Should aspirin (acetylsalicylic acid) be stopped before an epidural procedure?

Aspirin Management Before Epidural Procedures

For epidural procedures, aspirin should be discontinued for 5 days prior to the procedure to ensure adequate platelet function recovery and minimize bleeding risk, unless the patient has extremely high cardiovascular risk that warrants multidisciplinary discussion. 1

Risk Classification and Rationale

Epidural procedures are classified as high bleeding risk interventions where bleeding cannot be easily compressed and consequences can be catastrophic (epidural hematoma with permanent paralysis). 2, 1

• Aspirin irreversibly inhibits platelet function for the entire 7-10 day lifespan of platelets, making complete washout necessary for high-risk neuraxial procedures. 1
• The French Working Group on Perioperative Haemostasis specifically recommends a 5-day minimum washout period for aspirin before neuraxial procedures requiring complete correction of platelet function. 1
• While some older guidelines suggest 3 days may be sufficient for "moderate-risk" procedures, the 5-day minimum provides better safety margins for epidural procedures specifically. 1, 3

Evidence Supporting Discontinuation

The recommendation to stop aspirin is based on documented cases of epidural hematomas occurring in patients on aspirin:

• A 73-year-old woman on aspirin 81 mg daily developed an epidural hematoma 24 hours after spinal cord stimulator lead placement, with aspirin identified as the only variable that could have caused the complication. 4
• An 80-year-old woman on undisclosed aspirin developed an epidural hematoma with neurological deficits after a spinal cord stimulator trial, requiring emergent neurosurgical evacuation. 5
• Multiple studies demonstrate increased hemorrhagic complications when aspirin is continued or stopped for only 3-7 days before spinal procedures, but no increased bleeding risk when stopped 7-10 days preoperatively. 6

When Aspirin May Be Continued

The only scenario where aspirin continuation during epidural procedures may be considered is when:

• The benefit-risk ratio is exceptionally favorable (extremely high cardiovascular/thrombotic risk). 2
• There is no associated abnormality of hemostasis or concurrent anticoagulant therapy. 2
• Single-puncture spinal anesthesia is preferable to epidural anesthesia in this scenario. 2

However, this represents a minority exception requiring careful multidisciplinary discussion, not standard practice. 1

Critical Contraindications

Epidural procedures are absolutely contraindicated in patients on:

• P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) unless discontinued for 7, and 5 days respectively. 2, 1
• Dual antiplatelet therapy (aspirin plus P2Y12 inhibitors) unless both agents have been discontinued for appropriate intervals. 1

Resumption of Aspirin

Restart aspirin 12-24 hours after the procedure when adequate hemostasis has been achieved, to minimize thrombotic risk in patients requiring antiplatelet therapy. 1, 3

Common Pitfalls to Avoid

• Do not assume 3 days is sufficient for high-risk neuraxial procedures—epidural procedures specifically require the 5-day minimum. 1
• Do not overlook that epidural catheter removal carries the same bleeding risk as insertion—apply the same 5-day aspirin discontinuation criteria before catheter manipulation or removal. 2, 1
• Do not bridge with heparin or LMWH when discontinuing aspirin for the procedure—this increases bleeding risk without preventing thrombotic events. 7
• Do not perform epidurals in patients who fail to disclose aspirin use—specifically ask about all antiplatelet medications including over-the-counter aspirin. 5

Special Cardiovascular Considerations

For patients with recent myocardial infarction, coronary stents, or high cardiovascular risk:

• Postpone elective epidural procedures until dual antiplatelet therapy duration is complete (6 months to 1 year for drug-eluting stents). 1
• If the epidural is essential and cannot be delayed, perform only after multidisciplinary discussion weighing catastrophic bleeding versus thrombotic risks. 1
• The thrombotic risk of stopping aspirin (stroke recurrence risk 2.02%, cardiovascular events 1.83% within 30 days) must be balanced against the risk of permanent paralysis from epidural hematoma. 7