Rheumatoid Arthritis Is Associated With an Increased Risk of Postoperative Infection and Revision Surgery in Elderly Patients Undergoing Anterior Cervical Fusion

Horowitz, Jason A.; Puvanesarajah, Varun; Jain, Amit; Li, Xudong J.; Shimer, Adam L.; Shen, Francis H.; Hassanzadeh, Hamid

doi:10.1097/brs.0000000000002614

Cited by 23 publications

(11 citation statements)

References 30 publications

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“…Comorbidities could be among the risk factors correlated with perioperative complications after spine surgery, since patients with RA have a higher incidence of not only perioperative complications but also comorbidities than patients without RA (18). Regarding cervical spine surgery, signi cantly higher incidences of major medical complications and postoperative infection were observed in patients with RA over 65 years old who underwent anterior cervical fusion (19). In addition, the existence of cervical spine lesions by RA was suggested to be a risk factor for SSI (17).…”

Section: Discussionmentioning

confidence: 99%

“…Although surgical intervention has been the mainstay of treatment to resolve robust occipital pain and neurological de cits, perioperative complications, including infections, are of concern because patients with RA are more likely to have comorbidities and take immunosuppressive agents, such as biologics and JAK inhibitors. In various retrospective cohort series, the incidence of perioperative complications was reported to range from 8 to 30% (17)(18)(19)(20). However, the risk of perioperative complications after cervical spine surgery in patients with RA has not been well established.…”

Section: Introductionmentioning

confidence: 99%

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Risk Factor Analysis of Perioperative Complications in Patients with Rheumatoid Arthritis Undergoing Primary Cervical Spine Surgery

Sakuraba

Omori

Kai

et al. 2021

Preprint

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Background: Rheumatoid arthritis (RA) often causes cervical spine lesions as the disease condition progresses, which induce occipital neuralgia or cervical myelopathy requiring surgical interventions. Meanwhile, patients with RA are susceptible to infection or other complications in the perioperative period because they frequently have comorbidities and use immunosuppressive medications. However, the risk factors or characteristics of patients with RA who experience perioperative complications after cervical spine surgery remain unknown. A risk factor analysis of perioperative complications in patients with RA who underwent primary cervical spine surgery was conducted in the present study.Methods: A total of 139 patients with RA who underwent primary cervical spine surgery from January 2001 to March 2020 were retrospectively investigated. Age and height, weight, serum albumin, serum C-reactive protein, American Society of Anesthesiologists Physical Status (ASA-PS), Charlson comorbidity index, medications used, cervical spine lesion, surgery time, bleeding volume, and procedures were collected from medical records to compare the patients with complications to those without complications after surgery. The risk factors for perioperative complications were assessed by univariate and multivariate logistic regression analysis.Results: Twenty-eight patients (20.1%) had perioperative complications. Perioperative complications were significantly associated with the following factors [data presented as odds ratio (confidence interval)]: lower height [0.928 (0.880-0.980), p=0.007], higher ASA-PS [2.296 (1.007-5.235), p=0.048], longer operation time [1.013 (1.004-1.021), p=0.003], more bleeding volume [1.004 (1.000-1.007), p=0.04], higher rates of vertical subluxation [2.914 (1.229-6.911), p=0.015] and subaxial subluxation (SAS) [2.507 (1.063-5.913), p=0.036], occipito-cervical (OC) fusion [3.438 (1.189-9.934), p=0.023], and occipito-cervical/thoracic (long) fusion [8.021 (2.145-29.99), p=0.002] in univariate analyses. In multivariate analyses, lower height [0.915 (0.860-0.974), p=0.005], higher ASA-PS [2.622 (1.023-6.717), p=0.045] and long fusion [7.289 (1.694-31.36), p=0.008] remained risk factors. High-dose prednisolone use [1.247 (1.024-1.519), p=0.028], SAS [6.413 (1.381-29.79), p=0.018], OC fusion [17.93 (1.242-258.8), p=0.034] and long fusion [108.1 (6.876-1699), p<0.001] were associated with severe complications.Conclusions: ASA-PS and long fusion could be indicators predicting perioperative complications in patients with RA after cervical spine surgery. In addition, cervical spine lesions requiring OC fusion or long fusion and high-dose prednisolone use were suggested to be risk factors for increasing severe complications.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Risk Factor Analysis of Perioperative Complications in Patients with Rheumatoid Arthritis Undergoing Primary Cervical Spine Surgery

Sakuraba

Omori

Kai

et al. 2021

Preprint

View full text Add to dashboard Cite

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“…A similar study using inpatient data from the Nationwide Inpatient Sample found that patients with RA had significantly greater rates of infection, wound dehiscence, and systemic complications after hip and knee replacement compared to patients with OA [7]. Extending the data to other orthopedic surgeries, Horowitz et al found that patients with RA had higher rates of post-operative infection after cervical fusion (2.6% vs. 1.5%) [8]. It remains unclear, however, whether the increased risk of post-operative infection in RA is primarily related to medications, chronic systemic and local joint inflammation, or differences in comorbid conditions.…”

