SCS on ASA?

[tmvguy03]

Do you perform SCS on patients taking aspirin (81mg)? The ASRA guidelines of course make distinctions between those using aspirin for primary vs. secondary prevention, with more leeway and “shared decision making” for those using for secondary prevention.
I know some people who draw a hard line in the sand about not doing trials on aspirin period.

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[BobBarker]

I did a vflex today on a guy on ASA. Had to break out the bovie for the first time in almost 50 cases. Definitely bled a lot more.

 

[painfree23]

Done it a few times, no issues

 

[tmvguy03]

In the last few months I’ve done three or four on ASA 81, all of whom had h/o multiple strokes/CAD so didn’t want to dc. It’s been fine. My case today, Lead placement took 6 or 7 minutes, then I had to hold pressure for 10 after taking the introducer out over the lead for bleeding.. Added some dermabond, even oozed through that, a few more minutes of pressure and it was fine. Rechecked the site an hour after the procedure and still fine. In the future I would probably use lido/epi...but that wouldn’t do much for an epidural bleed...

 

[BobBarker]

Yes, I irrigated the field with local/epi and that help. After I am done with a vflex I just fill the hole up with local/epi.

 

[painfree23]

In the last few months I’ve done three or four on ASA 81, all of whom had h/o multiple strokes/CAD so didn’t want to dc. It’s been fine. My case today, Lead placement took 6 or 7 minutes, then I had to hold pressure for 10 after taking the introducer out over the lead for bleeding.. Added some dermabond, even oozed through that, a few more minutes of pressure and it was fine. Rechecked the site an hour after the procedure and still fine. In the future I would probably use lido/epi...but that wouldn’t do much for an epidural bleed...

wow i never stop asa for any procedure..never had an issue with excessive bleeding. hmm now you got me thinking

 

[callmeanesthesia]

Do you perform SCS on patients taking aspirin (81mg)? The ASRA guidelines of course make distinctions between those using aspirin for primary vs. secondary prevention, with more leeway and “shared decision making” for those using for secondary prevention.
I know some people who draw a hard line in the sand about not doing trials on aspirin period.

I ask patients why they are on it. If it’s for primary prevention I usually ask them to hold it. If it’s secondary prevention I tell them that there may be an increased risk of bleeding if we continue it but there is an increased risk of heart attack/stroke from stopping it. Most agree with continuing it.

 

[lobelsteve]

Never stop it. Lido w epi, bovie in every case.

 

[paindoc007]

When I was a fellow I was at a SCS course, and Jason Pope was teaching. He had a case with an epidural bleed with a pt on baby asa, luckily got to a neurosurgeon quick enough and decompressed in time.

He said after that, he holds asa at all times. Someone with that much experience, I listen to, so I do the same.

One of those things; it’s not a problem, until it is. Depends how conservative/risk adverse you want to be

 

[painfree23]

When I was a fellow I was at a SCS course, and Jason Pope was teaching. He had a case with an epidural bleed with a pt on baby asa, luckily got to a neurosurgeon quick enough and decompressed in time.

He said after that, he holds asa at all times. Someone with that much experience, I listen to, so I do the same.

One of those things; it’s not a problem, until it is. Depends how conservative/risk adverse you want to be

From an scs trial??

 

[Orin]

From an scs trial??

These are things that happen spontaneously. Pope was just unfortunate to have it happen while his lead was in the space on a patient with baby aspirin. Unfortunately for some of his patients, that negative reinforcement may keep him from doing what might be safest for patients at high risk of CVA/TIA/MI, but I suspect he probably weighs the risk/benefit carefully.

Spontaneous spinal epidural hematoma: literature review
"Spontaneous spinal epidural hematomas (SSEH), defined as blood within the epidural space without known traumatic or iatrogenic cause, have an estimated incidence of 0.1 in 100,000 per year."

I would say that I suspect lead placement/driving is likely a bigger risk factor for EH than the needle placement.

 

[Ronin1]

I suggest that you follow the ASRA guidelines from a medicolegal standpoint. Anecdotal stories of bleeding or no issues have little value in reality other than to make us feel better

 

[Ducttape]

Agreed. Relying on anecdotal stories will not stand in court, either.

It is hard to justify your actions if a cardiovascular catastrophe occurs, too...

 

[SommeRiver]

ASRA for me and there's no bending those rules in my clinic. I stop ASA for trials.

 

[lobelsteve]

Asra is wrong and the guidelines will harm more people than help. Realizing risk of hematoma may lead to surgery. Realizing risk of MI or CVA may lead to death. Greater risk of realizing death than hematoma. Bad guidelines.

 

[BobBarker]

Agree with Steve. ASRA recs holding Plavix for a knee injection. They are clearly wrong.

 

[Ronin1]

It’s a risk:benefit decision. Risk of losing a medmal case is increased if not following International guidelines. If you can truly have an informed consent it becomes a nonissue

 

[No_Pain_No_Gain]

Agree with Steve. ASRA recs holding Plavix for a knee injection. They are clearly wrong.

