Classification of bleeding risk for selected interventional pain procedures

High risk of bleeding

Spinal cord stimulator placement

Dorsal root ganglion stimulator placement

Vertebral augmentation procedures

Neuraxial infusion catheter and pump placement

Intermediate risk of bleeding^*

Epidural glucocorticoid injection

Sympathetic block (eg, celiac plexus, superior hypogastric plexus, and ganglion impar)

Sphenopalatine ganglion block

Trigeminal ganglion block

Cervical medial branch block and RFA

Low risk of bleeding^*

Trigger point injection

Joint injection

Lumbar or thoracic medial branch block and RFA

Peripheral nerve stimulator placement

Peripheral nerve block^¶

Neuraxial infusion implantable pulse generator or pump replacement

This table shows the classification of selected interventional pain procedures according to estimated risk of bleeding. Importantly, these are only general classifications. Risk assessment should be individualized based on conditions that change average risk for the procedure and risks associated with holding anticoagulants, if applicable.

RFA: radiofrequency ablation.

* Patient factors that increase the risk of bleeding (eg, older age, coagulopathy, severe liver or kidney dysfunction, prior surgery or radiation in the area of the procedure) may increase risk for otherwise low- or intermediate-risk procedures.

¶ Peripheral nerve blocks in anatomic locations not amenable to the application of pressure to control hemorrhage (ie, paravertebral blocks, deep plexus blocks, or deep peripheral nerve blocks) may be considered higher-risk procedures.

Adapted from: Narouze S, Benzon HT, Provenzano D, et al. 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. Reg Anesth Pain Med 2018; 43:225.

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Classification of bleeding risk for selected interventional pain procedures