Functional Neurosurgery · Quick Reference
Anticoagulation for Neuraxial Neuromodulation
A drug-by-drug hold-and-restart reference for SCS, DRG, and intrathecal device procedures
Spinal cord stimulator trials and implants, DRG stimulation, and intrathecal pump placement are managed here using the ASRA high bleeding-risk pathway. NACC stratifies neuromodulation separately (percutaneous SCS/DRG as moderate risk; paddle SCS/DBS as high risk), so NACC values are cited as SCS-placement comparators where they differ numerically.
Read before you use this table
This is a consolidated quick reference, not a substitute for individualized decision-making. Antithrombotic management is patient-specific: it must be made jointly with the prescribing physician, weighing the thrombotic risk of stopping against the bleeding risk of proceeding, and documented. Intervals change as new agents appear and are modified by renal function, age, and hepatic disease. Confirm every decision against the current ASRA / NACC guidance and the ASRA Coags mobile app at the point of care. The values here assume a HIGH-risk (neuraxial) procedure; lower-risk procedures permit shorter holds. Note the risk grade is procedure-specific: ASRA classifies initial SCS/DRG trial and implant and intrathecal catheter/pump implant as high-risk, but IPG/pump replacement and pocket revision as low-risk — so a generator swap or pump exchange may justify a less aggressive hold under shared decision-making.
Procedure bleeding-risk tiers
ASRA (Narouze 2018) stratifies interventional procedures into three tiers; the hold tables below give all three. NACC grades neurostimulation devices on its own scale, noted at right.
| ASRA tier | Representative procedures | NACC difference |
|---|---|---|
| High | SCS trial and implant; DRG stimulation; intrathecal catheter/pump implant; vertebral augmentation; percutaneous decompression; epiduroscopy. | NACC grades surgical/paddle SCS and DBS as high risk. |
| Intermediate | Interlaminar and transforaminal ESIs; cervical facet MBNB/RFA; intradiscal procedures; sympathetic blocks (stellate, celiac, splanchnic, lumbar, hypogastric). | NACC grades percutaneous SCS and DRG as moderate (vs ASRA high). |
| Low | Peripheral nerve blocks; trigger-point and SI-joint injections; thoracic/lumbar facet MBNB/RFA; PNS trial/implant when low vascular-risk; IPG/pump replacement and pocket revision. | NACC grades PNS as low risk; ASRA notes peripheral neuromodulation may be low-to-intermediate depending on target and invasiveness. |
Patients with bleeding diatheses (advanced age, prior bleeding, concurrent antithrombotics, cirrhosis, advanced renal disease) undergoing low- or intermediate-risk procedures should be managed one tier higher.
Antiplatelet agents
Hold time by procedure tier (high-risk column emphasized for SCS/DRG/pump implants). Restart once hemostasis is secure. For interlaminar cervical ESIs and stellate ganglion blocks, ASRA says to consider holding ASA/NSAIDs despite their intermediate-risk classification.
| Agent | High-risk hold | Intermediate | Low-risk | Restart | Notes |
|---|---|---|---|---|---|
| Aspirin (primary prophylaxis) | 6 days | Shared decision | No hold | 24 h | Discontinue for high-risk procedures. |
| Aspirin (secondary prophylaxis) | Shared (≥ 6 d) | Shared decision | No hold | 24 h | Weigh cardiovascular risk; minimize trial duration given the platelet-rebound window after stopping. |
| NSAID, short half-life (ibuprofen, diclofenac) | 1 day | No hold | No hold | 24 h | Longer with hepatic/renal dysfunction. |
| NSAID (etodolac) | 2 days | No hold | No hold | 24 h | — |
| NSAID, long half-life (naproxen, meloxicam) | 4 days | No hold | No hold | 24 h | ASRA and NACC agree. |
| COX-2 inhibitor (celecoxib) | No hold | No hold | No hold | — | No clinically significant platelet effect. |
| Clopidogrel | 7 days | 7 days | Shared decision | 12–24 h | 12 h usual dose, 24 h after loading. 5 days acceptable for a trial only if platelet-function testing confirms recovery. |
| Prasugrel | 7–10 days | 7–10 days | Shared decision | 24 h | Higher bleeding risk if age > 75, prior stroke/TIA, low body weight. |
| Ticagrelor | 5 days | 5 days | Shared decision | 24 h | — |
| Ticlopidine | 10 days | — | — | Per P2Y12 logic | Value from ASRA regional guideline (not tiered in the pain table); rarely used. |
| Cangrelor | ≥ 3 h | ≥ 3 h | Shared decision | 24 h | IV bridge/PCI agent; an interval longer than 3 h is preferred for high-risk procedures. |
| Dipyridamole (alone) | 48 h | No hold | No hold | Not specified | ASRA gives the 48 h hold but no separate restart interval; resume once hemostasis is secure. |
| Dipyridamole + ASA (Aggrenox) | Follow ASA (6 d) | Shared decision | No hold | 24 h | Combination raises bleeding risk. |
| Cilostazol | 48 h | No hold | No hold | 24 h | — |
| Abciximab (GP IIb/IIIa) | 2–5 days | 2–5 days | 2–5 days | 8–12 h | NACC values. PCI agent; elective device surgery on a patient still on it should essentially never occur. Monitor neurologically. |
| Eptifibatide / tirofiban | 8–24 h | 8–24 h | 8–24 h | 8–12 h | Renal clearance (esp. eptifibatide). |
Anticoagulants
Hold time by procedure tier (high-risk column emphasized). NACC device-placement values are noted where they differ.
