Article Text

Download PDFPDF

Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications: 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
  1. Samer Narouze, MD, PhD*,
  2. Honorio T. Benzon, MD,
  3. David A. Provenzano, MD,
  4. Asokumar Buvanendran, MD§,
  5. José De Andres, MD, PhD,
  6. Timothy R. Deer, MD#,
  7. Richard Rauck, MD** and
  8. Marc A. Huntoon, MD††
  1. *Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH
  2. Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL
  3. Pain Diagnostics and Interventional Care, Pittsburgh, PA
  4. §Rush Medical Center, Chicago, IL
  5. Department of Anesthesiology, Critical Care, and Pain Management, Valencia University School of Medicine, General University Hospital, Valencia, Spain
  6. #The Center for Pain Relief, Charleston, WV
  7. **Carolinas Pain Institute, Winston Salem, NC
  8. ††Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
  1. Address correspondence to: Samer Narouze, MD, PhD, Center for Pain Medicine, Western Reserve Hospital, 1900 23rd St, Cuyahoga Falls, OH 44223 (e-mail: narouzs{at}


Abstract Interventional spine and pain procedures cover a far broader spectrum than those for regional anesthesia, reflecting diverse targets and goals. When surveyed, interventional pain and spine physicians attending the American Society of Regional Anesthesia and Pain Medicine (ASRA) 11th Annual Pain Medicine Meeting exhorted that existing ASRA guidelines for regional anesthesia in patients on antiplatelet and anticoagulant medications were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors necessitated separate guidelines for pain and spine procedures.

In response, ASRA formed a guidelines committee. After preliminary review of published complication reports and studies, committee members stratified interventional spine and pain procedures according to potential bleeding risk as low-, intermediate-, and high-risk procedures. The ASRA guidelines were deemed largely appropriate for the low- and intermediate-risk categories, but it was agreed that the high-risk targets required an intensive look at issues specific to patient safety and optimal outcomes in pain medicine.

The latest evidence was sought through extensive database search strategies and the recommendations were evidence-based when available and pharmacology-driven otherwise. We could not provide strength and grading of these recommendations as there are not enough well-designed large studies concerning interventional pain procedures to support such grading. Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • The authors declare no conflict of interest.

    Drs Samer Narouze and Honorio T. Benzon contributed equally to this article.