Background: Interventional pain management is a specialty that utilizes invasive procedures
to diagnose and treat chronic pain. Patients undergoing these treatments may be receiving
exogenous anticoagulants and antithrombotics. Even though the risk of major bleeding is very
small, the consequences can be catastrophic. However, the role of antithrombotic therapy for
primary and secondary prevention of cardiovascular disease to decrease the incidence of acute
cerebral and cardiovascular events is also crucial.
Overall, there is a paucity of literature on the subject of bleeding risk in interventional pain
management along with practice patterns and perioperative management of anticoagulant and
anti-thrombotic therapy.
Study Design: Best evidence synthesis.
Objective: To critically appraise and synthesize the literature with assessment of the bleeding
risk of interventional techniques including practice patterns and perioperative management of
anticoagulant and antithrombotic therapy.
Methods: The available literature on the bleeding risk of interventional techniques and practice
patterns and perioperative management of anticoagulant and antithrombotic therapy was
reviewed.
Data sources included relevant literature identified through searches of PubMed and EMBASE
from 1966 through December 2012 and manual searches of the bibliographies of known
primary and review articles.
Results: There is good evidence for the risk of thromboembolic phenomenon in patients who
discontinue antithrombotic therapy, spontaneous epidural hematomas occur with or without
traumatic injury in patients with or without anticoagulant therapy associated with stressors such
as chiropractic manipulation, diving, and anatomic abnormalities such as ankylosing spondylitis,
and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDs),
including low dose aspirin prior to performing interventional techniques.
There is fair evidence that excessive bleeding, including epidural hematoma formation may
occur with interventional techniques when antithrombotic therapy is continued, the risk of
thromboembolic phenomenon is higher than the risk of epidural hematomas with discontinuation
of antiplatelet therapy prior to interventional techniques, to continue phosphodiesterase
inhibitors (dipyridamole [Persantine], cilostazol [Pletal], and Aggrenox [aspirin and dipyridamole]),
and that anatomic conditions such as spondylosis, ankylosing spondylitis and spinal stenosis, and
procedures involving the cervical spine; multiple attempts; and large bore needles increase the
risk of epidural hematoma; and rapid assessment and surgical or nonsurgical intervention to
manage patients with epidural hematoma can avoid permanent neurological complications. There is limited evidence to discontinue antiplatelet therapy with platelet aggregation inhibitors to avoid bleeding and epidural
hematomas and/or to continue antiplatelet therapy clopidogrel (Plavix), ticlopidine (Ticlid), or prasugrel (Effient) during
interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities.
There is limited evidence in reference to newer antithrombotic agents dabigatran (Pradaxa®) and rivaroxaban (Xarelto®) to
discontinue to avoid bleeding and epidural hematomas during interventional techniques and to continue to avoid cerebrovascular
and cardiovascular thromboembolic events.
Recommendations: The recommendations derived from the comprehensive assessment of the literature and guidelines
are to continue NSAIDs and low dose aspirin, and phosphodiesterase inhibitors (dipyridamole, cilostazol, Aggrenox) during
interventional techniques. However, the recommendations for discontinuation of antiplatelet therapy with platelet aggregation
inhibitors (clopidogrel, ticlopidine, prasugrel) is variable with clinical judgment to continue or discontinue based on the patient’s
condition, the planned procedure, risk factors, and desires, and the cardiologist’s opinion. Low molecular weight heparin
(LMWH) or unfractionated heparin may be discontinued 12 hours prior to performing interventional techniques. Warfarin
should be discontinued or international normalized ratio (INR) be normalized to 1.4 or less for high risk procedures and 2 or
less for low risk procedures based on risk factors. It is also recommended to discontinue Pradaxa for 24 hours for paravertebral
interventional techniques in 2 to 4 days for epidural interventions in patients with normal renal function and for longer periods
of time in patients with renal impairment, and to discontinue rivaroxaban for 24 hours prior to performing interventional
techniques.
Limitations: The paucity of the literature.
Conclusion: Based on the available literature including guidelines, the recommendations in patients with antithrombotic
therapy for therapy prior to interventional techniques are provided.
Key words: Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy,
interventional techniques, safety precautions
