Aspirin Management Before Epidural Procedures
Aspirin should be discontinued at least 5 days before epidural procedures to ensure adequate platelet function recovery and minimize the risk of spinal epidural hematoma. 1, 2
Evidence-Based Timing Recommendations
The most recent high-quality guidelines provide clear direction on aspirin discontinuation:
The French Working Group on Perioperative Haemostasis (2018) recommends a 5-day washout period for aspirin before neuraxial procedures, which are classified as high bleeding risk interventions requiring complete correction of platelet function. 1, 2
The Association of Anaesthetists of Great Britain & Ireland recommends stopping aspirin at least 3 days before moderate to high-risk procedures like epidurals, though this represents a minimum threshold rather than optimal timing. 2, 3
For spine surgery specifically, stopping aspirin 7-10 days preoperatively eliminates increased hemorrhagic complications, while stopping for only 3-7 days still carries elevated bleeding risk. 4
Physiologic Rationale
The timing recommendations are based on platelet biology:
Aspirin irreversibly inhibits platelet cyclooxygenase for the entire 7-10 day lifespan of platelets, making adequate washout periods essential for procedures with serious bleeding consequences. 2, 3, 5
Complete platelet function recovery requires sufficient time for new, unaffected platelets to replace the aspirin-inhibited population. 5
Critical Safety Considerations
The risk of spinal epidural hematoma, though rare, can result in catastrophic outcomes including permanent paralysis:
Pre-operative aspirin use is associated with a 3.2-fold increased risk of spinal epidural hematoma (RR 3.2,95% CI 1.25-8.22, P = 0.015), even when appropriately discontinued. 6
Case reports document irreversible paralysis from postoperative epidural hematomas in patients on aspirin, emphasizing the devastating potential consequences. 4, 7
Increased bleeding during epidural procedures has been documented in aspirin users, with bleeding times remaining elevated until 6 days after discontinuation. 7
Special Clinical Scenarios
For patients with high cardiovascular risk (recent MI or cardiac stents):
Aspirin should ideally be continued perioperatively when possible, as the thrombotic risk may outweigh bleeding risk. 1
If epidural anesthesia is essential in these patients, the procedure should be postponed until DAPT duration is complete, or performed only after multidisciplinary discussion weighing catastrophic bleeding vs thrombotic risks. 1
Patients with drug-eluting stents at high thrombotic risk should postpone elective procedures for 6 months to 1 year after stent placement. 2
Resumption of Therapy
Aspirin should be resumed as early as possible after the epidural procedure:
Restart aspirin the same day if adequate hemostasis is achieved, to minimize thrombotic risk in patients requiring antiplatelet therapy. 1, 3
Typical resumption occurs 12-24 hours post-procedure when hemostasis is confirmed. 2
Common Pitfalls to Avoid
Do not assume 3 days is sufficient for high-risk neuraxial procedures—the 5-day minimum provides better safety margins. 1, 2
Do not overlook that epidural catheter manipulation and removal carry the same bleeding risks as insertion—apply the same aspirin discontinuation criteria. 1
Do not combine NSAIDs with aspirin perioperatively, as this significantly increases bleeding risk. 3
Do not perform epidurals in patients on dual antiplatelet therapy (aspirin plus P2Y12 inhibitors) unless both agents have been discontinued for appropriate intervals (aspirin 5 days, clopidogrel 7 days, ticagrelor 5 days). 1