What are the recommendations for managing rheumatoid arthritis (RA) in patients undergoing spinal surgery?

Managing Rheumatoid Arthritis in Patients Undergoing Spinal Surgery

For RA patients undergoing elective spinal surgery, continue methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine through the perioperative period, but withhold all biologic agents prior to surgery, timing the procedure at the end of the dosing cycle for the specific biologic medication. 1

Perioperative Medication Management

Continue Non-Biologic DMARDs

• Continue methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine at current doses through the perioperative period 1
• Evidence from the American College of Rheumatology demonstrates that continuing these DMARDs actually reduces infection risk (relative risk 0.39,95% CI 0.17-0.91) compared to withholding them 1
• Continuing DMARDs also significantly reduces the risk of disease flares postoperatively (RR 0.06,95% CI 0.0-1.10) 1

Withhold Biologic Agents

• All biologic agents (TNF inhibitors, IL-6 inhibitors, etc.) must be withheld prior to surgery 1
• Schedule surgery at the end of the dosing cycle for the specific biologic medication to minimize immunosuppression at the time of surgery 1
• Restart biologic agents only after wound healing is confirmed (minimum 14 days) and absence of both surgical site and non-surgical site infection is established 1

Glucocorticoid Management

• Continue the patient's current glucocorticoid dose rather than using "stress-dose" protocols 1
• Do not escalate glucocorticoid dosing perioperatively, as this increases complication risk without demonstrated benefit 1
• Note that high-dose prednisolone use (>7.5 mg/day) is associated with increased severe complications in cervical spine surgery (OR 1.247, p=0.028) 2

Risk Stratification and Surgical Considerations

Elevated Complication Risks in RA Patients

RA patients undergoing spinal surgery face substantially higher risks compared to non-RA patients:

• Infection risk is 2.29 times higher (p=0.036) 3
• Overall complications are 1.61 times higher (p<0.0001) 3
• Implant-related complications are 3.93 times higher (p=0.009) 3
• Reoperation risk is 2.45 times higher (p<0.0001) 3
• Hospital length of stay is 4.6 days longer (p<0.0001) 3

Specific Risk Factors for Complications

The following factors independently predict perioperative complications in RA patients undergoing cervical spine surgery:

• Lower height (OR 0.915, p=0.005) 2
• Higher ASA-PS classification (OR 2.622, p=0.045) 2
• Long fusion procedures (occipito-cervical/thoracic fusion; OR 7.289, p=0.008) 2
• Vertical subluxation (OR 2.914, p=0.015) 2
• Subaxial subluxation (OR 2.507, p=0.036) 2

Procedures Requiring Extra Caution

• Occipito-cervical fusion carries 17.93 times higher risk of severe complications (p=0.034) 2
• Long fusion procedures carry 108.1 times higher risk of severe complications (p<0.001) 2
• These procedures should be performed only at centers with extensive experience in managing RA patients undergoing spinal surgery 3

Critical Contraindications

Avoid Spinal Manipulation

• Strongly avoid spinal manipulation with high-velocity thrusts in RA patients with spinal fusion or advanced spinal osteoporosis 1
• Case reports document spine fractures, spinal cord injury, and paraplegia following chiropractic manipulation in these patients 1
• This represents a catastrophic risk with no demonstrated benefit 1

Multidisciplinary Coordination

Mandatory Rheumatology Co-Management

• All RA patients undergoing spinal surgery must be co-managed perioperatively by a rheumatologist 3
• This ensures appropriate medication timing, monitoring for disease flares, and early detection of complications 3

Wound Monitoring Protocol

• Implement systematic wound assessment at 14 days minimum before restarting biologics 1
• Use visiting nurse services, telemedicine, or smartphone photography for wound evaluation if in-person visits are not feasible 1
• Screen for both surgical site and systemic infections before medication resumption 1

Common Pitfalls to Avoid

1. Do not withhold methotrexate or other non-biologic DMARDs - this increases both infection and flare risk 1
2. Do not use glucocorticoid "stress dosing" - continue baseline dose only 1
3. Do not restart biologics before confirming wound healing - wait minimum 14 days and verify absence of infection 1
4. Do not underestimate infection risk - RA patients have nearly double the infection rate after spinal surgery 3, 4
5. Do not proceed with complex fusion procedures without experienced surgical teams - complication rates are dramatically higher in RA patients 2