Elsevier

World Neurosurgery

Volume 149, May 2021, Pages e729-e736
World Neurosurgery

Original Article
Rheumatoid Arthritis Increases Risk of Medical Complications Following Posterior Lumbar Fusion

https://doi.org/10.1016/j.wneu.2021.01.110Get rights and content

Background

Rheumatoid arthritis (RA) is a systemic disease with prominent musculoskeletal manifestations that is associated with increased morbidity and mortality in patients undergoing cervical spine surgery; however, few studies have specifically examined postoperative outcomes in patients with RA following lumbar surgery. The aim of this study was to evaluate whether patients with RA who underwent posterior lumbar fusion experienced increased postoperative complications and economic burden compared with patients without RA.

Methods

Patients <85 years old who underwent elective 1- or 2-level instrumented posterior lumbar fusion for degenerative lumbar pathology between 2006 and 2012 were identified in the Medicare insurance claims database. Same-day revisions and cases for spinal infection, malignancy, and trauma were excluded. The resulting cohort was divided into patients with RA before fusion and patients without RA (controls). All outcomes of interest were compared using multivariate regression. Reoperation-free survival at 1- and 2-year follow-up was analyzed used log-rank test. Significance was defined as P < 0.05.

Results

RA patients had significantly higher risk of 90-day readmission (odds ratio [OR] = 1.27, P < 0.001), thromboembolic events (OR = 1.39, P = 0.010), sepsis (OR = 2.32, P < 0.001), pneumonia (OR = 1.57, P = 0.001), and wound complications (OR = 1.41, P < 0.001). Reoperation-free survival was significantly lower in RA patients at 2-year follow-up (90.4% vs. 92.4%, P < 0.001). Following adjusted regression, RA independently contributed to a $1491 increase in additional 90-day costs (P < 0.001).

Conclusions

Preexisting RA may increase risk for short-term postoperative medical complications following posterior lumbar fusion, specifically infectious events. In addition, patients with RA have higher rates of subsequent reoperation following index surgery. Patients with RA be should counseled regarding these risks.

Introduction

Rheumatoid arthritis (RA) is a chronic autoimmune disease of the lining of the synovial joints that clinically manifests as arthralgia and swelling.1 RA affects 0.5% of the insured U.S. population, with an estimated prevalence as high as 2.3% in people >60 years old.2,3 Although RA is typically diagnosed radiographically, serologies positive for rheumatoid factor and anti–cyclic citrullinated peptide can aid in the diagnosis. Spinal manifestations of RA are more prevalent in the cervical spine, causing subluxation of the C1-C2 vertebra, which can lead to long-standing neurological sequelae and deficits.4 While the association of RA and the cervical spine has been well established, the pathology of RA in the lumbar spine is less clear.5

Lumbar degenerative disease (LDD) is one of the most common musculoskeletal disorders, affecting approximately 31 million people in the United States alone.6,7 The current literature suggests that RA is associated with a host of degenerative lumbar spinal pathologies, including facet erosions, disc space narrowing, and spondylolisthesis, among others.8 Given the higher predominance of advanced forms of both RA and LDD in the later decades of life, a select number of patients undergoing lumbar surgery for LDD will have concomitant RA. Surgical management consists of various techniques, of which instrumented posterior lumbar fusion (PLF) remains one of the most common procedures, with 100,000 performed in the United States annually.9,10

Although several studies have evaluated outcomes of patients with RA following lumbar surgery, clinical results have been mixed, with most studies focused on patient-reported outcomes.11, 12, 13, 14, 15 The studies evaluating PLF have indicated that patients with RA may be more susceptible to postoperative complications; however, these studies were limited to small RA samples and did not stratify patients' risk of complications.12,14 The aim of the present study was to evaluate whether patients with RA have increased postoperative complications and economic burden following instrumented PLF compared with patients without RA.

Section snippets

Data Source

A retrospective database review was conducted using the PearlDiver Patient Records Database (www.pearldiverinc.com; PearlDiver Inc., Colorado Springs, Colorado, USA), which contains all Medicare patient records from 2005 to 2014, searchable by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and Current Procedural Terminology billing codes. The PearlDiver database of Medicare records contains 55 million Health Insurance Portability and Accountability

Patient Demographics and Comorbidities

Following applied study criteria and successful matching, 47,207 patients were identified as undergoing PLF. Of those patients, 3021 (6.4%) had a preexisting diagnosis of RA. Female-to-male ratio was approximately 3:1 in the RA group. The highest number of operations occurred in the 70- to 74-year age range. There were no significant differences in demographics, substance use, and preexisting comorbidities (Table 1).

90-Day Postoperative Outcomes and Reoperation-Free Survival

Following regression analysis, patients with RA were found to have increased

Discussion

Despite the known association between LDD and RA, there remains a paucity of literature examining the postoperative outcomes among patients with RA following lumbar surgery. Existing studies have conflicting data concerning clinical outcomes, most likely as a result of small RA sample sizes (n ≤ 40).12, 13, 14 While a majority of these studies indicated that patients with RA are at increased risk of poor postoperative outcomes, the magnitude of these risks compared with the general population

Conclusions

Preexisting RA may increase the risk for short-term postoperative medical complications following PLF, specifically infectious events. In addition, patients with RA have higher rates of subsequent reoperation following index surgery. Patients with RA should be counseled regarding these risks.

CRediT authorship contribution statement

Joshua Bell: Conceptualization, Formal analysis, Data curation, Writing - original draft, Writing - review & editing, Supervision. Sean Sequeira: Writing - original draft, Writing - review & editing. Pramod Kamalapathy: Data Curation, Writing - original draft, Writing - review & editing, Supervision. Varun Puvanesarajah: Writing - original draft, Writing - review & editing. Hamid Hassanzadeh: Conceptualization, Writing - original draft, Writing - review & editing, Supervision.

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  • Cited by (2)

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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