NSAIDs DURING a SCS trial?

[crazywiththecheezwhiz]

I know what the ASRA guidelines say regarding stopping and restarting specific NSAIDs during high-risk procedures. What about during the trial itself? Any guidance there?

I know certain anticoagulation is okay with epidural catheters that are in place. Does the same hold true while SCS leads are in place?

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[Ducttape]

Almost all my stim patients have been off NSAID a long time ago.

The few still on...I tell them to stop during trial both from anticoagulation standpoint and because being off them is a better assessment of pain reduction.

 

[lonelobo]

I never stop NSAIDS for SCS or any type of pain procedure

 

[lobelsteve]

This was sent out this morning. I would not hold ASA or NSAIDs for any procedure. I would do and joint, MBB, RFA, TFESI on any med. Would not do ILESI, kypho, SCS, LSB on antiplatelet or if INR >1.3

 

[manowar rules]

This was sent out this morning. I would not hold ASA or NSAIDs for any procedure. I would do and joint, MBB, RFA, TFESI on any med. Would not do ILESI, kypho, SCS, LSB on antiplatelet or if INR >1.3

I agree about the facet stuff, but why are you more lenient with a TFESI than an ILESI? Less risk of entrapped blood?

 

[lobelsteve]

I agree about the facet stuff, but why are you more lenient with a TFESI than an ILESI? Less risk of entrapped blood?

25G, less traumatic. Endres data. More likely to get MI or CVA off med than bleed in epidural space on med. Also, epidural bleed is less catastrophic than death from MI or CVA.

 

[paindoc007]

When do you guys restart plavix for stim trial? After trial itself, or after lead pull the following week?

 

[Biohazard685]

Worst case scenario treat it like an epidural catheter.

Look at the 2015 neuromodulation anticoagulation guidelines.

Table 2 specifies the half life and recommended holding times.

If they take nsaids during the trial make sure they stop it at an appropriate time prior to pulling the leads.

In residency we would sometimes put epidural catheters for triple a repairs and they get anticoagulated at certain parts of the case.

Just make sure you're not manipulating the neuraxis when there is iffy coagulation.

 

[Orin]

The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations on Bleeding and Coagulation Management in Neurostimulation Devices. - PubMed - NCBI

The 2017 Neurostimulation Appropriateness Consensus Committee (NACC) Coagulation Guidelines has a nice table about this for specific medications

The recommendations for the resumption of agents seems to be after the trial lead pull. I think they're treating this similarly to the epidural catheter as movement of it can tear blood vessels

It's primarily a risk/benefit discussion. I've seen fully anticoagulated patients get neuraxial catheters without a problem and I've seen straight forwards stim trials turn into hematomas, so it's all just minimizing the probability of a high-impact but very low probability event.

As stated earlier, the more difficult questions are in the folks who would benefit from interventions but also need anticoagulation.

An MI or a CVA are not trivial, but it's easier on the interventionalist than worrying about the hematoma they made but can't fix.

 

[Ducttape]

they stay off Plavix until end of trial. its the manipulation of the lead that "leads" to bleeding.

shorten trial may be indicated.

or consider other anticoagulation options. talk to the cardiologist or hematologist.

for one trial the cardiologist transitioned patient to lovenox and patient stopped 24 hours before trial lead implant, restarted 4 hours after getting home, then stopped again 24 hours before i took the lead out.

 

[Orin]

for one trial the cardiologist transitioned patient to lovenox and patient stopped 24 hours before trial lead implant, restarted 4 hours after getting home, then stopped again 24 hours before i took the lead out.

I worry about those cases as the perc trial leads do move a bit more when they aren't anchored down.

I'm debating whether just to bury the lead so it's well anchored, or do a buried Stimwave trial and just never come back if it works, or just see if I can get clearance for the old on-table "trial"

 

[SSdoc33]

This was sent out this morning. I would not hold ASA or NSAIDs for any procedure. I would do and joint, MBB, RFA, TFESI on any med. Would not do ILESI, kypho, SCS, LSB on antiplatelet or if INR >1.3

your link does not support keeping patients on plavix or coumadin for TFESI.

until one of the big societies advocate for it, im not going out on a limb.....

 

[lobelsteve]

your link does not support keeping patients on plavix or coumadin for TFESI.

until one of the big societies advocate for it, im not going out on a limb.....

But Endres study does.

 

[EruditeDoc]

If manipulating the neuraxial space and the patient is on the combination of an SSRI and NSAID, I will stop the NSAID. Studies do support increase risk of hematoma with this combination of drug classes

 

[Orin]

your link does not support keeping patients on plavix or coumadin for TFESI.

until one of the big societies advocate for it, im not going out on a limb.....

Here's the study he's discussing:
The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures. - PubMed - NCBI

 

[lobelsteve]

Here's the study he's discussing:
The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures. - PubMed - NCBI

The meat of the abstract:

RESULTS:
No complications attributable to anticoagulants were encountered in 4,766 procedures in which anticoagulants were continued. In 2,296 procedures in which anticoagulants were discontinued according to the guidelines, nine patients suffered serious morbidity, including two deaths.

CONCLUSIONS:
Lumbar transforaminal injections, lumbar medial branch blocks, trigger point injections, and sacroiliac joint blocks appear to be safe in patients who continue anticoagulants. In patients who discontinue anticoagulants, although low (0.2%) the risk of serious complications is not zero, and must be considered when deciding between continuing and discontinuing anticoagulants.

Correlates well with research I had to do as part of a court case. The patient died after hip injection when his Plavix was stopped.

 

[SSdoc33]

The meat of the abstract:

RESULTS:
No complications attributable to anticoagulants were encountered in 4,766 procedures in which anticoagulants were continued. In 2,296 procedures in which anticoagulants were discontinued according to the guidelines, nine patients suffered serious morbidity, including two deaths.

CONCLUSIONS:
Lumbar transforaminal injections, lumbar medial branch blocks, trigger point injections, and sacroiliac joint blocks appear to be safe in patients who continue anticoagulants. In patients who discontinue anticoagulants, although low (0.2%) the risk of serious complications is not zero, and must be considered when deciding between continuing and discontinuing anticoagulants.

Correlates well with research I had to do as part of a court case. The patient died after hip injection when his Plavix was stopped.

I love this data. And it completely makes sense. I would adopt it in a heartbeat.....

but if it is so cut and dried, why hasnt SIS or ASRA adopted these changes?

one study from 1 group isnt enough. yet. you get one bleed in those patients and ALL that great looking data goes away.

 

[Ducttape]

it is an observational study, by the people who did the procedures.

a good start but insufficient to make clinical guidelines due to this study

 

[olafa]

there is likely also some risk of implanted leads moving about in epidural space as the patient moves (not the paddle itself but caudad length oo the lead which is similar to catheter),the risk of implant and hematoma in the chronically anti coagulated is not discussed, stopping etc for the trial. An epidural hematoma is catastrophic- any thoughts on risk assessment 5 yr, 10 yrs out post implant? Even if low, paralysis is catastrophic

 

[lobelsteve]

there is likely also some risk of implanted leads moving about in epidural space as the patient moves (not the paddle itself but caudad length oo the lead which is similar to catheter),the risk of implant and hematoma in the chronically anti coagulated is not discussed, stopping etc for the trial. An epidural hematoma is catastrophic- any thoughts on risk assessment 5 yr, 10 yrs out post implant? Even if low, paralysis is catastrophic

Has it ever been reported?
Has epidural hematoma ever occurred spontaneously?
There is your answer.