Anti-platelet medications (Plavix, Aspirin) and anticoagulants (Coumadin, Xarelto, Eliquis, Pradaxa, etc…) are blood thinners used to treat patients with blood clots, heart stents, and strokes. However, they make it very difficult to pursue surgery, since bleeding can be difficult to control and may continue to ooze after surgery. Usually in spine surgery, we stop antiplatelets and anticoagulants prior to surgery. Many of the anticoagulants have reversal agents or metabolize quickly, however, Plavix and Aspirin have no antidote. These medications may remain in the patient’s system for 10-11 days, but many surgeons accept stopping antiplatelet agents about 5-7 days before surgery.
Here is an example of a compressive collection of blood (hematoma) pressing on the nerves after surgery. This is what surgeons fear with blood-thinning medications.
Stopping anti-platelets theoretically could decrease the risk of a compressive hematoma, but there may then be an increased risk of heart attack, stroke, and death. Historically, this was a risk most patient’s needed to accept to undergo surgery.
Newer research, specifically in tubular minimally invasive spine surgery, may show little increased risk of bleeding when the surgery is performed on patients actively taking Plavix or Aspirin. One of the advantages of tubular minimally invasive spine surgery is that the muscles are spread by the tubular dilator during surgery, but then the muscles retract back into position after the surgery. This collapse of the muscles back into place may discourage the formation of postoperative bleeding and hematoma formation.
At least in this newest study, there was no increased intraoperative bleeding or postoperative bleeding.
Moving forward, if we continue to observe a higher cardiovascular and stroke risk compared to surgical bleeding risk when antiplatelet medications are stopped, we may allow patients to continue their Plavix and Aspirin when pursuing minimally invasive spine surgery. While elective spine surgery can be delayed until a point at which patients can safely be off their blood-thinning medications, it may be unreasonable to defer surgical treatment and postpone the relief of debilitating pain and/or neurologic deficits.
Of note, this same effect may not be apparent in traditional open spine surgery. This may be another advantage to the tubular minimally invasive approach.
Kulkarni A et al. The Practice of Continuation of Anti-Platelet Therapy During the Peri-Operative Period in Lumbar Minimally Invasive Spine Surgery (MISS): How Different is the Morbidity in This Scenario?. Spine. 2019.