SCS and thrombocytopenia

[clubdeac]

So I got an L4-S1 decompression and fusion patient who is quickly failing everything including esi's, facets, and SIJ injections. I really have nothing left to offer other than a SCS trial. Only trick is his platelets are 77k. This will obviously never work right, despite giving him some platelets the day of the trial.

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[lobelsteve]

So I got an L4-S1 decompression and fusion patient who is quickly failing everything including esi's, facets, and SIJ injections. I really have nothing left to offer other than a SCS trial. Only trick is his platelets are 77k. This will obviously never work right, despite giving him some platelets the day of the trial.

How about talking about his pain pattern, agg/rel factors, imaging and how you progressed to esi, sij. How is he fused? If plif then I would think facets are gone and mbb makes no sense. Why stim? What's the meds? Desire to get better? F platelets. You already went esi, so why stop now?

 

[clubdeac]

How about talking about his pain pattern, agg/rel factors, imaging and how you progressed to esi, sij. How is he fused? If plif then I would think facets are gone and mbb makes no sense. Why stim? What's the meds? Desire to get better? F platelets. You already went esi, so why stop now?

Pain pattern is midline low sacral pain with referral into the bilateral buttocks and proximal posterior thighs. I did a few caudal ESIs with a 25g and even threw in a ganglion impar once for the low sacral/coccygeal pain. Nadda. If I give him platelets for the trial I think I will most likely need to give them when I pull at the end of the trial, right

 

[PinchandBurn]

Pain pattern is midline low sacral pain with referral into the bilateral buttocks and proximal posterior thighs. I did a few caudal ESIs with a 25g and even threw in a ganglion impar once for the low sacral/coccygeal pain. Nadda. If I give him platelets for the trial I think I will most likely need to give them when I pull at the end of the trial, right

Well when you pull it out, it should be 'atraumatic' so one could make the argument that you dont need to.

However, I would!

I think it goes back to the argument when I was doing anesthesia....Would you pull an epidural catheter out if the INR was elevated. It's a highly debated subject matter. Case Reports advocating both.

IN my opinion, the SCS leads are larger and thus 'more traumatic', I would do a plt transfusion before pulling it...........

 

[epidural man]

Well when you pull it out, it should be 'atraumatic' so one could make the argument that you dont need to.

However, I would!

I think it goes back to the argument when I was doing anesthesia....Would you pull an epidural catheter out if the INR was elevated. It's a highly debated subject matter. Case Reports advocating both.

IN my opinion, the SCS leads are larger and thus 'more traumatic', I would do a plt transfusion before pulling it...........

More than case reports. Here is a recent retrospective look at a bunch of catheters that were removed with INR>1.4

This was a a slap in the face of the ASRA guidelines eh?

As far as SCS in a patient with plts ~80? It depends really. Are the plts stable? Does it fluxate a lot or always stay around 80? If it stays around 80, are they functional? (You could do a TEG with platelet mapping if you have that available at your place). I think it is okay to do if she is a good candidate for the procedure, and you show that her plt function is normal and stable.

ASRA anticoagulation guidelines are just that - in addition, they are written for the perio-operative setting. They weren't written for things like what you are proposing.

Also, maybe it isn't your decision. Give the patient the options, completely inform her of the argument either way - and let them decide.
As docs, we often think we know what is best, but maybe at times like this, it shouldn't be OUR decision.

At any rate, I wouldn't give plts just for the procedure.

 

[drf]

I worry significantly less about pulling catheters on recently initiated warfarin, as described in the article as the non VII factors are still around. I think chronic dosing, of course, is much different.

I never really have problems with TKA/THA patients and epidurals. But I do have a moderate amount of trapped epidurals for big belly whack surgeries. We do a lot of Whipple's, for example, and frequently the INR creeps up to 1.5-2.5 postop without warfarin.

Usually a day or two of Vit K reverses this and if not, I give some FFP for >1.5.