NSAIDs Before Epidural Steroid Injection: Safety Assessment
NSAIDs do not need to be withheld before epidural steroid injections (ESI) in patients with normal renal function and no other bleeding risk factors. Current guidelines from the American Society of Regional Anesthesia (ASRA), American Society of Interventional Pain Physicians (ASIPP), and International Spine Intervention Society (ISIS) support continuing NSAIDs in the peri-procedural period 1.
Evidence-Based Safety Profile
Large-Scale Safety Data
- A prospective study of 1,214 epidural steroid injections found zero spinal hematomas in patients taking NSAIDs, including 158 patients on aspirin 2
- NSAIDs did not increase the frequency of minor hemorrhagic complications (blood noted during needle placement occurred in 5.2% overall, with no difference between NSAID and non-NSAID groups) 2
- The study confirmed that epidural steroid injection is safe in patients receiving aspirin-like antiplatelet medications 2
Guideline Recommendations
- The Association of Anaesthetists of Great Britain & Ireland explicitly states that NSAIDs require "no additional precautions" for neuraxial procedures 3
- NSAIDs can be continued without timing restrictions before or after epidural catheter placement 3
Critical Exceptions and Risk Factors
Absolute Contraindications to NSAIDs
Do not use NSAIDs in patients with:
- Creatinine clearance <40 mL/min 3
- Pre-existing renal insufficiency 3
- History of gastrointestinal bleeding or peptic ulcer disease 3
- Concurrent anticoagulation therapy (warfarin, heparin) 3
High-Risk Scenarios Requiring NSAID Discontinuation
Consider withholding NSAIDs when multiple risk factors are present:
- Chronic renal insufficiency combined with other antiplatelet agents (fluoxetine, fish oil, vitamin E) 1
- Spinal stenosis with female gender and advanced age 1
- Concurrent corticosteroid therapy 3
- Age >60 years with compromised fluid status 3
A case report documented epidural hematoma and tetraplegia following cervical ESI in a patient with chronic renal insufficiency who received intramuscular ketorolac post-procedure, along with concurrent fluoxetine, fish oil, and vitamin E 1. This catastrophic outcome occurred despite the additive antiplatelet effects being individually minimal, highlighting that cumulative risk from multiple agents must be considered 1.
Practical Clinical Algorithm
Pre-Procedure Assessment
- Screen for renal function: Obtain creatinine clearance if any concern for renal impairment 3
- Document all antiplatelet/anticoagulant medications: Include SSRIs (fluoxetine), supplements (fish oil, vitamin E), and aspirin 1
- Assess bleeding history: Prior bruising, bleeding episodes, or family history 2
Decision Framework
- Normal renal function + no other antiplatelet agents: Continue NSAIDs 3, 2
- CrCl 40-60 mL/min: Avoid NSAIDs entirely 3
- Multiple antiplatelet agents (≥3 including NSAIDs): Consider withholding NSAIDs 1-2 days before procedure 1
- History of GI bleeding + age >60: Use alternative analgesics (acetaminophen up to 3g/day) 3
Post-Procedure NSAID Use
Timing Considerations
- NSAIDs can be resumed immediately after ESI in low-risk patients 3
- Avoid intramuscular ketorolac immediately post-procedure in patients with multiple risk factors, as this potent antiplatelet agent may compromise hemostasis when vascular injury has occurred 1
Monitoring Requirements
- Watch for new neurologic symptoms lasting >24 hours (median duration 3 days in 3.5% of patients) 2
- Differentiate minor post-injection symptoms from epidural hematoma requiring emergency intervention 2
Risk-Benefit Context
While catastrophic complications (paralysis, stroke) from ESI are extensively documented, their true incidence is too small to calculate even in the largest cohorts 4. The most common adverse events are minor, transient, and occur at rates <1% 4. The risk from withholding effective analgesia in most patients outweighs the theoretical bleeding risk from NSAIDs 2.
However, when multiple risk factors converge—particularly renal insufficiency, advanced age, spinal stenosis, and concurrent antiplatelet medications—the cumulative risk justifies NSAID discontinuation 1. Even strict adherence to anticoagulation guidelines does not eliminate all risk, as demonstrated by a case of epidural hematoma despite following ASRA protocols 5.