To Hold or not to hold - MBB/RFA?

[Blitz2006]

Just wondering what everyone's practice is on holding anti-coagulation for:

1. Cervical MBB/RFA

2. Lumbar MBB/RFA

Generally I tend to continue AC for Lumbar MBB/RFTC, Hold for Cervical MBB/RFTC...

Good? Bad? Suggestions? Discuss!

---

Members don't see this ad.

 

[deleted131481]

Don't hold for either. Discussion should be available in other threads.

Risk (MI, stroke) vs benefit (nondebilitating paraspinal hematoma).

 

[Blitz2006]

True. But ASRA states for cervical to hold.

 

[SSdoc33]

dont hold for any facet procedures

ASRA is wrong

 

[Taus]

No hold for either.

 

[SommeRiver]

Never hold for facets

 

[callmeanesthesia]

I used to follow ASRA and hold for cervical. Stopped doing that. Now no hold for any MBB/RFA.

 

[nvrsumr]

I use 22g if anticoagulated as a punt. It’s annoying that asra is behind on this issue and increases our liability for making the correct medical decision.

 

[painfree23]

no hodl

 

[Nodolor]

What Hodor said

 

[pmrmd]

I hold for ILESI and SCS only. Everything else I have them maintain their regimen.

 

[SSdoc33]

I hold for ILESI and SCS only. Everything else I have them maintain their regimen.

Tfesi? Going the lobel route i see. Using a 25g?

I still cant pull the trigger on that one

 

[pmrmd]

Haven’t held for a lumbar TF in forever. Usually 25g but sometimes 22g if 5 or 6 inches down. Heck I did a two level thoracic kypho today and kept the guy on his warfarin.

 

[DubVille]

Are people holding for S1 TF?

I dont for all other lumbar TFE. Dont hold for mbb, facets, rfa.

 

[deleted131481]

Are people holding for S1 TF?

I dont for all other lumbar TFE. Dont hold for mbb, facets, rfa.

What's your concern with S1? I tend to get vascular more often there but should be small vessels unlike concern for lumbar TF with artery of adamkiewicz. I still hold for all TFESI, but I'd be more inclined to continue for lower levels vs higher.

 

[painfree23]

Haven’t held for a lumbar TF in forever. Usually 25g but sometimes 22g if 5 or 6 inches down. Heck I did a two level thoracic kypho today and kept the guy on his warfarin.

waat

 

[lobelsteve]

Even I hold for kypho. But I do pass out when I see blood....

 

[bedrock]

Are people holding for S1 TF?

I dont for all other lumbar TFE. Dont hold for mbb, facets, rfa.

Exactly. S1 should be treated differently from other TFESI as an inch of the needle is placed into a completely enclosed and very vascular space. Easy to bleed and nowhere for the blood to go. If you hold for caudal you should hold for S1.

Very different at other TF levels as the needle is barely in the foremen and bleeding is much less likely to cause an issue.

 

[MD87]

Exactly. S1 should be treated differently from other TFESI as an inch of the needle is placed into a completely enclosed and very vascular space. Easy to bleed and nowhere for the blood to go. If you hold for caudal you should hold for S1.

Very different at other TF levels as the needle is barely in the foremen and bleeding is much less likely to cause an issue.

I understand what you’re saying, But I don’t completely agree that s1 and caudal should be in the same category. I stop for s1, not caudal. One of the main risk factors for having a SYMPTOMATIC hematoma is spinal stenosis. Lots of people have spinal stenosis at L4/L5, so injecting at s1 is not terribly far from there. However, sacral stenosis is a rare entity, and the needle should be going at most to s3 and usually lower for a caudal. That’s pretty far from where most people develop stenosis.

For what it is worth, there will be a publication coming out in the next 4 to 6 months in pain physician that I worked on in patients who receive caudal ESI on blood thinners. None had complications.

 

[SommeRiver]

I do not hold for lumbar TFESI or caudal. If I want to do S1 and they're on AC I just do an L5-S1.

 

[DubVille]

I typically follow the modified SIS 2013 guidelines from the Goodman et al paper.

Seems to be in agreement with most here but has you hold for IL, caudals, S1, cervical tf (I dont do them), and scs/kypho.

I would love to have recs not to hold for S1. I will sometimes perform infraneural L5 if they cant go off thinners but I dislike infraneural approach if I can avoid it.

 

[lobelsteve]

I won’t stop for S1.

 

[pmrmd]

I've haven't been holding for S1 TF because Lobel bullied me but it makes me nervous.

 

[SommeRiver]

On AC just do an L5-S1 TFESI. Why do S1 on thinners? Just do L5-S1.

 

[Baron Samedi]

Is there any data on efficacy between S1 and L5-S1? Medication spreads 1 level up 2 levels down, right? Haven't done S1 in a long time and haven't really felt the need to.

 

[drrosenrosen]

I don't hold for RF or MBB ever. I do still hold for TFE, but I guess there's not really a need

 

[SSdoc33]

Is there any data on efficacy between S1 and L5-S1? Medication spreads 1 level up 2 levels down, right? Haven't done S1 in a long time and haven't really felt the need to.

for a true S1 radic or a paracentral HNP at L5-S1 hitting the S1 nerve, you should try to put the medication as close to S1 as possible. that means a S1 TFESI or L5-S1 ILESI. there is no data saying which is better

 

[painfree23]

dont hold for any facet procedures

ASRA is wrong

wat can we say to lawyers if hematoma results?