ASRA does not recommend holding any anticoagulation (including Plavix) for knee injections or any other "peripheral joint or musculoskeletal injections". Source below for ASRA's recommendations.
Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition)

 

[BobBarker]

Ok, corrected there.
I quit paying attention in the past when they had mbb and rfa’s misclassified but looks like they have corrected that as well.

 

[tmvguy03]

Never stop it. Lido w epi, bovie in every case.

I agree with lido/epi
Devils advocate: On a stim trial there is no bovie...
I'm just rethinking things based on how much bleeding I saw during the trial.....

 

[lobelsteve]

I agree with lido/epi
Devils advocate: On a stim trial there is no bovie...
I'm just rethinking things based on how much bleeding I saw during the trial.....

No bovie for trials, yes for implants until wires on field.
How does one do a trial, kypho, or implant without local with epi?

I never see bleeding during my cases. I close my eyes until the tech can get rayteks over the area. I might pass out.

 

[painfree23]

No bovie for trials, yes for implants until wires on field.
How does one do a trial, kypho, or implant without local with epi?

I never see bleeding during my cases. I close my eyes until the tech can get rayteks over the area. I might pass out.

I do all my trials with just local (lido + bupi) no epi. No bleeding issues.

 

[lobelsteve]

I do all my trials with just local (lido + bupi) no epi. No bleeding issues.

You using an 11blade to make the stab incision?

 

[Timeoutofmind]

You using an 11blade to make the stab incision?

Not necessary
Can stab with 20G first if needed

 

[Timeoutofmind]

ASRA for me and there's no bending those rules in my clinic. I stop ASA for trials.

Judging from this thread...

A lot of people seem to misunderstand the ASRA guidelines for ASA for secondary prophylaxis

There are no guidelines from them in this instance. Its just R/B.

 

[Orin]

Do you use epi in patients with cardiovascular comorbidites? I worry about an accidental stress test and just tolerate a little more oozing.

 

[SommeRiver]

Trial - Lido 2% x 5cc and 1% x 10cc. No epi. Never had any bleeding. No stab incision either, just numb the skin and drive the tuohy through it.

 

[lobelsteve]

Lido with epi for all. Had 1 patient get tachy to 140 for 2 minutes once in 15 years.
Have never tried pushing a 14G blunt needle through skin without an 11 blade to open it.
That just seems mean.

 

[nvrsumr]

I put the 18g needle that I use as pointer thru the numbed skin to dilate then tuohy. Never use epi in office but to each their own.

 

[BobBarker]

I scalpel or do the 18g. Just depends on if they remember to open a scalpel. The only local the hospital has in abundant supply is .5% bupi with epi.

 

[dhcofc]

18g prick.

 

[SommeRiver]

Numb skin with 27 gauge 1.5, then use 22 gauge 3.5 through the same hole for a deep needle tract, then 14 tuohy through that. Never had a problem with it.

 

[soccrwz]

When I was reviewing articles on how to reduce infection rates, I've seen at least two papers that noted an increase in bacteria counts with LA with Epi vs LA only. Just an FYI

A Review of Surgical Techniques in Spinal Cord Stimulator Implantation to Decrease the Post-Operative Infection Rate

To date, there are no large scale randomized control studies regarding the impact of epinephrine use on postoperative infection rate. Stratford et al. [102] demonstrated that lidocaine use prior to inoculation of bacteria was associated with a greater than 70% decrease in bacterial count in their in vivo study (lidocaine infiltration vs. preinfiltration of lidocaine in a guinea pig model). Conversely, the addition of epinephrine (1:100,000) to lidocaine was associated with a 20-fold increase in bacterial count compared with control values (lidocaine with epinephrine infiltration vs pre-infiltration of lidocaine). This is the first study using an in vivo surgical wound model to demonstrate inhibition of bacterial growth by a local anesthetic, and a subsequent reversal of this protective effect with the addition of epinephrine. Moreover, when epinephrine is used, there is a substantial increase in bacterial growth, suggesting epinephrine may increase risk of surgical wound infection.

 

[Timeoutofmind]

When I was reviewing articles on how to reduce infection rates, I've seen at least two papers that noted an increase in bacteria counts with LA with Epi vs LA only. Just an FYI

A Review of Surgical Techniques in Spinal Cord Stimulator Implantation to Decrease the Post-Operative Infection Rate

To date, there are no large scale randomized control studies regarding the impact of epinephrine use on postoperative infection rate. Stratford et al. [102] demonstrated that lidocaine use prior to inoculation of bacteria was associated with a greater than 70% decrease in bacterial count in their in vivo study (lidocaine infiltration vs. preinfiltration of lidocaine in a guinea pig model). Conversely, the addition of epinephrine (1:100,000) to lidocaine was associated with a 20-fold increase in bacterial count compared with control values (lidocaine with epinephrine infiltration vs pre-infiltration of lidocaine). This is the first study using an in vivo surgical wound model to demonstrate inhibition of bacterial growth by a local anesthetic, and a subsequent reversal of this protective effect with the addition of epinephrine. Moreover, when epinephrine is used, there is a substantial increase in bacterial growth, suggesting epinephrine may increase risk of surgical wound infection.

