Common Contraindications and Blood Thinner Management for Pain Management Interventional Procedures

Any procedure comes with some common absolute or relative contraindications. There are always exceptions and special situations, but these are some general guidelines to consider. This isn’t an exhaustive list, but it’s a starting point.

Absolute Contraindications

  1. Infection
    1. systemic
    2. infection overlying the injection site or around the target site
  2. Pregnancy
  3. True contrast/Iohexol/omnipaque allergy (if the procedure calls for contrast)
    1. True and severe reactions are rare [See the American College of Radiology Manual on Contrast Media, Topic 8]
    2. Gadolinium can be used as an alternative

Relative Contraindications

  1. Infection
    1. In the authors’ experience, some localized infections are usually safe for certain types of procedures (e.g., non-steroid injections). E.g., infections at unrelated sites (e.g., small infected cut in the periphery) or localized infection that’s near resolution (e.g., pneumonia that’s improving and at the tailend of antibiotic treatment).
  2. Comorbidities
    1. This requires clinical judgement. Generally ensure that chronic problems are stable and are not acutely active.
  3. Blood sugar
    1. Higher chronic levels will put a patient at risk of infection. Steroid injections can cause an increase in blood glucose, acutely worsening the problem.
  4. Blood pressure
    1. Consider that steroid injections can acutely increase the blood pressure, so a patient with asymptomatic hypertension preop, might develop high enough hypertension post op to develop symptoms or other consequences of the increased blood pressure.
  5. Coagulation disorders

Blood Thinners

ASRA publishes guidelines that will provide guidance in most situations.

  1. Details and nuances can be seen in the original article
    1. 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.
  2. The ASRA app is useful for accessing this information in an interactive form
    1. Google Play Store
    2. Apple App Store
  3. In clinical practice it’s often helpful to have a simplified/protocolized version. One for pain management procedures is outlined below (See the original Google Doc here to print or copy the protocol)


  1. Neuraxial Anesthesia and Peripheral Nerve Blocks in Patients on Anticoagulant – NYSORA