Neuraxial anesthesia encompasses spinal, epidural, and caudal blocks used for pain management in surgical procedures. The primary concern when patients are on anticoagulants involves the increased risk of bleeding complications, particularly spinal hematoma — a rare but potentially devastating complication that can cause permanent neurological injury.
Neuraxial techniques involve the administration of local anesthetics near the spinal cord. Spinal anesthesia uses a single injection into the subarachnoid space, epidural anesthesia delivers medication into the epidural space via injection or catheter, and caudal anesthesia targets the caudal epidural space, largely used in pediatric patients.
Anticoagulants — including heparin, warfarin, and direct oral anticoagulants (DOACs) — are widely used in the surgical population for thromboprophylaxis and therapeutic indications. Each class has distinct pharmacokinetics that affect the timing of neuraxial procedures.
The American Society of Regional Anesthesia and Pain Medicine (ASRA) provides evidence-based guidance for managing neuraxial anesthesia in anticoagulated patients. Recommendations include appropriate intervals between the last dose of anticoagulant and the initiation of neuraxial block, clinical judgment regarding coagulation testing, post-procedure neurological monitoring, and coordinated communication among medical teams caring for the patient.