should I go off coumadin temporarily for procedures?

[CindyLou]

Hi all,

I am in a quandry and am seeking any input or advice. I was scheduled last week for a trigger point injection in my right tfl muscle and repeat cervical rhizotomy. My last cervical rhizotomy was one year ago, and gave me incredible relief for that whole time. At the last minute they both had to be canceled due to my being on coumadin. I would need my primary's approval to go off for 5 days in order to have these procedures performed. Well, I talked to my primary (who has only seen me once, in reality, after my pulmonary emboli, but I am in limbo, because his practice is closed. He only saw me on an emergency basis, the one time. And my regular primary left this same practice last month, so I don't have a replacement yet. So I guess you would call him my temporary, in limbo primary. Just to get you up to speed.)

So....after talking with him on the phone, he did not think it was a good idea to stop the coumadin, even for 5 days, due to my p.e. only having been 3 months ago. He really thought the procedures should wait at least another 3 months. I wasn't happy about it, but went along with his assessment of my situation. Now, my neck pain is getting increasingly worse. I feel shaky and almost nauseous trying to hold my head up. Past MRI's have revealed severe stenosis at C5-6 and C6-7. No arm pain tho. Past MRI's have also revealed herneated discs that have worsened over time. I am now beginning to think I need to way the risks but get these procedures done, especially the rhizotomy, due to my less than ideal pain levels. I just can't see going through the holidays in this much pain.

However, he has me scared ****less at the other alternative, should I have another emboli during those 5 days. Both of my pulmonary embolisms were triggered after a major surgery or prolonged laying around after my bicycle trauma. Any perspective from anyone?

I am also finally taking the bull by the horns and going down to Mayo Clinic in Rochester the first week of December for a second opinion on my right hip.

[Justin]

Originally Posted by CindyLou

Hi all,

I am in a quandry and am seeking any input or advice. I was scheduled last week for a trigger point injection in my right tfl muscle and repeat cervical rhizotomy. My last cervical rhizotomy was one year ago, and gave me incredible relief for that whole time. At the last minute they both had to be canceled due to my being on coumadin. I would need my primary's approval to go off for 5 days in order to have these procedures performed. Well, I talked to my primary (who has only seen me once, in reality, after my pulmonary emboli, but I am in limbo, because his practice is closed. He only saw me on an emergency basis, the one time. And my regular primary left this same practice last month, so I don't have a replacement yet. So I guess you would call him my temporary, in limbo primary. Just to get you up to speed.) So....after talking with him on the phone, he did not think it was a good idea to stop the coumadin, even for 5 days, due to my p.e. only having been 3 months ago. He really thought the procedures should wait at least another 3 months. I wasn't happy about it, but went along with his assessment of my situation. Now, my neck pain is getting increasingly worse. I feel shaky and almost nauseous trying to hold my head up. Past MRI's have revealed severe stenosis at C5-6 and C6-7. No arm pain tho. Past MRI's have also revealed herneated discs that have worsened over time. I am now beginning to think I need to way the risks but get these procedures done, especially the rhizotomy, due to my less than ideal pain levels. I just can't see going through the holidays in this much pain. However, he has me scared ****less at the other alternative, should I have another emboli during those 5 days. Both of my pulmonary embolisms were triggered after a major surgery or prolonged laying around after my bicycle trauma. Any perspective from anyone?
I am also finally taking the bull by the horns and going down to Mayo Clinic in Rochester the first week of December for a second opinion on my right hip.

Cindylou, I am so sorry you are still struggling. I know the holidays are approaching and you want to enjoy them with the least amount of pain. However, I would not go off your coumadin (especially in light of your history). We can talk about this more via PM if you wish.

[2cool4U]

Cindylou,

I'm sorry to hear that you're in such a bind. Unfortunately, no one will do an interventional procedure on a patient who is on blood thinners until they are stopped. The risk of bleeding into or around major nerve structures or even the spinal cord (epidural hematoma) is much higher, so the risk of permanent nerve or cord damage is much higher.

Unlike actual open surgery, if bleeding starts during a minimally invasive needle procedure, there is no way to control it. Although it's hard to believe, it's actually safer to take out a gallbladder from a patient on blood thinners than it is to stick a small needle near the spine.

One option sometimes used when it's important for the patient to be off of the medication for as little time as possible: Admit the patient to the hospital and switch the patient from oral coumadin to IV heparin. When the coumadin has had time to be eliminated, the heparin can be stopped for a few hrs. prior to the procedure and then restarted after the procedure. The patient is then switched back to oral coumadin and discharged. This is possible because heparin is much shorter-acting than coumadin.

All in all, this can take 2-5 days in the hospital. It requires that the doctor performing the procedure be willing to do it in the hospital rather than in a free-standing outpatient facility. It also requires your primary care doctor to admit you to the hospital and manage your meds before/after the procedure. It also adds a whole 'nother layer to the costs. However, it can be an option if no other possibilities exist.

Good luck.

Tim

[Terry]

CindyLou:

Would you consider cervical disc replacements as well as the lumbar ones you already have? It sounds like your neck has some major issues as well.

I also am sorry you are still struggling. I hope there is upcoming solutions for you.

Terry Newton

[Harrison]

This is a great question for your PCP (primary care physician).

And do you happen to know your INR before taking this blood thinner? After taking it? A consultative hematologist would be a real help right now in helping you sort through these issues -- will your PCP refer you to one?

[CindyLou]

Thank-you all. Harrison, that is a great idea. I'll see if I can get a name or referral for a hematologist. I think that's why I've been stuck in the mire, as I don't have a regular primary who "knows me." My other one just up and left the practice with no forwarding information last month. And I loved her.

Terry, at this point in time, I just cannot afford to pay for another procedure out of pocket, nor mentally fight the good fight with my insurance for cervical ADR's. That's why I want to buy time with the rhizotomy and the relief it gives me, albeit temporary, a year is a long time.

Gosh, I'd hate to think it would involve a 3-4 day hospitalization to accomodate my necessity for blood thinners. But, something to think about in a worst case scenario.

Justin, I was hoping you would chime in, but I hate your reply. I better PM you to hear you out.

[Justin]

Originally Posted by CindyLou

Justin, I was hoping you would chime in, but I hate your reply. I better PM you to hear you out.

CindyLou, check your PMs.

[CindyLou]

Thank-you again everyone for the input. I did make an appt. w/ a hematologist, however I cannot see him until two days before Christmas. Kind of a bummer. Am wondering if I should add that to the list for who to see when I am at Mayo Clinic, the first week of December, if one is available. At least, perhaps, they could give the ok for going off the coumadin for 5 days, and replacing it with the Heparin. Then I could get the cervical procedure done earlier. And continue to keep my appt. with the local hematologist for regular anti-coagulation follow-up. Does that seem too convoluted?