Successful Spinal Cord Stimulator Trial Placement in a Patient with Presumed Heparin-Induced Thrombocytopenia Treated with Argatroban: A Case Report

Background: Interventional pain procedures such as spinal cord stimulator placement are safely performed when anticoagulation medications are discontinued beforehand in accordance with published recommendations. However, current guidelines for direct thrombin inhibitors are limited to dabigatran, rivaroxaban, apixaban, and edoxaban. One recommendation is to allow a 5-half-life interval between discontinuation of these medications and a high-risk interventional spine procedure to avoid complications such as spinal hematoma. Case Report: We report a case of a 53-year-old woman with multiple comorbidities who was placed on a heparin infusion after presenting with acute radial artery occlusion and right hand ischemia. The patient underwent vascular bypass of the right arm and then developed compartment syndrome postoperatively, which was treated via fasciotomy. The patient subsequently developed heparin-induced thrombocytopenia and began argatroban for anticoagulation. The patient developed severe right upper extremity ischemic pain, but both medical management and treatment via peripheral nerve catheters failed to control her pain. A cervical spinal cord stimulator trial was placed. The patient did not report significant pain relief after 7 days, so the spinal cord stimulator was removed. Five half-lives were used for discontinuation of argatroban before both spinal cord stimulator trial lead placement and removal. Five half-lives were also used for restarting argatroban following these procedures. No complications were seen with the placement or removal of spinal cord stimulator leads. Conclusion: This case report demonstrates that discontinuing argatroban 5 half-lives before cervical spinal cord stimulator trial placement can be done safely in this patient population and reveals the need for larger case studies to provide additional evidence for guideline recommendations. Key words: Anticoagulation guidelines, direct thrombin inhibitors, interventional pain, interventional spine, ischemic pain, neuromodulation