Epidurals and stroke

[interjectionreflection]

Hi everyone, I have a patient that is scheduled for a lumbar ILESI and during workup for carotid artery stenosis there was a tiny subacute lacunar infarct on imaging about 10 days ago. So presumably stroke is anywhere from 3+ weeks old or more now. He has no neurologic change and is on ASA the neurologist wants to start on DAPT I talked to the patient he still wants the epidural and I discussed the risks and is adamant he wants to have it now which makes sense rather than waiting till he starts DAPT and then stopping Plavix later as he does not want to stop DAPT once on it.

I wanted to get people's thoughts on how long to wait after an incidental tiny CVA or if they would just document discussion and proceed?

---

Members don't see this ad.

 

[Ducttape]

dont delay on the DAPT.

aspirin alone is a no brainer - do injection even ILESI.

would suggest consider TFESI instead of iLESI. that way the patient can start dual antiplatelet therapy without delay.

 

[interjectionreflection]

That was my thought as well to get the treatment done prior to DAPT but I wasn’t sure if I needed to delay it. Thanks for the clarification. I am okay to do ILESI on Asa but where I trained and by ASRA I was always taught to hold ASA or any antiplatelet agent for TFESI which is why I opted for the ILESI, are people routinely doing TFESI on DAPT?

 

[RoloTomassi]

Yes they got it backwards. TF is less hematoma risk than IL. Pretty sure ASRA even says that, no?

 

[Ferrismonk]

ASRA says hold plavix for all epidurals, although SIS says plavix is okay for TFESI. I'd start DAPT right away, and do TFESI after discussing possible increased risk of bleeding.

 

[MitchLevi]

I think you've gotten the correct answer already, and I'll add to the collective here...TFESI and go ahead and start Plavix.

ILESI >>> TFESI for hematoma risk.

I do TFESI on thinners routinely. I never stop thinners for TF, especially if the pt is taking it for atrial fib or if they're s/p multiple cardiac stents (I have one pt with > 10 stents).

I'll do an IL on ASA, but never something like Plavix.

Meticulous technique + 25g needle.

 

[lobelsteve]

Every week we get another thread on this topic.

FactFinders - Spine Intervention Society

https://www.redsonoguide.com/wp-content/uploads/2019/10/anticoagulants.pdf

The Risks of Continuing or Discontinuing Anticoagulants for Patients Undergoing Common Interventional Pain Procedures - PubMed​

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...

pubmed.ncbi.nlm.nih.gov

Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group​

The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.In August ...

www.ncbi.nlm.nih.gov
(see Table 22): For clinical practice they recommend discontinue ac only after assessing risks/benefits.

Counterpoint:
https://esraeurope.org/wp-content/u...ntiplatelet-and-Anticoagulant-Medications.pdf

 

[deleted875186]

I would tell them to start Plavix immediately. I would consider no injection at all based on the severity or degree of symptoms and imaging, otherwise TFESI on blood thinners.

 

[10KHertz]

If the patient is high risk and on blood thinners and is suffering in pain; perform a caudal, on BT, educate patient on likely benefit (40-50%). Revisit in a few months .