172 A – What is the optimal protocol for management of patients who are on aspirin for a non-spine related disorder prior to spine surgery?

Chadi Tannoury, Ryan Sutton

Response/Recommendation: Prior to spine surgery, low dose-aspirin (LD-ASA) (81 mg – 500 mg) used for primary and secondary cardiovascular prevention, can be stopped for one to three days. For ASA doses > 1 g per day, ASA should be stopped for at least seven days prior to surgery. However, in patients with extensive cardiac history, it is reasonable to maintain LD-ASA (81 mg) throughout spine surgery.

Strength of the Recommendation: Moderate.

Rationale: ASA is commonly used for patients with cardiovascular disease. ASA irreversibly inhibits platelet aggregation, with platelets typically requiring seven to ten days to fully regenerate¹. ASA discontinuation prior to non-cardiac surgery has been associated with a rebound hypercoagulation effect and a 5- to 10-fold increase in the mortality rate related to acute myocardial infarction^2,3.

Park et al., evaluated the timing of ASA cessation prior to one- or two-level lumbar fusion (three to seven days vs. seven to ten days prior to surgery)⁴. They evaluated three groups: ASA naïve patients vs. patients who stopped ASA three to seven days pre-surgery, vs. patients who stopped ASA seven to ten days pre-surgery⁴. Patients who stopped ASA three to seven days prior to surgery experienced more surgical drainage and longer time of surgical drainage compared to the other two groups⁴. They also found that if ASA was stopped more than seven days before spine surgery, there was no significant difference in bleeding risk compared to the other two groups⁴. On the other hand, Kang et al., compared two groups of patients undergoing spinal fusion: ASA naïve patients vs. patients who stopped LD-ASA (100 mg) at least seven days prior to surgery⁵. The ASA group experienced significantly increased rates of postoperative hemorrhage, higher transfusion requirements, and wound complications even when ASA was stopped at least seven days prior to surgery⁵. Nonetheless, they recommended stopping LD-ASA seven days preoperatively⁵. In another study, Park et al., divided patients who underwent two or more level lumbar fusions into three groups: ASA naïve (group I, 38 patients) vs. patients who stopped ASA one week prior to surgery (group II, 38 patients), vs. patients who continued LD-ASA throughout surgery (group III, 30 patients)⁶. They found that LD-ASA significantly increased bleeding for groups II and III compared to ASA naïve patients⁶. Furthermore, the additional utilization of non-steroidal anti-inflammatory (NSAID) medication was a confounding variable that increased perioperative blood loss in all three groups⁶. Therefore, it is also suggested to stop NSAID in the perioperative phase.

On the other hand, Cuellar et al., retrospectively analyzed 200 patients with cardiac stents who were randomized to either a group that underwent spine surgery while taking ASA (81 mg or 325 mg; 100 patients) or a group that stopped ASA five days prior to spine surgery (100 patients)⁷. They demonstrated that patients who did not stop ASA had shorter length of hospitalization, reduced operative time, similar blood loss, and comparable overall complication and readmission rates to the patients who stopped ASA five days before surgery⁷. Importantly, there was no major increase in the rate of epidural hematoma formation in patients who continued ASA⁷. Similarly, Soleman et al., conducted a retrospective analysis of 102 patients undergoing non-instrumented lumbar decompression surgery⁸. They compared perioperative risks of bleeding and cardiovascular complications of patients on daily ASA 100 mg (40 patients) vs. a control group who stopped ASA (62 patients)⁸. They demonstrated that ASA continuation was safe, and did not lead to higher risk of morbidity, perioperative blood loss, surgical time, or length of hospitalization⁸. Nevertheless, one patient remaining on LD-ASA developed an epidural hematoma, resulting in irreversible paralysis⁸. This complication challenges the safety of continuing perioperative ASA in spine surgery.

More recently, The American Society of Regional Anesthesia (ASRA) published its guidelines on managing anticoagulation in patients undergoing interventional spine and pain procedures. The ASRA concluded that surgery can be performed safely after ASA cessation as follows: after 12 hours if LD-ASA (< 1 g) is used for secondary prevention, and after three days if ASA is used for primary prevention⁹. This cessation time is extended to one week preoperatively for ASA doses greater than 1 g per day⁹. The ASRA also suggested that 81 mg ASA can be reasonably maintained in patients with extensive cardiac history (i.e., drug eluting stents), with its potential benefits outweighing the risk of major surgical bleeding⁹. This recommendation was supported by other recent studies, suggesting the safety of continuing antiplatelet drugs throughout spine surgery^10,11.

Despite the mixed and contrasting data, prophylactic LD-ASA (81 mg – 500 mg) can typically be stopped for one to three days prior to spine surgery, but for one week if the ASA dose is greater than 1 g per day. In patients with extensive cardiac history, it is reasonable to maintain LD-ASA (81 mg) throughout spine surgery.

References:

1. Park HJ, Kwon KY, Woo JH. Comparison of blood loss according to use of aspirin in lumbar fusion patients. Eur Spine J. 2014;23: 1777-1782.
2. Chassot PG, Marcucci C, Delabays A, Spahn DR. Perioperative antiplatelet therapy. Am Fam Physician. 2010 Dec 15; 82(12):1484-9.
3. Gerstein NS, Schulman PM, Gerstein WH, Petersen TR, Tawil I. Should more patients continue aspirin therapy perioperatively?: Clinical impact of aspirin withdrawal syndrome. Ann Surg 2012; 255: 811-9.
4. Park JH, Ahn Y, Choi BS, Choi KT, Lee K, Kim SH, Roh SW. Antithrombotic effects of aspirin on 1- or 2-level lumbar spinal fusion surgery: a comparison between 2 groups discontinuing aspirin use before and after 7 days prior to surgery. Spine (Phila Pa 1976). 2013 Aug 15; 38(18): 1561-5.
5. Kang SB, Cho KJ, Moon KH, Jung JH, Jung SJ. Does low-dose aspirin increase blood loss after spinal fusion surgery? Spine J. 2011; 11: 303-7.
6. Park JH, Ahn Y, Choi BS, Choi KT, Lee K, Kim SH, Roh SW. Antithrombotic effects of aspirin on 1- or 2-level lumbar spinal fusion surgery: a comparison between 2 groups discontinuing aspirin use before and after 7 days prior to surgery. Spine (Phila Pa 1976). 2013 Aug 15; 38(18): 1561-5.
7. Cuellar JM, Petrizzo A, Vaswani R, Goldstein JA, Bendo JA. Does aspirin administration increase perioperative morbidity in patients with cardiac stents undergoing spinal surgery? Spine (Phila Pa 1976). 2015; 40: 629-635.
8. Soleman J, Baumgarten P, Perrig WN, Fandino J, Fathi AR. Noninstrumented extradural lumbar spine surgery under low-dose acetylsalicylic acid: a comparative risk analysis study. Eur SpineJ. 2016; 25: 732-9.
9. Narouze S, Benzon HT, Provenzano D, Buvanendran A, De Andres J, Deer T, Rauck R, Huntoon MA. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 2018 Apr; 43(3): 225-262.
10. Shin WS, Ahn DK, Lee JS, Yoo IS, Lee HY. The Influence of Antiplatelet Drug Medication on Spine Surgery. Clin Orthop Surg. 2018;10(3):380-4.
11. Zhang C, Wang G, Liu X, Li Y, Sun J. Safety of continuing aspirin therapy during spinal surgery: a systematic review and meta-analysis. Medicine (Baltimore). 2017; 96: e8603.