| Agent | High-risk hold | Intermediate | Low-risk | Restart | Notes |
|---|---|---|---|---|---|
| Warfarin | 5 days | 5 days | Shared decision | Next day (~24 h) | Document INR normalized before the procedure (ASRA ≤ 1.2; NACC < 1.2). Restart uses the conservative NACC/summary-text timing (ASRA table lists 6 h). |
| Acenocoumarol | 3 days | 3 days | Shared decision | Next day | Confirm INR normalized. |
| UF heparin, IV (therapeutic) | ≥ 6 h + normal aPTT | 6 h | 6 h | 24 h | Hold: ASRA ≥ 6 h vs NACC 4 h — use the longer for SCS. Restart: ASRA minimum 2 h (24 h for moderate/high-risk procedures, especially if bloody) vs NACC 24 h; table uses 24 h. |
| UF heparin, SC (prophylactic) | 24 h + normal aPTT | 6 h | 6 h | 24 h | Hold: ASRA 24 h (high) vs NACC 8–10 h — use the longer. Restart: ASRA 6–8 h vs NACC 24 h; table uses the conservative 24 h. |
| LMWH, prophylactic (enoxaparin 30–40 mg) | 12 h | 12 h | 12 h | 12–24 h | Restart 4 h for low-risk procedures. Caution with renal insufficiency, age ≥ 65, extremes of weight. |
| LMWH, therapeutic (enoxaparin 1 mg/kg) | 24 h | 24 h | 24 h | 12–24 h | ASRA and NACC agree on the 12–24 h restart for high-risk procedures. |
| Fondaparinux | 4 days | 4 days | Shared decision | 24 h | Restart 6 h for low-risk procedures. Favor the full 4-day hold in the elderly or with spinal stenosis. |
| Fibrinolytics (tPA) | Avoid; ≥ 48 h | 48 h | 48 h | Generally avoid | Verify normal coagulation studies before proceeding. |
Direct oral anticoagulants (DOACs)
ASRA pain guideline uses a "5 half-lives" rule for high- and intermediate-risk procedures (shared decision at low risk) and a 24-hour restart.
| Agent | High-risk hold | Intermediate | Low-risk | Restart | Notes |
|---|---|---|---|---|---|
| Dabigatran | 4 days | 4 days | Shared decision | 24 h | Extend to 5–6 days in severe renal impairment / ESRD (NACC: 4–6 days). |
| Rivaroxaban | 3 days | 3 days | Shared decision | 24 h | Longer with renal/hepatic impairment. |
| Apixaban | 3 days | 3 days | Shared decision | 24 h | 3 days is the 5-half-life derivation (half-life ~12 h). |
| Edoxaban | 3 days | 3 days | Shared decision | 24 h | Longer with renal impairment. |
A caution on DOAC renal tiers
The graded creatinine-clearance hold tables (e.g., 72/96/120 h) that circulate online come from the ASRA regional anesthesia guideline (Horlocker 2018), not the interventional pain guideline (Narouze 2018), which uses the 5-half-lives framework above. Do not mix the two; if you want the CrCl-graded approach, cite the regional guideline explicitly.
Herbals and supplements
ASRA 2018 discusses these agents but does not assign formal risk-tier hold intervals; the values below are conservative pharmacologic/consensus estimates, relevant mainly at high doses or combined with antiplatelets.
| Agent | Hold before | Restart after | Notes |
|---|---|---|---|
| Fish oil (omega-3) | 6 days | 24 h | Treat like an antiplatelet at high doses. |
| Garlic, ginkgo, ginseng | ~1 week | 24 h | Discontinue coagulation-active herbals for high-risk procedures. |
| Vitamin E | Caution > 400 IU/day | — | Timing similar to aspirin. |
| Pentosan polysulfate | 5 days | 24 h | — |
The general principles behind the table
Restart once hemostasis is secure — for high-risk procedures the standard is ~24 hours for nearly all agents (warfarin is restarted the next day; clopidogrel at its usual dose may resume at 12 h). Hold antithrombotics through the entire trial, not just the implant; when a patient cannot safely stop therapy for that long, consider a shortened or staged trial. Age and renal function are not a fixed "add X days" rule but push every interval toward its more conservative end (age ≥ 65 is specifically flagged for LMWH). When ASRA and NACC differ, this reference uses the longer ASRA high-risk hold.
References
- Narouze S, Benzon HT, Provenzano DA, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (second edition): guidelines from ASRA, ESRA, AAPM, INS, NANS, and WIP. Reg Anesth Pain Med. 2018;43(3):225–262. PubMed
- Deer TR, Narouze S, Provenzano DA, et al. The Neurostimulation Appropriateness Consensus Committee (NACC): recommendations on bleeding and coagulation management in neurostimulation devices. Neuromodulation. 2017;20(1):51–62. PubMed
- Horlocker TT, Vandermeuelen E, Kopp SL, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: ASRA evidence-based guidelines (fourth edition). Reg Anesth Pain Med. 2018;43(3):263–309. PubMed (Source of the ticlopidine value and the graded-CrCl DOAC framework.)