of blood transfusions in 24 hours 1, 2
• Severe thrombocytopenia with platelet count less than 50,000/mcL 1, 2
• Recent central nervous system bleeding or intracranial hemorrhage 1, 2

Anticoagulation-Related Contraindications

• Recent spinal anesthesia or lumbar puncture in patients on anticoagulation creates risk of spinal or epidural hematoma resulting in long-term paralysis 1
• Current anticoagulation therapy makes neuraxial procedures contraindicated until appropriate cessation times are achieved 1

For patients on dabigatran requiring emergency lumbar puncture: Idarucizumab should be administered before the procedure if LP is indispensable; non-activated or activated prothrombin complex concentrates cannot be recommended as they do not guarantee normalization of hemostasis 1

Specific anticoagulant cessation times before neuraxial procedures: 1

• Argatroban: 8 hours after stopping infusion with plasma level confirmed <0.1 mg/mL
• Bivalirudin: 8 hours after stopping infusion
• Direct oral anticoagulants (DOACs): Last dose at D-5 or plasma concentration <30 ng/mL
• Danaparoid and fondaparinux: Stop >48 hours to achieve levels <0.1 U anti-Xa/mL

Cardiopulmonary Contraindications

• Insufficient cardiopulmonary health to safely tolerate sedation or general anesthesia 1
• Hemodynamic instability contraindicates elective spinal procedures 1

Allergy Contraindications

• Known allergy to the polymer to be used for vertebral augmentation procedures 1

Relative Contraindications

Anatomic and Neurologic Factors

• Significant spinal canal stenosis or compressive myelopathy resulting from retropulsed fracture fragments or epidural tumor extension 1
• Radiculopathy exceeding local vertebral pain 1
• Extensive involvement of the posterior vertebral body wall requires experienced operators and should be systematically combined with radiation therapy for vertebral augmentation 1

Bleeding Risk Factors

• Chronic clinically significant bleeding lasting more than 48 hours 1, 2
• Moderate thrombocytopenia with platelet count between 50,000-150,000/mcL 2
• Severe platelet dysfunction from uremia, medications, or dysplastic hematopoiesis 1, 2
• Recent major surgery associated with high bleeding risk 1
• High risk for falls and/or head trauma 1, 2

Antiplatelet Therapy Considerations

For low-to-intermediate risk spinal procedures: Recent evidence suggests aspirin may be continued for some procedures, though discontinuation for at least 3 days is recommended for high-risk and moderate-risk procedures 3, 4

For high-risk procedures: 5, 3

• Aspirin/Clopidogrel: Stop ≥7-10 days preoperatively
• Clopidogrel, ticlopidine, ticagrelor, prasugrel: Discontinue to avoid epidural hematomas
• P2Y12 inhibitors: 80-87% of surgeons always discontinue preoperatively

Critical Clinical Caveats

Not Contraindications

• Prolonged aPTT in patients with lupus anticoagulant or antiphospholipid syndrome is not a contraindication; these patients may require indefinite anticoagulation 1, 2
• Peptic ulcer disease without active bleeding 2
• History of guaiac-positive stools alone 2

Risk Stratification Factors That Upgrade Risk

Multiple variables increase bleeding risk and should upgrade procedure risk category: 3

• Anatomic pathology with spinal stenosis or ankylosing spondylitis
• Combining moderate-risk procedures with anatomic risk factors
• Bleeding observed during the procedure
• Multiple attempts during procedures

Timing Considerations for Resumption

• If thromboembolic risk is high: Low molecular weight heparin bridge therapy can be instituted during anticoagulant cessation, discontinued 24 hours before the procedure 3
• Antithrombotic therapy resumption: May resume 12 hours after the interventional procedure if thromboembolic risk is high 3
• Platelet inhibition resumption: Average 4 ± 2.5 days postoperatively, with orthopedic surgeons recommencing earlier than neurosurgeons 6

Emergency Situations

For emergency diagnostic lumbar puncture in suspected meningitis: Any situation delaying LP requires empiric antibiotic therapy with blood culture before antibiotics; LP should be performed as soon as possible after correction of contraindications 1

Special Populations

• Patients with heparin-induced thrombocytopenia (HIT): Postpone surgery beyond first month following HIT diagnosis if possible; neuraxial procedures require extended cessation times for alternative anticoagulants 1
• Patients with empyema or prior chest radiation: Require careful individual assessment for vertebral augmentation 1