Mid Atlantic Spine &
Pain Physicians, Newark, DE;
1,5-8 Temple University Hospital,
Philadelphia, PA
Authors: Manchikanti Laxmaiah 
Published: March 2021

Background: The role of antithrombotic therapy is well known for its primary and secondary prevention
of cardiovascular disease by decreasing the incidence of acute cerebral, cardiovascular, peripheral
vascular, and other thrombotic events. The overwhelming data show that the risk of thrombotic events
is significantly higher than that of bleeding during surgery after antiplatelet drug discontinuation.
It has been assumed that discontinuing antiplatelet therapy prior to performing interventional pain
management techniques is a common practice, even though doing so may potentially increase the
risk of acute cerebral and cardiovascular events. There are no data available concerning these events,
specifically in relation to the occurrence of thromboembolic events, even though some data are
available concerning bleeding complications. Even then, interventionalists seem to routinely discontinue
all antithrombotic therapy prior to all interventional pain management techniques.
Objective: To assess the perioperative antiplatelet and anticoagulant practice patterns of US
interventional pain management physicians as well as adverse events in patients on antithrombotic
therapy who undergo interventional pain management techniques when that therapy is continued or
stopped.
Study Design: An online survey of interventional pain management physicians.
Study Setting: Interventional pain management practices in the United States.
Methods: An online survey was commissioned among 2,300 members of the American Society of
Interventional Pain Physicians. The survey was designed to assess practice patterns and complications
encountered.
Results: Of the 2,300 members surveyed, 325 responded. These results showed that all physicians
discontinued warfarin therapy; whereas, 97% discontinued clopidogrel; 96% ticlopidine; 95%
Aggrastat (tirofiban); 93% cilostazol, 85% dipyridamole, 60% aspirin 350 mg; 39% aspirin 81 mg;
and 39% other nonsteroidal anti-inflammatory drugs (NSAIDs) prior to performing interventional pain
management techniques. The majority of physicians accepted an international normalized ratio of 1.5
or less as a safe level.
An assessment of serious complications showed thromboembolic events were 3 times more frequent
than bleeding complications: 162 thromboembolic events and 55 serious bleeding complications from
epidural hematomas. Thromboembolic complications were severe and higher when antiplatelet therapy
was discontinued. Bleeding complications from epidural hematomas were similar whether antiplatelet
therapy was continued or discontinued (26 versus 29).
Limitations: This study was limited by its being an online survey of the membership of one organization
in one country and that there was a 14% response rate. Underreporting in surveys is common. Further,
the incidence of thromboembolic events or epidural hematomas may be misrepresented as a percentage
since these drugs were continued in a very small percentage of patients. Consequently, the incidences
described in this manuscript may not show appropriate percentages. Conclusion: The results illustrate an overwhelming pattern of discontinuing antiplatelet and warfarin therapy as well as aspirin
and other NSAIDs prior to performing interventional pain management techniques. However, thromboembolism complications
may be 3 times more prevalent than epidural hematomas (162 versus 55 events). It is concluded that clinicians must balance the
risks of thromboembolism and bleeding in each patient prior to the routine discontinuation of antiplatelet therapy.
Key words: Interventional pain management, interventional techniques, hemostasis, anticoagulants, antiplatelet therapy,
thromboembolic events, bleeding, complications, aspirin, clopidogrel (Plavix), warfarin (Coumadin).