How long should aspirin be held before a spinal procedure in an adult patient with a history of cardiovascular disease?

Aspirin Management Before Spinal Procedures

For intracranial and spinal neurosurgery, aspirin should be discontinued for 5 days before the procedure to minimize bleeding risk, as these are classified as high-risk neuraxial interventions requiring complete restoration of platelet function. 1

Risk Stratification and Timing

High-Risk Spinal Procedures (Intracranial Neurosurgery and Spinal Surgery)

• Discontinue aspirin 5 days before surgery 1
• This extended washout period is necessary because aspirin irreversibly inhibits platelet function for the entire 7-10 day lifespan of platelets, and high-risk neuraxial procedures require complete correction of platelet function in all patients 2
• The 5-day minimum provides better safety margins compared to the 3-day recommendation for lower-risk procedures 2

Moderate-Risk Spinal Procedures

• For epidural procedures and other moderate-risk spinal interventions, discontinue aspirin for at least 3 days 1, 2
• However, if the procedure involves neuraxial access with high bleeding consequences, consider extending to 5 days 2

Low-Risk Spinal Procedures (Lumbar Puncture)

• Aspirin does not need to be discontinued for diagnostic lumbar puncture 3
• Lumbar puncture can be safely performed in patients on aspirin monotherapy with no delay required 3

Critical Cardiovascular Considerations

Patients with Coronary Stents

This is where the decision becomes most complex and requires careful risk stratification:

• For drug-eluting stents (DES) placed <3 months ago or bare-metal stents (BMS) placed <30 days ago: Elective spinal surgery should be postponed until the minimum dual antiplatelet therapy (DAPT) duration is complete 4
• If surgery cannot be deferred, aspirin should be continued perioperatively and only the P2Y12 inhibitor discontinued, with multidisciplinary discussion weighing catastrophic spinal bleeding risk versus stent thrombosis risk 4
• For established coronary artery disease without recent stents: The thrombotic risk of aspirin discontinuation must be weighed against bleeding risk, as discontinuation increases the absolute risk of cardiovascular events by approximately 2% within 30 days 4

Balancing Thrombotic vs. Bleeding Risk

• The French Working Group emphasizes that thrombotic risk associated with discontinuing antiplatelet therapy varies significantly with the indication, and this must be assessed individually 1
• For patients with prior myocardial infarction, stroke, or peripheral arterial disease, the risk of thromboembolic events with aspirin interruption may exceed the risk of epidural hematoma 5

Postoperative Resumption

Restart aspirin as soon as adequate hemostasis is achieved, typically within 12-24 hours after the procedure 2, 4

• For patients with high cardiovascular risk (coronary stents, prior MI, stroke), aspirin should be restarted immediately postoperatively once the surgeon confirms adequate hemostasis 4
• Maximal antiplatelet effect occurs within minutes of taking aspirin 1
• For patients on DAPT, the P2Y12 inhibitor should also be resumed as soon as possible, recognizing that clopidogrel takes 4-5 days to reach maximal effect with maintenance dosing alone 4

Evidence Quality and Nuances

The recommendation for 5-day discontinuation before high-risk spinal procedures comes from the 2018 French Working Group guidelines, which represent the most specific guidance for neurosurgical procedures 1. This contrasts with the 2022 American College of Chest Physicians guideline, which suggests ≤7 days for high-bleed-risk procedures but does not specifically address spinal surgery 1.

Important caveat: The POISE-2 trial showed that perioperative aspirin continuation did not reduce cardiovascular events but increased major bleeding in general non-cardiac surgery 1. However, this trial excluded patients with recent stents and those undergoing carotid surgery, limiting its applicability to high-risk cardiovascular patients 1.

Common Pitfalls to Avoid

• Do not assume 3 days is sufficient for high-risk spinal neurosurgery—the 5-day minimum provides necessary safety margins for procedures with catastrophic bleeding consequences 2
• Do not perform spinal procedures in patients on dual antiplatelet therapy (aspirin plus clopidogrel/ticagrelor/prasugrel) unless both agents have been discontinued for appropriate intervals: aspirin 5 days, clopidogrel 7 days, ticagrelor 5 days, prasugrel 7-9 days 1, 2
• Do not overlook that epidural catheter removal carries the same bleeding risk as insertion—apply the same aspirin discontinuation criteria 2
• Do not indefinitely withhold aspirin postoperatively in cardiovascular disease patients, as thrombotic events cluster early after discontinuation with highest risk in the first 30 days 4
• Do not rely solely on cardiologists to determine timing—spine surgeons must understand these risks as medical consultants may not appreciate the specific bleeding risks of spinal procedures 6

Clinical Evidence from Spinal Surgery

Research specific to spinal surgery shows conflicting results:

• One meta-analysis found that aspirin continuation did not increase intraoperative blood loss, operative time, or transfusion requirements 7
• However, a retrospective study found significantly higher postoperative blood drainage (864 cc vs. 458 cc) and transfusion requirements in patients who had taken aspirin, despite stopping it 7 days preoperatively 8
• A German survey found that 80% of neurosurgical facilities have policies for aspirin discontinuation (mean 7 days), and 66% of surgeons consider aspirin a risk factor for hemorrhagic complications 9

The weight of guideline evidence supports the 5-day discontinuation for high-risk spinal neurosurgery, prioritizing prevention of epidural hematoma and catastrophic neurological sequelae over the conflicting research data. 1, 2