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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): 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 Provenzano, MD,
  4. Asokumar Buvanendran, MD§,
  5. José De Andres, MD,
  6. Timothy Deer, MD**,
  7. Richard Rauck, MD†† and
  8. Marc A. Huntoon, MD‡‡
  1. *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. §Department of Anesthesiology, Rush University Medical Center, Chicago, IL
  5. Valencia University Medical School and Department of Anesthesiology Critical Care and Pain Management, General University Hospital, Valencia, Spain
  6. **Spine and Nerve Center of The Virginias, Charleston, WV
  7. ††Carolinas Pain Institute, Winston-Salem, NC
  8. ‡‡Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA
  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 The American Society of Regional Anesthesia and Pain Medicine (ASRA) 2012 survey of meeting attendees showed that existing ASRA anticoagulation guidelines for regional anesthesia were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors required separate guidelines for pain and spine procedures. In response, a guidelines committee was formed. After preliminary review of published complications reports and studies, the committee stratified interventional spine and pain procedures according to potential bleeding risk: low-, intermediate-, and high-risk procedures. The ASRA regional anesthesia anticoagulation guidelines were largely deemed appropriate for the low- and intermediate-risk categories, but the high-risk category required further investigation. The first guidelines specific to interventional spine and pain procedures were published in 2015. Recent reviews evaluating bleeding complications in patients undergoing specific interventional pain procedures, the development of new regional anesthesia and acute pain guidelines, and the development of new anticoagulants and antiplatelet medications necessitate complementary updated guidelines. The authors desired coordination with the authors of the recently updated regional and acute pain anticoagulation guidelines. 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 because 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. This publication is intended as a living document to be updated periodically with consideration of new evidence.

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  • Brian D. Sites, MD, was acting Editor-in-Chief for this submission.

    S.N. is a paid member of an advisory board for Abbott Laboratories. D.P. receives research funding from Abbott Laboratories and Medtronic. He serves as a consultant to Abbott, Boston Scientific, Medtronic, Nevro, and Halyard. T.D. is a paid consultant for Axonics, Abbott, Bioness, Flowonix Medical, Jazz Pharmaceuticals, Nalu, SpineThera, Saluda Medical, Mainstay Medical, Vertos, Vertiflex. R.R. receives funding from Boston Scientific, Biodelivery Science Inc, and Jazz Pharma. In addition, R.R. receives ongoing research grants from Nektar, Biogen, Pfizer, SPR Therapeutics, Neuros, Mainstay, Saluda, Nevro, and Stimwave and also serves as chair of Data Safety Monitoring Boards and Clinical Events Committee of Mainstay and Saluda trials. He also serves as a speaker for AstraZeneca. M.A.H. serves on the Clinical Events Committee for a study funded by Saluda Medical Americas, Inc. and the Data Safety Monitoring Committee for a study funded by Mainstay Medical International PLC. He otherwise declares no potential conflicts of interest. The other authors declare no conflict of interest.

    S.N. and H.T.B. equally contributed to the manuscript.