In a patient with an acute L1 vertebral compression fracture who is taking an oral anticoagulant (e.g., warfarin, dabigatran, apixaban, rivaroxaban, edoxaban), what is the safest initial management of the anticoagulation and need for reversal before any invasive spinal procedure?

Management of Anticoagulation in Acute L1 Vertebral Compression Fracture

Immediate Anticoagulation Management

For patients with acute L1 compression fracture on oral anticoagulants, immediately discontinue the anticoagulant and assess whether the fracture requires invasive spinal intervention, as spinal/intraspinal bleeding is classified as a critical site that constitutes major bleeding requiring reversal agents. 1

Initial Assessment and Stabilization

• Stop all oral anticoagulants immediately upon diagnosis of acute L1 compression fracture, regardless of whether active bleeding is present, because intraspinal bleeding is classified as a critical anatomic site where bleeding can cause severe functional consequences. 1

• Obtain immediate imaging (CT or MRI) to identify any epidural or paraspinal hematoma, as these can develop even without overt bleeding and may cause neurological compromise requiring urgent surgical decompression. 1, 2

• Check baseline coagulation studies: INR for warfarin patients, and consider specific DOAC levels if available, though treatment should not be delayed waiting for these results. 1

• Assess renal function using Cockcroft-Gault formula, as this determines drug clearance time and influences reversal strategy. 1, 3

Reversal Strategy Based on Anticoagulant Type

For Warfarin:

• Administer 5-10 mg IV vitamin K immediately. 1
• Administer 4-factor prothrombin complex concentrate (4F-PCC) for rapid reversal, which is superior to fresh frozen plasma due to faster administration, no need for blood type matching, and lower volume overload risk. 1
• Do not use recombinant factor VIIa as first-line reversal agent. 1

For Dabigatran:

• Administer idarucizumab (specific reversal agent) if available for immediate neutralization. 1
• If idarucizumab unavailable, administer 4F-PCC or activated PCC, though these have not proven complete neutralization and are second-line options. 1, 2

For Factor Xa Inhibitors (Rivaroxaban, Apixaban, Edoxaban):

• Administer andexanet alfa (specific reversal agent for apixaban/rivaroxaban) if available. 1
• If andexanet alfa unavailable, administer 4F-PCC as second-line hemostatic agent. 1, 2
• Consider tranexamic acid as adjunctive therapy to improve coagulation. 2

Pre-Procedural Planning for Invasive Spinal Procedures

If Vertebroplasty, Kyphoplasty, or Surgical Stabilization Required

Neuraxial procedures (including vertebroplasty/kyphoplasty at L1) are classified as very high hemorrhagic risk because bleeding in the spinal canal can cause permanent neurological damage and surgical hemostasis cannot be safely performed in this location. 1, 3

Minimum Drug Clearance Times Before Spinal Intervention

For Warfarin:

• Wait until INR <2.0 before proceeding with any spinal procedure. 1
• This typically requires 5 days of discontinuation plus vitamin K administration. 4, 5

For Dabigatran:

• CrCl >50 mL/min: Wait 4 days (96 hours) minimum. 1, 3
• CrCl 30-50 mL/min: Wait 5 days (120 hours) minimum. 1, 3
• If idarucizumab administered, neuraxial procedure can proceed immediately after confirmed neutralization. 1

For Rivaroxaban (Xarelto):

• CrCl >50 mL/min: Wait 3 days (72 hours) minimum for high-risk procedures, but up to 5 days for neuraxial procedures. 1, 3, 6
• CrCl 30-50 mL/min: Wait 4-5 days minimum. 3, 6
• Age >80 years or P-gp/CYP3A4 inhibitors present: Consider 5-day hold. 3, 6

For Apixaban:

• Wait 48 hours (2 days) minimum before neuraxial procedures with normal renal function. 7
• Extend to 72 hours if CrCl 30-50 mL/min. 1

For Edoxaban:

• Wait 3 days minimum before high-risk procedures. 1
• Extend to 4-5 days for neuraxial procedures or if CrCl 30-50 mL/min. 1

Critical Pre-Procedure Requirements

• Never perform neuraxial procedures with possible residual anticoagulant concentration due to insufficient discontinuation time—this is the single most important pitfall that can result in spinal hematoma with permanent paralysis. 1, 3, 6, 8

• Verify adequate hemostasis before proceeding: for warfarin patients, confirm INR <2.0; for DOAC patients, ensure minimum clearance time has elapsed based on renal function. 1

• Do not use bridging anticoagulation with heparin or LMWH during the discontinuation period, as this increases bleeding risk without benefit for spinal procedures. 1, 3, 9

Conservative Management Without Invasive Procedure

If the L1 compression fracture is stable and does not require invasive intervention:

• Anticoagulation can be restarted 48-72 hours after the acute injury once adequate hemostasis is confirmed and no epidural hematoma is present on imaging. 1

• Monitor closely for signs of epidural hematoma: severe midline back pain, rapid neurological deterioration, bowel/bladder dysfunction. 1, 6

• Obtain urgent MRI if any neurological symptoms develop, as surgical decompression within hours is required to prevent permanent paralysis. 1

Thrombotic Risk Management During Anticoagulation Hold

• Assess the indication for anticoagulation: atrial fibrillation with high CHA₂DS₂-VASc score, recent VTE, mechanical valve (though DOACs contraindicated), or other high-risk condition. 1

• For patients at very high thrombotic risk (e.g., recent VTE within 3 months, mechanical valve on warfarin), consider bridging with therapeutic LMWH only if spinal procedure can be safely delayed and no active spinal bleeding present. 1, 9

• Stop LMWH bridging 24 hours before any planned spinal procedure. 1, 9

• The risk of thrombotic events during brief anticoagulation interruption (3-5 days) is generally lower than the risk of catastrophic spinal hematoma if procedures performed with inadequate drug clearance. 9, 5

Post-Procedure Anticoagulation Resumption

After vertebroplasty, kyphoplasty, or surgical stabilization:

• Resume anticoagulation 48-72 hours post-procedure once adequate hemostasis confirmed and no ongoing bleeding. 1, 3, 6

• For very high bleeding risk procedures (open spinal surgery), consider delaying restart to postoperative day 5-7 depending on surgical hemostasis. 5

• Monitor neurological status closely during the first 24-48 hours after restarting anticoagulation for signs of delayed epidural hematoma. 1, 8