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Anesthesiology:
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Caution in Performing Epidural Injections in Patients on Several Antiplatelet Drugs

Benzon, Honorio T. M.D.; Wong, Hak Y. M.D.; Siddiqui, Talha M.D.; Ondra, Stephen M.D.

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To the Editor:—
We wish to alert our colleagues about the danger of performing epidural injections in patients who are receiving several antiplatelet drugs. A patient with acute onset of quadriparesis was referred to our hospital with a large cervical epidural hematoma. He developed numbness and weakness of his arms and legs within 30 min after the performance of a cervical epidural steroid injection. At the time of injection, he was taking several antiplatelet drugs (diclofenac, clopidogrel, and possibly aspirin) that had been started after a prior coronary angioplasty. He had a prior uneventful cervical epidural steroid injection 11 days before the incident in question, but it is not clear if he was taking these antiplatelet drugs then. The patient had no history of easy bruisability. His prothrombin time, international normalized ratio, and partial thromboplastin time were within normal limits, and his platelet count was 160,000/μl but the timing of the last doses of antiplatelet drugs was unclear. He underwent an emergency C3–T3 laminectomy and evacuation of cervical epidural hematoma, which extended from the C2 to C7 vertebral levels, approximately 14 h after the epidural injection. Postoperatively, the strength in the patient's upper extremities improved, but his lower extremities remained paralyzed. Three months after surgery, he had regained his strength in his upper extremities, but the paralysis of his lower extremities remained.
The relative safety of epidural injections in patients on antiplatelet drugs has been established. 1 In the rare case reports of spinal hematoma involving antiplatelet drugs, some complicating factors were present: concomitant heparin administration, 2 epidural venous angioma, 2 repeated epidural injections, 3 and technical difficulties in performing the injection. 4–6 The latter factor has been suggested as major risk factor in the development of spinal hematoma. 1,5–8
The thienopyridine derivatives ticlopidine and clopidogrel represent a newer class of antiplatelet drugs with antiplatelet mechanisms different from that of aspirin. These drugs inhibit induced platelet aggregation, possibly by altering platelet membrane and blocking the interaction between fibrinogen and the membrane glycoprotein receptor, GPIIb/IIIa. 9–11 Clopidogrel and ticlopidine also seem to modulate vascular smooth muscle, resulting in reduced vascular contraction. 12 These drugs inhibit platelet adhesion to the vascular endothelium and shear stress‐induced platelet aggregation and secretion. 13 Clopidogrel is 40–100 times more potent than ticlopidine. 14 After discontinuation of clopidogrel therapy, platelet aggregation and bleeding time return to baseline within 5 days. Although there has been no case report of spinal hematoma after a neuraxial block in patients receiving clopidogrel alone, there has been a case of spinal hematoma in a patient on ticlopidine. 6
The drug package literature for clopidogrel cautions its use with aspirin, warfarin, or nonsteroidal antiinflammatory drugs that have different, and possibly additive, antiplatelet mechanisms.* Despite the lack of data on the effect of combination of these drugs on duration of antiplatelet inhibition, we recommend that neuraxial blocks be postponed for 5–7 days in patients who are receiving several antiplatelet drugs.
Honorio T. Benzon M.D.
Hak Y. Wong M.D.
Talha Siddiqui M.D.
Stephen Ondra M.D.
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References

1. Urmey WF, Rowlingson J: Do antiplatelet agents contribute to the development of perioperative spinal hematoma? Reg Anesth Pain Med 1998; 23S:146—51

2. Eastwood DW: Hematoma after epidural anesthesia: Relationship of skin and spinal angiomas. Anesth Analg 1991; 73:352–4

3. Williams KN, Jackowski A, Evans PJD: Epidural haematoma requiring surgical decompression following repeated cervical epidural steroid injections for chronic pain. Pain 1990; 42:197–9

4. Greensite F, Katz J: Spinal subdural hematoma associated with attempted epidural anesthesia and subsequent spinal anesthesia. Anesth Analg 1980; 59:72–3

5. Gerancher JC, Waterer R, Middleton J: Transient paraparesis after postdural puncture spinal hematoma in a patient receiving ketorolac. ANESTHESIOLOGY 1997; 86:490–4

6. Mayumi T, Dohi S: Spinal subarachnoid hematoma after lumbar puncture in a patient receiving antiplatelet therapy. Anesth Analg 1983; 62:777–9

7. Lerner S, Gutterman P, Jenkins F: Epidural hematoma and paraplegia after numerous lumbar punctures. ANESTHESIOLOGY 1973; 39:550–1

8. Rengachary S, Murphy D: Subarachnoid hematoma and paraplegia following lumbar puncture causing compression of the cauda equina: Case report. J Neurosurg 1974; 41:252–4

9. Herbert JM, Frechel D, Vallee E, Kieffer G, Gouy D, Berger Y, Necciari J, Defren G, Maffrand JP: Clopidogrel, a novel antiplatelet and antithrombotic agent. Cardiovasc Drug Rev 1993; 11:180–98

10. Defreyn G, Gachet C, Savi P, Driot F, Cazenave JP, Maffrand JP: Ticlopidine and clopidogrel (SR 25990C) selectively neutralize ADP inhibition of PGE1-activated platelet adenylate cyclase in rats and rabbits. Thromb Haemost 1991; 65:186–90

11. Hirsh J, Dalen JE, Fuster V, Harker LB, Patrono C, Roth G: Aspirin and other platelet active drugs: The relationship among dose, effectiveness, and side effects. Chest 1995; 108:247S–57S

12. Yang LH, Fareed J: Vasomodulatory action of clopidogrel and ticlopidine. Thromb Res 1997; 86:479–91

13. Schror K: Antiplatelet drugsz: A comparative review. Drugs 1995; 50:7–28

14. Boneu B, Destelle G, on behalf of the study group: Platelet anti-aggregating activity and tolerance of clopidogrel in artherosclerotic patients. Thromb Haemost 1996; 76:939–43

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