Pain Procedures and anticoagulants

[lobelsteve]

Efficacy/Safety of Performing Fluoroscopically Guided Spinal Interventions in Conjunction with Anticoagulation Therapy

S. Endres, MD, DABPM, N. Bogduk, PhD, DSC; M. Schlimgen, MD;
A. Shufelt, RA; B. Endres, RA.

Pain Physician 2011 Volume 12, Issue 9, p. 1442

Background: Spinal injections are contraindicated in anticoagulated patients. Present standards for performing interventional spinal procedure in the presence of anticoagulation and anti-platelet therapies are extrapolated from reviews from surgical and anesthesia literature. These standards were based on complications from regional anesthetic injection procedures done using anatomical landmarks with needles and catheters placed without fluoroscopic guidance.

Objective: Assess the efficacy/safety of fluoroscopic guided lumbosacral spinal interventions on patients with therapeutic anticoagulation and anti-platelet therapy.

Criteria: Transforaminal ESI, facet, MBB, SI joint injections and non-spinal musculoskeletal
procedures were performed by experienced interventionists using ISIS endorsed techniques Follow up ranged from 1 to 4 weeks either in clinic or via phone call.

Methodology. Chart review from 1/1/2005 to present was performed. Data included: demographics, diagnosis of the condition requiring a procedure, reason for anticoagulation or antiplatelet therapy, medication dose, (INR) if applicable, whether the medicine was stopped or not stopped, how long was it stopped, number procedures performed, type and gauge of needle used, the fluoroscopy time, the pre/post VAS, procedural complications
and anticoagulant complications.

Results: 473 charts were reviewed. 1,936 procedures were performed. 255 TF injections, 521 facet injections, 73 SI joint injections and 105 non spinal musculoskeletal injections were performed on patients with therapeutic anticoagulation and anti-platelet therapy. 311 TF injections, 143 interlaminar injections, 275 facet injections, 19 SI joint injections, and 18 non spinal musculoskeletal injections were performed on patients whose anticoagulation therapy
and anti-platelet therapy was stopped and INR was normalized. No post procedure complications were noted.

Conclusion: This review demonstrates that anticoagulants or anti-platelet therapies need not be discontinued for selected fl uoroscopic guided spinal interventions.

That's great. But it won't work in the USA.

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[ampaphb]

That's great. But it won't work in the USA.

Lead author practices in Eau Claire, WI.

 

[lobelsteve]

Lead author practices in Eau Claire, WI.

I said USA.

 

[ampaphb]

So apparantly USA only = Northwest GA?

 

[bedrock]

ASRA guidelines are still the standard of care in the USA. If your man in WI can make us immune from US lawsuits, I'd reconsider his paper.

 

[Ducttape]

Efficacy/Safety of Performing Fluoroscopically Guided Spinal Interventions in Conjunction with Anticoagulation Therapy

S. Endres, MD, DABPM, N. Bogduk, PhD, DSC; M. Schlimgen, MD;
A. Shufelt, RA; B. Endres, RA.

Pain Medicine 2011 Volume 12, Issue 9, p. 1442

Background: Spinal injections are contraindicated in anticoagulated patients. Present standards for performing interventional spinal procedure in the presence of anticoagulation and anti-platelet therapies are extrapolated from reviews from surgical and anesthesia literature. These standards were based on complications from regional anesthetic injection procedures done using anatomical landmarks with needles and catheters placed without fluoroscopic guidance.

Objective: Assess the efficacy/safety of fluoroscopic guided lumbosacral spinal interventions on patients with therapeutic anticoagulation and anti-platelet therapy.

Criteria: Transforaminal ESI, facet, MBB, SI joint injections and non-spinal musculoskeletal
procedures were performed by experienced interventionists using ISIS endorsed techniques Follow up ranged from 1 to 4 weeks either in clinic or via phone call.

Methodology. Chart review from 1/1/2005 to present was performed. Data included: demographics, diagnosis of the condition requiring a procedure, reason for anticoagulation or antiplatelet therapy, medication dose, (INR) if applicable, whether the medicine was stopped or not stopped, how long was it stopped, number procedures performed, type and gauge of needle used, the fluoroscopy time, the pre/post VAS, procedural complications
and anticoagulant complications.

Results: 473 charts were reviewed. 1,936 procedures were performed. 255 TF injections, 521 facet injections, 73 SI joint injections and 105 non spinal musculoskeletal injections were performed on patients with therapeutic anticoagulation and anti-platelet therapy. 311 TF injections, 143 interlaminar injections, 275 facet injections, 19 SI joint injections, and 18 non spinal musculoskeletal injections were performed on patients whose anticoagulation therapy
and anti-platelet therapy was stopped and INR was normalized. No post procedure complications were noted.

Conclusion: This review demonstrates that anticoagulants or anti-platelet therapies need not be discontinued for selected fl uoroscopic guided spinal interventions.

nice little study. good enough to get into a throughaway journal, bad enough that it would be ripped apart by academia.

retrospective. follow up by phone? what criteria was used? not blinded at all.

no complications were noted at all in 1936 injections. is a <0.1% rate of complication typical?
no interlaminar injections were done when anticoagulation was continued - how can you make claims that it is okay to continue in this situation, with no data?

why was anticoagulation stopped for SI or nonspine injections? why is there such a big difference (73:19 and 105:18) between the number of SI and non-spine injections? why were over twice as many facet injections performed for patients who were continued on anticoagulation?

this study tells me nothing.

 

[ampaphb]

No interlaminar injections were done when anticoagulation was continued - how can you make claims that it is okay to continue in this situation, with no data? They make no such claim. Conclusion reads "This review demonstrates that anticoagulants or anti-platelet therapies need not be discontinued for selected fluoroscopic guided spinal interventions."

why was anticoagulation stopped for SI or nonspine injections? why is there such a big difference (73:19 and 105:18) between the number of SI and non-spine injections? why were over twice as many facet injections performed for patients who were continued on anticoagulation? This was a study accomplished at a private practice that consisted of a number of pain physicians. Some adopted the practice of holding anticoagulants, some did not. The number of individual procedures done were the result of variation in practice patterns.

This study was presented at the 2011 ISIS Annual Meeting. The abstract was then published in Pain Medicine, not Pain Physician as I originally had said.

Since Prof. Bogduk is an author, and you feel the study lacks academic rigor, I invite you to tell him that when he is speaking in NY at this years Annual Meeting

 

[Ducttape]

Sure, after you convince my wife to let me go.


Sorry, I don't see the value of this article. What is it telling us, besides the fact that this clinic didn't have any problems?

 

[pastafan]

Not exactly on point but a good review and info source about newer agents:

Managing New Oral Anticoagulants in the Perioperative and Intensive Care Unit Setting
http://journals.lww.com/anesthesiol...naging_New_Oral_Anticoagulants_in_the.37.aspx

 

[nvrsumr]

Pastafan-Good work. It appears 48 hours is more than a sufficent and conservative time to stop Xarelto. Anyone else read this differently? Have a patient in a week or so on this who will need esi

Best