Transforaminal Epidural Steroid Injection on Apixaban With Poor Glycemic Control
Mrs. C is a 62-year-old woman with 8 weeks of right L5 radicular pain from L4-L5 foraminal stenosis. Pain is 8/10, with dorsiflexion weakness (4+/5) and numbness in the L5 distribution. She takes apixaban 5 mg twice daily for atrial fibrillation; CHA2DS2-VASc is 6. Her eGFR is 45 mL/min/1.73 m², A1c 8.9%, platelets 180,000/µL, and INR 1.0. She requests a transforaminal epidural steroid injection. She has tried physical therapy and gabapentin without relief. She is adamant about avoiding surgery. Her cardiologist is unavailable for urgent consultation.
1. Would you proceed with the injection, and how would you manage apixaban?
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I would not proceed immediately without addressing anticoagulation and glycemic control. Per ASRA, apixaban should be held for 72 hours before a neuraxial procedure; this is a shared decision because CHA2DS2-VASc 6 indicates high stroke risk. Bridging with heparin is not routinely recommended for DOACs and may increase bleeding. I would contact cardiology or the anticoagulation service; if they cannot be reached, I would postpone the injection rather than proceed unsafely. Platelets and INR are acceptable. The transforaminal route carries additional risk of spinal cord infarction, so I would use image guidance, contrast, and a nonparticulate steroid. If the patient cannot safely hold apixaban, I would offer noninterventional care and reassess.
2. How would you mitigate the risks of steroid in a patient with A1c 8.9% and CKD?
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A1c 8.9% increases the risk of steroid-induced hyperglycemia and infection. I would check a fingerstick glucose before the procedure, use the lowest effective steroid dose (e.g., dexamethasone 4–8 mg or triamcinolone 20–40 mg), and warn the patient about glucose elevation for several days. I would coordinate with her primary care clinician. I would not use ketorolac for postprocedure pain because of CKD and anticoagulation. Physical therapy should continue. If she has systemic infection or uncontrolled diabetes with ketosis, I would postpone.
3. What if she cannot safely hold anticoagulation?
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If she cannot hold apixaban, options include postponing until cardiology clears a plan, using a noninterventional approach, or considering a lower-risk procedure. I would not unilaterally stop anticoagulation. I would document the risk–benefit discussion, the patient's preference to avoid surgery, and the plan for follow-up. If she develops progressive weakness, bowel or bladder dysfunction, or saddle anesthesia, urgent imaging and surgical consultation are needed.