I am also unclear, from my research, on the impact of adding epi to the lido on surgical wound healing

 

[soccrwz]

I am also unclear, from my research, on the impact of adding epi to the lido on surgical wound healing

From the NACC recommendations...

Incisions should be executed with a scalpel with a clean cut, and the incision site made as small as possible for both leads and battery site. Minimizing dead space in the battery pocket also limits seroma and hematoma development. Epinephrine used in conjunction with a local anesthetic has been suggested to increase both risk of delayed healing due to vasoconstriction at the incision site as well as increased bacterial count. High epinephrine dose has been suggested to inhibit skin fibroblast migration, while lidocaine prevents initial wound signaling and mast cell degranulation via nociceptive blockade (144). Cautious use of epinephrine should be implemented in order to minimize tissue damage and decrease postoperative infection rate. However, this risk must also be weighed against the potential benefits of reduced bleeding due to vasoconstriction, as blood can serve as a medium for bacterial growth.

 

[painfree23]

Numb skin with 27 gauge 1.5, then use 22 gauge 3.5 through the same hole for a deep needle tract, then 14 tuohy through that. Never had a problem with it.

yes this is the way. totally agree

 

[SommeRiver]

Let's be real too, initial skin entry point isn't always the one that works. We've all had to come a cm inferior or whatever after realizing we are too steep in our approach.

 

[lobelsteve]

From the NACC recommendations...

Incisions should be executed with a scalpel with a clean cut, and the incision site made as small as possible for both leads and battery site. Minimizing dead space in the battery pocket also limits seroma and hematoma development. Epinephrine used in conjunction with a local anesthetic has been suggested to increase both risk of delayed healing due to vasoconstriction at the incision site as well as increased bacterial count. High epinephrine dose has been suggested to inhibit skin fibroblast migration, while lidocaine prevents initial wound signaling and mast cell degranulation via nociceptive blockade (144). Cautious use of epinephrine should be implemented in order to minimize tissue damage and decrease postoperative infection rate. However, this risk must also be weighed against the potential benefits of reduced bleeding due to vasoconstriction, as blood can serve as a medium for bacterial growth.

Any chance you got a PDF lying around? I'd like to read and review. Might be time to update my practice technique. The Best Practices article in 2017 Spine did not mention local.

 

[soccrwz]

Any chance you got a PDF lying around? I'd like to read and review. Might be time to update my practice technique. The Best Practices article in 2017 Spine did not mention local.

I'll look for more

 

[No Pain All gain]

I used to use lido w epi. I had one case where the pocket developed an eschar. Now I use no more than 10cc lido w epi 1:100k. The rest of the local I use for implants (about 30cc total) is 0.5% bupi.

I just put the 14ga through the skin. No issues.


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[BobBarker]

I use around 8cc .5% bupi 1:200,000 for implants. Scalpel for epidermis, bovie the rest of the way.

 

[244913]

I stopped using epi after reading NACC recommendations, then helped a plastic surgeon out with a case and she said the no epi thing was all bunk.

So I went back to using it and it's nice not even having to use the Bovie to cauterize.

Lido with epi T1/2 is what, about 2 hours? Maybe I'm missing something but how does that impair wound healing. I think frying the wound with Bovie is more likely to devascularize and cause problems.

I'm pretty superstitious and obsessive about my implants, I have blind spots for sure. Would be nice to hear a reasonable consensus on this issue from experienced people.

I'll also reach out to some plastic surgeon friends

 

[soccrwz]

Plast Reconstr Surg. 2002 Oct;110(5):1275-9.
Effect of lidocaine and epinephrine on Staphylococcus aureus in a guinea pig model of surgical wound infection.
Stratford AF1, Zoutman DE, Davidson JS.


All control sites had a consistent presence >or=10 cfu/ml, the threshold for bacterial inhibition of wound healing. Infiltration of the wound with 2 ml of 2% lidocaine prior to inoculation was associated with an average decrease in bacterial count of >70 percent ( n= 19). On the other hand, the addition of epinephrine (1:100,000) to lidocaine was associated with a 20-fold in bacterial counts compared with control values ( n= 10).

The efficiency of topical anesthetics as antimicrobial agents: A review of use in dentistry

Stratford et al. [62] reported that lidocaine produced a 70% reduction in bacterial count in vivo, however adding epinephrine resulted in a 20-fold increase in bacterial count compared to controls. This suggested that hypoxia resulting from vasoconstriction may directly increase the risk of surgical site infection

From the same article:
A solution of 1:100,000 epinephrine and 2% Xylocaine®, was shown to inhibit the growth of specific organisms and to be bactericidal to others. Its bactericidal activity was significantly less than 2% Xylocaine® without epinephrine.

Multiple local anesthetics at concentrations typically used in the clinical setting, such as 0.125% – 0.75% bupivacaine and 1% – 3% lidocaine, inhibit the growth of numerous bacteria and fungi. Bupivacaine and lidocaine inhibit growth to a significantly higher degree than ropivacaine.