Epidural Steroid Injection on Anticoagulation
A 61-year-old woman with L5 radiculopathy has an MRI showing a left L4–L5 disc herniation concordant with her symptoms. She has completed 6 weeks of physical therapy and NSAIDs without adequate relief. She takes apixaban 5 mg twice daily for atrial fibrillation and aspirin 81 mg daily; A1c is 9.1%. Platelets are 210,000/µL, INR 1.1, and creatinine is normal. She requests an interlaminar epidural steroid injection and reports 3 months of relief from a prior injection. She is scheduled for a colonoscopy in 10 days.
1. Assess whether she is an appropriate candidate for an interlaminar epidural steroid injection now, and identify the key periprocedural risks.
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She has a concordant radicular syndrome and has failed conservative care, so an epidural steroid injection is a reasonable option. However, she is not a routine candidate today because of combined anticoagulation, poorly controlled diabetes, and a pending colonoscopy. The key risks are spinal epidural hematoma, infection, steroid-induced hyperglycemia, and bleeding at other sites. The benefit is modest and time-limited. Shared decision-making should include continued therapy, a nerve-stabilizing medication, or surgical referral. I would not proceed until the anticoagulation plan, glycemic control, and colonoscopy timing are coordinated.
2. Detail the anticoagulation management plan, including timing of apixaban and aspirin around the procedure.
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For a neuraxial procedure, apixaban should be stopped 72 hours before the injection, assuming normal renal function, and restarted 24 hours after, once bleeding has been excluded. Aspirin 81 mg can generally continue for neuraxial access, but this should be verified with the proceduralist and cardiology because of the combined effect. INR is not useful for monitoring apixaban. Coordinate with the cardiologist about stroke risk and with the endoscopist about colonoscopy timing; if polypectomy is likely, the apixaban interruption must cover both procedures. Document the plan and a responsible clinician.
3. What alternatives and risk-mitigation strategies would you discuss, including glycemic control and timing?
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Discuss alternatives: continue physical therapy, add duloxetine or gabapentin because renal function is normal, consider a transforaminal injection with the same bleeding risk, or refer to spine surgery. If proceeding, use the lowest effective steroid dose, check glucose before and after, and advise sick-day monitoring. Delay if A1c can be improved or if colonoscopy is imminent. Risk mitigation includes sterile technique, fluoroscopic guidance, and a postprocedure neurological check. Provide written instructions for back pain, fever, or weakness. Document that the patient understands the tradeoffs.