Reducing risk of spinal haematoma from spinal and epidural pain procedures

Breivik, Harald; Norum, Hilde M.; Fenger-Eriksen, Christian; Alahuhta, Seppo; Vigfusson, G.; Thomas, Owain; Lagerkranser, Michael

doi:10.1515/sjpain-2018-0041

Cited by 18 publications

(42 citation statements)

References 98 publications

(234 reference statements)

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“…Based on published guidelines, derived by clinical case reports and consensus, a large subset of clinicians report stopping antiplatelet therapy and consider this concept as a standard of care (1,20,33,(36)(37)(38)(122)(123)(124)(125)(126)(127)(128)(129). Although the overall incidence of bleeding complications and epidural hematoma in the non-obstetric epidural literature has been reduced, the incidence has been higher with procedures involving cervical and thoracic spine (1,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(52)(53)(54)129). Of note, the clinical literature reports of incidences of epidural hematoma cases accompanying interventional techniques and neuraxial techniques are increasing rapidly (1,20,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)…”

Section: Introductionmentioning

confidence: 99%

“…Although the overall incidence of bleeding complications and epidural hematoma in the non-obstetric epidural literature has been reduced, the incidence has been higher with procedures involving cervical and thoracic spine (1,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(52)(53)(54)129). Of note, the clinical literature reports of incidences of epidural hematoma cases accompanying interventional techniques and neuraxial techniques are increasing rapidly (1,20,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(130)(131)(132)(133)(134)(135)(136)(137)(138)(139)(140)(141)(142)(143)(144)(145)(146)…”

Section: Introductionmentioning

confidence: 99%

“…Of note, the clinical literature reports of incidences of epidural hematoma cases accompanying interventional techniques and neuraxial techniques are increasing rapidly (1,20,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(130)(131)(132)(133)(134)(135)(136)(137)(138)(139)(140)(141)(142)(143)(144)(145)(146)(147)(148)(149). While some reports indicate a decreasing incidence of bleeding complications related to neuraxial techniques (145), multiple studies have been performed assessing the prevalence and risks related to bleeding complications and epidural hematoma with neuraxial procedures, specifically interventional techniques (1,20,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)...…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Manchikanti

