What are the risks of undergoing spine surgery while taking disease-modifying antirheumatic drugs (DMARDs)?

Risk of Undergoing Spine Surgery on DMARD Drugs

For patients on nonbiologic DMARDs (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine), continue these medications through spine surgery, as they actually reduce infection risk; however, for biologic DMARDs, withhold them prior to surgery and time the procedure at the end of the dosing cycle due to increased infection risk.

Evidence Quality and Applicability

The available guidelines are based on total hip and knee arthroplasty (THA/TKA), not spine surgery specifically. The ACR/AAHKS guidelines explicitly acknowledge that "infection risks may vary markedly from THA or TKA" when applied to spine procedures 1. Despite this limitation, these remain the highest-quality perioperative DMARD management guidelines available and provide the best framework for decision-making 1.

Nonbiologic DMARDs: Continue Through Surgery

Continue methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine at their current doses perioperatively 1, 2.

• Continuing nonbiologic DMARDs actually reduces infection risk with a relative risk of 0.39 (95% CI 0.17-0.91) compared to stopping them 1
• Disease flares are significantly less frequent when DMARDs are continued (RR 0.06) 1
• This recommendation is based on low-to-moderate quality evidence from orthopedic surgery studies 1

Biologic DMARDs: Withhold Before Surgery

Withhold all biologic agents (TNF inhibitors, rituximab, abatacept, tocilizumab, sarilumab) and schedule surgery at the end of the dosing cycle for that specific medication 1.

• Biologic agents increase serious infection risk with odds/hazards/risk ratios approximately 1.5 (range 0.61-8.87) 1
• The dosing cycle timing is more relevant than serum half-life because infection risk is strongly associated with high-dose therapy 1
• Plan surgery when the drug effect is at its nadir (end of dosing interval) 1

Targeted Synthetic DMARDs (JAK Inhibitors)

Withhold tofacitinib, baricitinib, and upadacitinib for at least 3 days prior to surgery 2.

• JAK inhibitors carry warnings for serious infections, major adverse cardiac events, venous thromboembolism, and malignancy 3
• The 3-day withholding period balances infection risk against disease flare risk 2

Spine-Specific Considerations and Risks

The spine surgery literature reveals higher complication rates than suggested by joint arthroplasty data:

• Among patients continuing DMARDs perioperatively in spine surgery: 26% had surgical site infections or wound dehiscence, 10.5% had delayed wound healing, and 15% required revision surgery 4
• Fusion rates were only 73.6% in one spine study of patients on DMARDs 4
• Patients with rheumatoid arthritis undergoing spine surgery have 2.29 times higher infection risk, 1.61 times higher overall complications, 3.93 times higher implant-related complications, and 2.45 times higher reoperation risk compared to non-RA patients 5
• Hospital length of stay is 4.6 days longer for RA patients undergoing spine surgery 5

Medication Potency Stratification

Risk increases with medication potency in spine surgery patients 6:

• No biologic or DMARD: OR 2.33 for adverse events
• DMARDs only: OR 3.86 for adverse events
• Biologic ± DMARDs: OR 5.69 for adverse events

Glucocorticoids

Continue the current daily glucocorticoid dose rather than administering supraphysiologic "stress doses" 1, 2.

• This applies to patients receiving ≤16-20 mg/day prednisone equivalent 1
• No hemodynamic benefit was demonstrated with stress dosing 1
• Doses >15 mg/day increase infection risk following joint arthroplasty 1

Restarting Medications Postoperatively

Resume withheld antirheumatic medications once the wound shows healing, sutures/staples are removed, there is no significant swelling/erythema/drainage, and no ongoing infection—typically around 14 days 2.

• Use visiting nurse services, photographs, or telemedicine to assess wounds before restarting biologics 1
• Ensure both surgical site and non-surgical site infections are absent 1

Critical Caveats for Spine Surgery

The spine surgery context differs substantially from joint arthroplasty:

• Spine procedures may have inherently different infection risks than THA/TKA 1
• Bone fusion is a critical outcome in spine surgery that may be compromised by DMARDs 4
• The 73.6% fusion rate observed with continued DMARDs is lower than typical spine fusion rates 4
• Consider withholding even nonbiologic DMARDs in complex spine fusions where bone healing is paramount, despite guideline recommendations to continue them 4

Additional risk factors requiring attention:

• Alcohol abuse, diabetes mellitus, obesity, and tobacco use independently increase infection risk 7
• Patients on increasingly immunosuppressive regimens require heightened perioperative monitoring 6

Shared Decision-Making

All recommendations are conditional due to low-quality evidence 1. This mandates shared decision-making that weighs:

• Patient preference regarding infection versus disease flare risk
• Complexity of the planned spine procedure
• Importance of bone fusion for the specific surgery
• Individual patient infection risk factors 1

Co-management with rheumatology is essential for all RA patients undergoing spine surgery 5.