1. 2017;20;437-443Continuing Anti-thrombotic Medication During Low-to-Intermediate Risk Spinal Procedures: A Retrospective Evaluation
   Retrospective Study
   Noud van Helmond, MD, Wesley Day, *, and Kenneth B. Chapman, MD.

BACKGROUND: The current American Society of Regional Anesthesia (ASRA) guidelines recommend discontinuing anti-thrombotic therapy prior to any interventional spine procedures to decrease the incidence of bleeding complications. However, discontinuing anti-thrombotics may pose considerable danger in terms of cerebrovascular and cardiovascular events. Recent evidence suggests that some spinal interventions may still be performed safely with anti-thrombotics on board and some practitioners thus elect to continue certain anti-thrombotics for these procedures.

OBJECTIVE: To assess the rate of adverse events in patients undergoing spine procedures that are currently classified by the ASRA guidelines as “low-to-intermediate bleeding risk,” while being on continued anti-thrombotic therapy.

STUDY DESIGN: Retrospective cohort study.

SETTING: Interventional pain management practice.

METHODS: A retrospective chart review was performed on patients who underwent low-to-intermediate risk spine procedures with variable anti-thrombotic medications continued throughout the course of treatment.

RESULTS: Between October 2015 and May 2016, out of 2,204 patients who underwent low-to-intermediate risk spine procedures, we identified 490 patients on anti-thrombotic medications. These included aspirin (N = 275), P2Y12 inhibitors (N = 129), warfarin (N = 62), heparin (N = 10), factor Xa inhibitors (N = 55), and dipyridamole (N = 1). Forty-two patients were on multiple anti-thrombotics. Anti-thrombotics were continued throughout the procedure for 467 of 490 patients (88%). One bleeding complication (injection site bleeding) occurred in a patient that continued clopidogrel and aspirin during a lumbar radiofrequency ablation. We encountered no bleeding complications attributable to anti-thrombotics in the other 466 procedures in which anti-thrombotics were continued during lumbar (N = 260), thoracic (N = 18), and cervical (N = 40) medial branch injections, sacroiliac injections (N = 47), and during lumbar (N = 87) thoracic (N = 2), and cervical (N = 12) medial branch radiofrequency ablations.

LIMITATIONS: The retrospective nature of the study and its reliance on electronic medical records are potential limitations.

CONCLUSIONS: Continuing anti-thrombotic medication during medial branch and sacroiliac injections may be possible.

KEY WORDS: Interventional pain management, thrombotic complications, hemostasis, anti-coagulation, bleeding complications