The Pitfalls in Surgical Management of Lumbar Canal Stenosis Associated With Rheumatoid Arthritis

Abstract

There have been few clinical studies in the area of cervical spine that focused on surgery for treating degenerative lumbar disease in patients with rheumatoid arthritis (RA). High rates of wound complications and instrumentation failure have been reported more for RA than for non-RA patients, although clinical outcomes are similar between the two groups. Lumbar canal stenosis in RA is caused not only by degeneration but also by RA-related spondylitis, which includes facet arthritis and inflammation around the vertebral endplate. The pitfalls in surgical management of lumbar canal stenosis in RA patients are highlighted in this study. The study reviewed 12 patients with RA,who were surgically treated for lumbar canal stenosis. Two out of five patients with pulmonary fibrosis died of worsened pulmonary condition, even though there were no perioperative pulmonary complications. Two patients with pedicle screw fixation showed no instrumentation failure, but two patients with spinous process fixation needed re-operation or vertebral fracture. Surgical treatment for lumbar canal stenosis in RA patients needs to be individually adjusted. Preoperative assessments and treatments of pulmonary fibrosis and osteopenia are essential. Surgery for lumbar canal stenosis with RA should be deferred for patients with advanced pulmonary fibrosis because of its potential life-threatening risk. Fusion surgery is indicated only in patients with kyphosis or severe symptoms caused by intervertebral instability. Pedicle screw fixation with hydroxyapatite granules or sublaminar tape is recommended. Closer follow-up after surgery is necessary because of possible delayed wound infection, instrumentation failure, pathological fracture, and respiratory deterioration.

Postoperative outcomes after degenerative lumbar spine surgery in rheumatoid arthritis patients -a propensity score-matched analysis

“…Steroid usage has been part of the classic presentation of RA patients and places significant burdens on surgical outcomes in general. Mitsuyama et al also classically reported the pitfalls in surgical management of lumbar spinal canal stenosis in RA patients lie in the higher risk of infection, instrumentation failure and vertebral fracture showing the post-operative results of their 11 out of 12 patients being on steroid [ 24 ]. Second, as treatment options have markedly increased with the introduction of biologics, steroid usage might be interpreted as a surrogate marker of suboptimal RA control [ 25 ].…”

The Influence of Rheumatoid Arthritis on Higher Reoperation Rates over Time Following Lumbar Spinal Fusion—A Nationwide Cohort Study

“…However, the number of lumbar lesions with RA might increase because the main pathology is degeneration, not synovitis. Thus, life expectancy should increase, resulting in greater age-related degeneration [ 9 ]. The facets and vertebral end-plates are the most important areas affected in the lumbar spine [ 6 , 8 , 10 ].…”

“…The facets and vertebral end-plates are the most important areas affected in the lumbar spine [ 6 , 8 , 10 ]. Consequently, chronic facet arthritis and enthesopathy at the disco-vertebral junction are important findings in the lumbar spine and are present in up to 25% of patients with RA [ 1 , 9 ]. Common pathological findings in the lumbar spine that are encountered in patients with RA are degenerative spondylolisthesis, endplate erosions, disc space narrowing, facet erosion, facet cysts, and vertebral fractures secondary to osteoporosis [ 2 , 11 , 12 ].…”

Surgical Management of the Lumbar Spine in Rheumatoid Arthritis

“…Compared to patients without RA, patients with RA who undergo surgical management have worse subjective scoring outcomes and increased rates of complications. 21 , 48 Common complications include wound infections, pseudoarthrosis, nonunion, implant complications, and adjacent level degeneration. A recent outcomes study of posterolateral lumbar fusion showed that compared to patients without RA, those with RA had almost a 3-fold increase in complications such as radiographic evidence of nonunion ( P = .001), implant failure ( P = .032), symptomatic adjacent segment disease ( P = .001), and infection ( P = .031).…”

“… 19 Furthermore, patients with RA have higher frequencies of vertebral fractures and higher complication rates following surgical interventions compared to patients without RA undergoing similar interventions. 20 , 21 The management of RA affecting the cervical spine is well described, but there are limited studies discussing the management of rheumatoid involvement of the lumbar spine.…”