Methotrexate After Spine Surgery
Yes, methotrexate can generally be continued after spine surgery, as evidence from orthopedic procedures demonstrates no increased risk of postoperative complications when methotrexate is maintained perioperatively. 1
Evidence Supporting Continuation
The strongest guideline evidence comes from the 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons, which conditionally recommends continuing methotrexate at the current dose for patients undergoing elective orthopedic surgery based on moderate-quality evidence showing a decreased infection risk (RR 0.39,95% CI 0.17-0.91) when methotrexate is continued. 1
The British Association of Dermatologists guidelines similarly state that methotrexate can be continued during the perioperative period, as prospective randomized studies in 64 and 388 patients showed no increased risk of infection or postoperative complications following orthopedic surgery. 1
Key Supporting Research
A large prospective randomized study of 388 rheumatoid arthritis patients found that continuing methotrexate resulted in lower complication rates (2%) compared to stopping methotrexate (15%) or no methotrexate use (10.5%), with statistical significance (p<0.003). 2 Additionally, patients who continued methotrexate had zero disease flares at 6 weeks postoperatively, compared to 8% flares in those who stopped the medication. 2
Important Caveats for Spine Surgery
While the evidence is derived from hip and knee arthroplasty rather than spine surgery specifically, the principles apply. 1 However, for major spine surgery in patients with significant comorbidities (diabetes, immunocompromise), the decision must be made case-by-case, weighing infection risk against disease flare risk. 1
When to Consider Temporary Discontinuation
Methotrexate should be temporarily stopped if: 3
- Postoperative infection develops requiring antibiotics—hold until infection resolves and antibiotic course completes 1
- Abnormal liver function with transaminases >2x upper limit of normal 3
- Bone marrow suppression with WBC <3.5×10⁹/L or neutrophils <2×10⁹/L 3
- Significant renal impairment with creatinine clearance <20 mL/min (contraindicated) or 20-50 mL/min (reduce dose by half) 3
Practical Management Algorithm
Preoperatively:
- Continue methotrexate at usual dose through surgery 1, 4
- Verify adequate renal function (eGFR) 3
- Maintain folic acid supplementation (≥5 mg weekly) 4
Postoperatively:
- Resume methotrexate at usual schedule if no complications 3
- Monitor CBC, liver function, and renal function if recently dosed 3
- Watch for toxicity signs: mucositis, fever, diarrhea, ulceration 3
If complications arise:
- Hold methotrexate for active infection requiring antibiotics 1
- Resume once infection cleared and wound healing progresses (typically ~14 days) 4
Common Pitfall
The outdated practice of routinely stopping methotrexate perioperatively actually increases both infection risk and disease flare risk compared to continuation. 2 One older study from 1996 suggested increased infections with continuation 5, but this has been contradicted by larger, higher-quality subsequent trials showing the opposite effect. 2