 

[cowboydoc]

wat can we say to lawyers if hematoma results?

Any case law showing 6 figure settlement for a hematoma?

Risks, benefits and alternatives.

Would you lose sleep over causing a hematoma? How about a CVA?

 

[BobBarker]

Let’s talk about that Coumadin kypho... that is the most interesting thing in this thread.

 

[DubVille]

wat can we say to lawyers if hematoma results?

Hematoma outside the spinal canal from facet injection or mbb??
If you did an intrarticular joint injection steroids decrease bleeding risk, so hemarthrosis is extremely unlikely.

 

[painfree23]

Hematoma outside the spinal canal from facet injection or mbb??
If you did an intrarticular joint injection steroids decrease bleeding risk, so hemarthrosis is extremely unlikely.

I get it. But Lawyers gonna understand “outside” va “inside” the canal? But DOCTOR , what about the ASRA guidelines?

 

[Ducttape]

it would be why your lawyer hires someone from SIS to give counterargument.

 

[Nodolor]

Haven’t held for a lumbar TF in forever. Usually 25g but sometimes 22g if 5 or 6 inches down. Heck I did a two level thoracic kypho today and kept the guy on his warfarin.

don't think many recommend that

 

[pmrmd]

Let’s talk about that Coumadin kypho... that is the most interesting thing in this thread.

So the guy had fractures for weeks now. If he was going to bleed through that bone he would have already. Cement kills bugs and stops bleeders. Done several now with people that couldn't stop their Plavix or Coumadin or whatever. I'm more nervous about the S1 TFs on anti-coagulation than a kypho.

 

[painfree23]

So the guy had fractures for weeks now. If he was going to bleed through that bone he would have already. Cement kills bugs and stops bleeders. Done several now with people that couldn't stop their Plavix or Coumadin or whatever. I'm more nervous about the S1 TFs on anti-coagulation than a kypho.

Dang, I think you need to rewrite the asra guidelines!

 

[deleted875186]

I’ll be honest, this thread is entirely at odds with the standard practice in my area. Everyone follows ASRA guidelines, everyone will stop AC for TFESI, casual, or ILESI, all are accessing the epidural space.

kypho on AC! No way.

 

[SSdoc33]

I’ll be honest, this thread is entirely at odds with the standard practice in my area. Everyone follows ASRA guidelines, everyone will stop AC for TFESI, casual, or ILESI, all are accessing the epidural space.

kypho on AC! No way.

Haven't checked in a while but doesnt ASRA also want you to stop aspirin?

 

[deleted875186]

Haven't checked in a while but doesnt ASRA also want you to stop aspirin?

For high risk procedures yes.

I don’t think I could bring myself to go against the guidelines by my board recommends. It would be like an anesthesiologist scoffing at NPO guidelines, even though aspiration is an extremely rare event.

 

[SSdoc33]

For high risk procedures yes.

I don’t think I could bring myself to go against the guidelines by my board recommends. It would be like an anesthesiologist scoffing at NPO guidelines, even though aspiration is an extremely rare event.

My point exactly

Holding ASA for an epidural is asinine.

We are not talking about NPO orders here

 

[deleted875186]

My point exactly

Holding ASA for an epidural is asinine.

We are not talking about NPO orders here

NPO orders feel similar to me.

very rare event with potential for significant harm to patient if aspiration occurs. Not based on great evidence, but we are held to ASA guidelines. Just because some other society makes different guidelines, say for instance the ER physician guidelines in sedation and NPO, doesn’t mean an anesthesiogidt can ever defend giving sedation to a full stomach hip dislocation and reduction in the ED.

 

[deleted875186]

Is there a PMR society or neurology society that has recommendations about anticoagulation and epidurals?

 

[SSdoc33]

NPO orders feel similar to me.

very rare event with potential for significant harm to patient if aspiration occurs. Not based on great evidence, but we are held to ASA guidelines. Just because some other society makes different guidelines, say for instance the ER physician guidelines in sedation and NPO, doesn’t mean an anesthesiogidt can ever defend giving sedation to a full stomach hip dislocation and reduction in the ED.

You dont have a heart attack if you skip breakfast. That's the difference. There is inherent risk is holding blood thinners

 

[SommeRiver]

Ludicrous to stop blood thinners for a caudal or lower lumbar TFESI.

No one has argued for ILESI on thinners.

 

[SSdoc33]

Is there a PMR society or neurology society that has recommendations about anticoagulation and epidurals?

No. Just SIS, but they are spineless.


Hey-oooooooh

 

[BobBarker]

I don’t think of ASRA being the definitive pain society which is what several of you are implying.

 

[deleted875186]

I don’t think of ASRA being the definitive pain society which is what several of you are implying.

As an anesthesiologist not following the ASRA guidelines is indefensible, even if they’re guidelines are outdated. They are the society that grants me board certification.

 

[deleted875186]

You dont have a heart attack if you skip breakfast. That's the difference. There is inherent risk is holding blood thinners

What about the risk of delaying a procedure that requires sedation due to NPO.

 

[bedrock]

As an anesthesiologist not following the ASRA guidelines is indefensible, even if they’re guidelines are outdated. They are the society that grants me board certification.

I suppose it’s easier to ignore ASRA as a PMR/Pain physician.

I do feel the SIS guidelines are the most applicable to the real world practice of interventional spine procedures.

 

[BobBarker]

I have no ASRA board certifications and have never been a member. ASRA isn’t the ABA.