When can aspirin (acetylsalicylic acid) be restarted after a cervical epidural steroid injection (ESI)?

When to Restart Aspirin After Cervical Epidural Steroid Injection

Aspirin can typically be restarted 12-24 hours after cervical epidural steroid injection once adequate hemostasis has been achieved. 1

Evidence-Based Timing for Aspirin Resumption

The most direct guidance comes from procedural guidelines specifically addressing neuraxial interventions:

• Standard recommendation: Resume aspirin 12-24 hours post-procedure when hemostasis is confirmed 1
• This timing aligns with general surgical principles where aspirin is restarted within 24 hours after procedures when bleeding risk is acceptable 2, 3

Risk-Stratified Approach to Resumption

High Thrombotic Risk Patients

For patients with recent coronary stents, acute coronary syndrome, or recent stroke:

• Restart aspirin as soon as possible within 24 hours of the procedure 3
• Consider maintaining aspirin throughout the perioperative period if bleeding risk is acceptable, though this requires careful risk-benefit assessment 2
• Patients with drug-eluting stents have particularly high thrombotic risk if antiplatelet therapy is interrupted 2, 4

Standard Risk Patients

For patients on aspirin for stable cardiovascular disease or primary prevention:

• Resume within 24 hours is appropriate and safe 1, 3
• For primary prevention only, reassess whether aspirin needs to be restarted at all 3

Critical Safety Considerations

Pre-Resumption Assessment

Before restarting aspirin, confirm:

• No evidence of neurologic deterioration suggesting epidural hematoma 5
• Adequate hemostasis at the procedure site 1
• No procedural complications such as blood noted during needle placement 6

Bleeding Risk Factors

Be particularly cautious in patients with:

• Anticoagulant use (5.4-fold increased complication risk) 7
• History of venous thromboembolism (3-fold increased risk) 7
• Existing neurologic deficits (3-fold increased procedural complication risk) 7
• Obesity or anxiety disorders (associated with higher complication rates) 7

Important Clinical Context

Procedural Complications Are Rare

• Overall complication rate within 7 days is only 1.7%, with neurologic complications occurring in 0.5% of cases 7
• No spinal hematomas occurred in a large prospective study of 1,214 epidural steroid injections in patients on NSAIDs 6
• Recent data suggests cervical transforaminal ESI may be safely performed even with patients continuing anticoagulation, with no reported epidural hematomas in 2,792 procedures 8

Transforaminal vs Interlaminar Approach

• Transforaminal approach carries 1.55-fold higher procedural complication risk compared to interlaminar 7
• Neurologic complications are 1.69-fold higher with transforaminal technique 7

Common Pitfalls to Avoid

• Do not delay resumption unnecessarily in high-risk cardiac patients, as thrombotic risk may outweigh bleeding risk 3
• Do not restart if new neurologic symptoms develop post-procedure—investigate for epidural hematoma first 5
• Do not assume all patients need aspirin restarted—reassess indication, especially for primary prevention 3
• Avoid gaps >48 hours in patients who underwent aspirin desensitization for aspirin-exacerbated respiratory disease, as tolerance may be lost 1

Algorithm for Aspirin Resumption

1. Immediate post-procedure (0-12 hours): Monitor for complications, assess hemostasis
2. 12-24 hours post-procedure:
   • High thrombotic risk → restart aspirin
   • Standard risk → restart aspirin if no bleeding concerns
3. If complications present: Delay resumption until bleeding controlled or neurologic issues resolved 3
4. Beyond 24 hours: All patients without contraindications should have aspirin restarted 1, 3