Should Aspirin 81mg Be Held Before Cervical Stenosis Surgery?
For cervical stenosis surgery, aspirin 81mg should be stopped ≤7 days (ideally 5-7 days) before surgery due to the high bleeding risk associated with spinal procedures in closed anatomical spaces where even minor hemorrhage can cause catastrophic neurological complications. 1
Rationale for Discontinuation in Spinal Surgery
Cervical spine surgery is classified as a high-bleeding-risk procedure where bleeding occurs in a closed space, making it fundamentally different from most general surgical procedures. 1 The American College of Chest Physicians specifically addresses this scenario, stating that for "select patients undergoing a non-cardiac surgery associated with a high-bleed-risk (eg, intracranial, spinal); if ASA interruption is adopted, we suggest interruption for ≤7 days." 1
Key Considerations for Timing
Stop aspirin 5-7 days preoperatively for neurosurgery and spinal procedures where bleeding in closed spaces can lead to severe complications including spinal cord compression and permanent neurological injury. 2
The standard recommendation of ≤7 days interruption (rather than the traditional 7-10 days) is sufficient to restore normal platelet function while minimizing the thrombotic risk window. 1
Aspirin's antiplatelet effect is irreversible and lasts for the lifespan of affected platelets (7-10 days), but adequate hemostasis typically returns after 5-7 days as new platelets are produced. 1
Resumption of Therapy
Restart aspirin within 24 hours postoperatively once adequate hemostasis is achieved and there is no evidence of ongoing bleeding or epidural hematoma. 3, 2 The maximal antiplatelet effect occurs within minutes after taking aspirin, providing rapid cardioprotection. 1
Special Circumstances Requiring Individualized Assessment
Patients with Coronary Stents
If the patient has a drug-eluting stent placed within the past 12 months, the decision becomes more complex as aspirin discontinuation carries substantial thrombotic risk. 2
For patients with recent stent placement (especially <6 months), strongly consider delaying elective cervical surgery until the mandatory dual antiplatelet therapy period has passed. 3, 2
If surgery cannot be delayed and the patient has a coronary stent, consultation with cardiology is essential to weigh the competing risks of stent thrombosis (potentially fatal) versus spinal epidural hematoma (potentially paralyzing). 1
Patients with High Cardiovascular Risk
For patients with established coronary artery disease, recent acute coronary syndrome, or multiple cardiovascular risk factors, the thrombotic risk of aspirin discontinuation must be carefully weighed. 1
However, the closed-space nature of spinal surgery generally tips the balance toward discontinuation even in high-risk patients, as an epidural hematoma can cause irreversible spinal cord injury. 1, 2
Common Pitfalls to Avoid
Do not continue aspirin through cervical spine surgery based on general surgical guidelines that apply to procedures with lower bleeding consequences. 1, 2
Do not stop aspirin for longer than 7 days unnecessarily, as this extends the thrombotic risk window without additional hemostatic benefit. 1, 2
Ensure thorough medication reconciliation as patients may not report over-the-counter NSAIDs with antiplatelet effects that compound bleeding risk. 3, 2
Verify the patient is not on additional antiplatelet agents (clopidogrel, ticagrelor, prasugrel) which would require different discontinuation timeframes and further increase bleeding risk. 1
Evidence Quality Note
The recommendation to hold aspirin for spinal surgery comes from the highest-quality guideline available (2022 American College of Chest Physicians), which specifically addresses high-bleeding-risk procedures including spinal surgery. 1 While the POISE-2 trial showed no cardiovascular benefit from perioperative aspirin continuation in general non-cardiac surgery, it did not specifically evaluate high-risk bleeding procedures like spinal surgery where the risk-benefit calculation differs substantially. 1