Section: The Risk Of Post-operative Infection In Patients With Ramentioning

confidence: 96%

“…A number of studies have demonstrated that patients with RA are at increased risk of postoperative infection after orthopedic surgery [3][4][5]. Several recent studies have shown similar findings, suggesting this remains true in the modern era [6][7][8][9]. Cordtz et al evaluated approximately 125,000 patients including 3913 patients with RA undergoing hip or knee arthroplasty in linked Danish registries and found a greater risk of prosthetic joint infection in patients with RA [HR 1.46 (1.13-1.88)] [6].…”

Section: The Risk Of Post-operative Infection In Patients With Ramentioning

confidence: 98%

Perioperative management of immunosuppression in patients with rheumatoid arthritis

George

Baker

2019

Current Opinion in Rheumatology

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Purpose of review: Patients with rheumatoid arthritis are at increased risk of infection after surgery. Recent literature has provided more data and updated guidelines to guide the management of immunosuppression in the perioperative period.Recent findings: Studies over the past few years have confirmed that patients with rheumatoid arthritis are at increased risk of infection after surgery. Patients treated with biologics are at greater risk of post-operative infection, but this risk might be explained by the comorbidities and greater disease severity often seen in these patients. Recent observational studies have suggested that interruption of biologic therapies before surgery may not be associated with better outcomes. Glucocorticoids, however, have consistently been found to be risk factors for infection. Recent guidelines from the American College of Rheumatology/American Association of Hip and Knee Surgeons recommend continuing conventional disease modifying drugs and holding biologics for one dosing interval before surgery.Summary: Prolonged interruption of conventional and biologic therapies before surgery does not appear to substantially reduce infection risk. Guidelines now recommend continuing conventional DMARDs and holding biologics for just one dosing interval before surgery. Glucocorticoids are strongly associated with the risk of post-operative infection and should be minimized before surgery.

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“…Although DMARDs and biologics have the potential to slow the progression of rheumatoid arthritis and protect the joints from permanent damage, 3,4 infectious and potentially other side effects have been attributed to use of DMARDs. 5,6 Many patients with RA will require surgical treatment for advanced disease even with a proper use of medication regimen, 3,7,8 though this may be decreasing over time. 9 As the spine is a frequent location for RA involvement, surgical intervention may be indicated in patients with myelopathy, radiculopathy, instability, or deformity.…”

Section: Introductionmentioning

confidence: 99%

Rheumatoid Arthritis in Spine Surgery: A Systematic Review and Meta-Analysis

Streufert

Onyedimma

Yolcu

et al. 2022

Global Spine Journal

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Study Design Systematic Review and Meta-analysis Objective The purpose of this study is to synthesize recommendations for perioperative medical management of RA patients and quantify outcomes after spine surgery when compared to patients without RA. Methods A search of available literature on patients with RA and spine surgery was performed. Studies were included if they provided a direct comparison of outcomes between patients undergoing spine surgery with or without RA diagnosis. Meta-analysis was performed on operative time, estimated blood loss, hospital length of stay, overall complications, implant-related complications, reoperation, infection, pseudarthrosis, and adjacent segment disease. Results Included in the analysis were 9 studies with 703 patients with RA undergoing spine surgery and 2569 patients without RA. In RA patients compared to non-RA patients undergoing spine surgery, the relative risk of infection was 2.29 times higher (P = .036), overall complications 1.61 times higher (P < .0001), implant-related complications 3.93 times higher (P = .009), and risk of reoperation 2.45 times higher (P < .0001). Hospital length of stay was 4.6 days longer in RA patients (P < .0001). Conclusions Treatment of spinal pathology in patients with RA carries an increased risk of infection and implant-related complications. Spine-specific guidelines for perioperative management of antirheumatic medication deserve further exploration. All RA patients should be perioperatively co-managed by a rheumatologist. This review helps identify risk profiles in RA specific to spine surgery and may guide future studies seeking to medically optimize RA patients perioperatively.

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Rheumatoid Arthritis Is Associated With an Increased Risk of Postoperative Infection and Revision Surgery in Elderly Patients Undergoing Anterior Cervical Fusion

Abstract: 3.

Cited by 23 publications

References 30 publications

Risk Factor Analysis of Perioperative Complications in Patients with Rheumatoid Arthritis Undergoing Primary Cervical Spine Surgery

Risk Factor Analysis of Perioperative Complications in Patients with Rheumatoid Arthritis Undergoing Primary Cervical Spine Surgery

Perioperative management of immunosuppression in patients with rheumatoid arthritis

Rheumatoid Arthritis in Spine Surgery: A Systematic Review and Meta-Analysis

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