Anticoagulants (heparin, LMWH, and warfarin) can cause bleeding around the spinal cord (neuroaxial) in a few patients who receive spinal or epidural anesthesia and analgesia. With the introduction of LMWH as a prophylactic agent after hip and knee replacement, neuroaxial bleeding has been seen in a small number of patients. In 1998, the American Society of Regional Anesthesia offered recommendations about minimizing bleeding in joint replacement patients who are being considered for LMWH prophylaxis. Patients who receive pre-op LMWH should not undergo spinal or epidural anesthesia. When indwelling catheters are used for neuroaxial anesthesia or analgesia, LMWH should not be begun until at least 2 hrs after the indwelling catheter has been removed. If indwelling catheters are used for longer than 24 hrs post-op, an alternate method of prophylaxis should be considered. The best alternate method is calf-high pneumatic compression of the lower extremities

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