2019

Pain Phys

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Background: Interventional pain management involves diagnosis and treatment of chronic pain. This specialty utilizes minimally invasive procedures to target therapeutics to the central nervous system and the spinal column. A subset of patients encountered in interventional pain are medicated using anticoagulant or antithrombotic drugs to mitigate thrombosis risk. Since these drugs target the clotting system, bleeding risk is a consideration accompanying interventional procedures. Importantly, discontinuation of anticoagulant or antithrombotic drugs exposes underlying thrombosis risk, which can lead to significant morbidity and mortality especially in those with coronary artery or cerebrovascular disease. This review summarizes the literature and provides guidelines based on best evidence for patients receiving anti-clotting therapy during interventional pain procedures. Study Design: Best evidence synthesis. Objective: To provide a current and concise appraisal of the literature regarding an assessment of the bleeding risk during interventional techniques for patients taking anticoagulant and/or antithrombotic medications. Methods: A review of the available literature published on bleeding risk during interventional pain procedures, practice patterns and perioperative management of anticoagulant and antithrombotic therapy was conducted. Data sources included relevant literature identified through searches of EMBASE and PubMed from 1966 through August 2018 and manual searches of the bibliographies of known primary and review articles. Results: 1. There is good evidence for risk stratification by categorizing multiple interventional techniques into low-risk, moderate-risk, and high-risk. Also, their risk should be upgraded based on other risk factors. 2. There is good evidence for the risk of thromboembolic events in patients who interrupt antithrombotic therapy. 3. There is good evidence supporting discontinuation of low dose aspirin for high risk and moderate risk procedures for at least 3 days, and there is moderate evidence that these may be continued for low risk or some intermediate risk procedures.4. There is good evidence that discontinuation of anticoagulant therapy with warfarin, heparin, dabigatran (Pradaxa®), argatroban (Acova®), bivalirudin (Angiomax®), lepirudin (Refludan®), desirudin (Iprivask®), hirudin, apixaban (Eliquis®), rivaroxaban (Xarelto®), edoxaban (Savaysa®, Lixiana®), Betrixaban(Bevyxxa®), fondaparinux (Arixtra®) prior to interventional techniques with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors increases safety. 5. There is good evidence that diagnosis of epidural hematoma is based on severe pain at the site of the injection, rapid neurological deterioration, and MRI with surgical decompression with progressive neurological dysfunction to avoid neurological sequelae. 6. There is good evidence that if thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during cessation of the anticoagulant, and the low molecular weight heparin can be discontinued 24 hours before the pain procedure. 7. There is fair evidence that the risk of thromboembolic events is higher than that of epidural hematoma formation with the interruption of antiplatelet therapy preceding interventional techniques, though both risks are significant. 8. There is fair evidence that multiple variables including anatomic pathology with spinal stenosis and ankylosing spondylitis; high risk procedures and moderate risk procedures combined with anatomic risk factors; bleeding observed during the procedure, and multiple attempts during the procedures increase the risk for bleeding complications and epidural hematoma. 9. There is fair evidence that discontinuation of phosphodiesterase inhibitors is optional (dipyridamole [Persantine], cilostazol [Pletal]. However, there is also fair evidence to discontinue Aggrenox [dipyridamole plus aspirin]) 3 days prior to undergoing interventional techniques of moderate and high risk. 10. There is fair evidence to make shared decision making between the patient and the treating physicians with the treating physician and to consider all the appropriate risks associated with continuation or discontinuation of antithrombotic or anticoagulant therapy. 11. There is fair evidence that if thromboembolic risk is high antithrombotic therapy may be resumed 12 hours after the interventional procedure is performed. 12. There is limited evidence that discontinuation of antiplatelet therapy (clopidogrel [Plavix®], ticlopidine [Ticlid®], Ticagrelor [Brilinta®] and prasugrel [Effient®]) avoids complications of significant bleeding and epidural hematomas. 13. There is very limited evidence supporting the continuation or discontinuation of most NSAIDs, excluding aspirin, for 1 to 2 days and some 4 to 10 days, since these are utilized for pain management without cardiac or cerebral protective effect. Limitations: The continued paucity of the literature with discordant recommendations. Conclusion: Based on the survey of current literature, and published clinical guidelines, recommendations for patients presenting with ongoing antithrombotic therapy prior to interventional techniques are variable, and are based on comprehensive analysis of each patient and the risk-benefit analysis of intervention. Key words: Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy, interventional techniques, safety precautions, pain

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Manchikanti

2019

Pain Phys

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“…Another single‐centre study, identified zero spinal haematomas and abscesses in 3035 postoperative patients treated with epidural analgesia for a mean duration of 2.1 catheter days from 2008 to 2013 . Historically, the incidence of serious complications after epidural analgesia has been considered to be extremely low, but nowadays it is accepted that the incidence may range from 1:6000 to 1:1000 epidural procedures depending on patient‐related risk factors, such as antihaemostatic medication use and anatomy of the spinal column . The aim of this survey was to quantify trends in practice of epidural analgesia and to assess the extent to which epidural alert systems for neurological complications of epidural analgesia have been introduced in clinical practice.…”

Section: Introductionmentioning

confidence: 99%

Trends in practice and safety measures of epidural analgesia: Report of a national survey

Bos

Schut

Quelerij

et al. 2018

Acta Anaesthesiol Scand

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“…The 3rd UK National Audit Project (NAP 3) recorded no cases of vertebral canal haematoma among 365,000 spinal anaesthetics. The risk may be slightly increased in older patients with hepatic/renal impairment, spinal deformity and those undergoing repeated attempts at spinal needle insertion , but the Association of Anaesthetists recommends that such cases should be attended to by ‘experienced’ clinicians to minimise this risk .…”

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confidence: 99%