From the Research
The recommended INR cutoff for an epidural steroid injection is generally less than 1.5, as supported by the most recent and highest quality study available 1.
Key Considerations
- Patients with an INR above this threshold may face an increased risk of bleeding complications during the procedure.
- For patients on anticoagulant therapy such as warfarin, medication should typically be discontinued 5-7 days before the procedure to allow the INR to normalize, with specific timing determined by individual patient factors.
- After the procedure, anticoagulation can usually be resumed after 24 hours, though this timing may vary based on the specific case.
Rationale
The INR cutoff exists because epidural injections involve placing a needle in close proximity to the spinal cord and major blood vessels, where bleeding could potentially cause serious complications including epidural hematoma and neurological damage.
Individualized Decision-Making
However, the decision to proceed with an epidural steroid injection should always be individualized, weighing the risks of bleeding against the benefits of the procedure, particularly in patients who require ongoing anticoagulation for medical conditions, as highlighted in studies such as 2 and 3.
Procedure Safety
Epidural steroid injections have been used for decades as part of a rehabilitation program to relieve back or neck pain and the associated radicular nerve component that often accompanies these problems, with studies like 4 discussing the technical aspects of the procedure to maximize benefit and minimize complications.
Anticoagulation Management
The management of anticoagulation therapy is crucial, with guidelines such as those from the Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy providing recommendations for outpatient management, including the use of low-molecular-weight heparin (LMWH) and the maintenance of specific INR levels for different conditions 3.
Recent Findings
Recent studies, such as 1, have found that joint and soft tissue injections appear to be safe in patients receiving warfarin anticoagulation with an INR <3, suggesting that continuation of anticoagulants may reduce staff workload and patient inconvenience without increasing the risk of complications.