Lumbar Puncture & Myelogram on Anticoagulants
Conservative neuraxial timing with catheter buffers, INR rules, and renal cautions
LP and myelogram sit in the neuraxial category. That means you plan holds and restarts more conservatively than for routine low-risk procedures. The safest plan depends on the drug class, renal function, the presence of a neuraxial catheter, and how secure hemostasis looks immediately after the tap or contrast study.
Neuraxial hard-stops: avoid elective LP/myelogram if dabigatran CrCl < 30 mL/min. Use extreme caution when apixaban CrCl < 25 mL/min or rivaroxaban/edoxaban CrCl < 30 mL/min. Consult Hematology and Anesthesia.
TL;DR for quick decisions
- Warfarin: stop ~5 days before; INR < 1.5 before LP; restart 12–24 h (low/mod) or 48–72 h (high/neuro) if hemostasis is secure.
- DOACs: use neuraxial/high-risk windows; do not bridge; if a catheter is in place, no dosing until removal; earliest restart is removal + 24 h and use the later of baseline vs catheter rule.
- LMWH: prophylaxis last dose ≥ 12 h; therapeutic ≥ 24 h. Restart ~24 h (low/mod) or 48–72 h (high/neuro). With catheter: earliest LMWH dose is removal + 4 h.
- UFH infusion: stop 4–6 h pre-LP and verify aPTT normal. Restart ~24 h (low/mod) or 48–72 h (high/neuro). With catheter: earliest is removal + 1 h and normal aPTT.
Summary table
| Drug | Pre-LP/myelogram hold | Post-procedure restart | Catheter rule |
|---|---|---|---|
| Apixaban / Rivaroxaban / Edoxaban | Use neuraxial/high-risk windows; extend with renal impairment | 24–72 h if hemostasis is secure | No dosing with catheter; earliest dose is removal + 24 h (use later of baseline vs catheter rule) |
| Dabigatran | Renal-tiered holds; avoid elective neuraxial if CrCl < 30 | 24–72 h if hemostasis is secure | No dosing with catheter; earliest dose is removal + 24 h (use later of baseline vs catheter rule) |
| Warfarin | Stop ~5 days; ensure INR < 1.5 | 12–24 h (low/mod) or 48–72 h (high/neuro) | INR < 1.5 prior to catheter removal |
| LMWH (therapeutic) | ≥ 24 h | ~24 h (low/mod), 48–72 h (high/neuro) | First dose ≥ removal + 4 h; never while catheter in place |
| LMWH (prophylactic) | ≥ 12 h | As above | First dose ≥ removal + 4 h |
| UFH infusion | Stop 4–6 h; verify aPTT normal | ~24 h (low/mod), 48–72 h (high/neuro) | First dose ≥ removal + 1 h; verify aPTT normal |
Warfarin: governance and timing
Warfarin is stopped about five days before LP/myelogram and you must check INR prior to the procedure; the target is < 1.5. If INR is ≥ 1.5 within 24–48 hours of the planned tap, correct or delay. Restart timing depends on bleeding risk and hemostasis: 12–24 h after low/moderate risk procedures; 48–72 h after high-risk/neuraxial procedures when hemostasis is secure.
DOACs: conservative neuraxial approach
For apixaban, rivaroxaban, edoxaban, and dabigatran, use neuraxial/high-risk windows and extend holds as renal function declines. Do not bridge DOACs. If thrombotic risk is truly extreme, MD Anderson Appendix I lists rare exceptions—consult Hematology rather than auto-bridging.
LMWH and UFH around the tap
For LMWH, the last dose is ≥ 12 hours for prophylaxis or ≥ 24 hours for therapeutic dosing. For UFH infusion, stop 4–6 hours pre-procedure and verify aPTT is normal. Post-procedure restarts follow the summary table and must respect catheter removal buffers.
Neuraxial catheter gating
- Never dose anticoagulants while a neuraxial catheter is in place.
- DOACs: earliest restart = catheter removal + 24 h; use the later of baseline window vs catheter rule.
- LMWH: earliest restart = removal + 4 h.
- UFH infusion: earliest restart = removal + 1 h with a normal aPTT.
For a one-page quick reference, see neuraxial catheter timing.
Red flags and when to delay
- Any anticoagulant dose given within the hold window.
- Traumatic puncture or ongoing bleeding.
- Neuraxial catheter still in place.
- CrCl thresholds that trigger the hard-stops above.
- Platelets low or other bleeding risks without mitigation.
- Hemostasis not clearly secure post-procedure.
When any of these are present, delay and reassess with the proceduralist and anesthesia.
Related reading
- Warfarin before procedures: INR goals and bridging
- Enoxaparin timing (prophylactic vs therapeutic)
- UFH infusion before procedures: stop window and aPTT checks
- Neuraxial catheter gating rules (quick reference)
Source and conservative alignment
- MD Anderson Peri-Procedure Anticoagulants, V8 (approved 07/15/2025) — DOACs: Table 3 (p.10) & Appendix I (pp.29–31); Warfarin: Appendix J (p.32); LMWH/UFH: Appendix D (pp.13–14) & Appendix H (pp.26–28).
- ASRA/Stanford institutional guidance — neuraxial catheter buffers (DOAC ≥ 24 h, LMWH ≥ 4 h, UFH ≥ 1 h) and no dosing while a catheter is in place.
This article supports, not replaces, clinical judgment. Confirm local policy and ASRA guidance for neuraxial catheters.
Implements: MD Anderson Peri-Procedure Anticoagulants, V8 (approved 07/15/2025). Last updated: 07 Oct 2025.