Clinical Study|Articles in Press

Rheumatoid arthritis patients are at increased risk for adverse events following lumbar discectomy



      Lumbar discectomy is a common procedure for which patients with rheumatoid arthritis (RA) may be considered. RA is an autoinflammatory disease that may predispose patients to postoperative adverse outcomes.


      To assess the relative odds of adverse events after lumbar discectomy for those with versus without RA in a large, national, administrative dataset.


      Retrospective cohort study using the 2010 to 2020 MSpine PearlDiver dataset.


      After exclusion of patients under 18 years old, those with any trauma, neoplasm, or infection diagnosis within the month before lumbar discectomy, and any patients who had any alternative lumbar spinal surgery performed on the same day as lumbar discectomy, we identified 36,479 lumbar discectomy patients. 2,937 (8.1%) of these patients had a prior diagnosis of RA. After matching 4:1 by patient age, sex, and Elixhauser Comorbidity Index (ECI, a longitudinal measure of patient comorbidity burden generated via ICD-9 and 10 diagnosis codes), 8,485 lumbar discectomy patients without RA and 2,149 with RA were included.


      Incidence of severe and minor adverse events in the 90-days following lumbar discectomy, predictive factors for adverse events within 90-days of lumbar discectomy, risk of adverse events within 90-days of lumbar discectomy stratified by patient medication regimen, 5-year survival to reoperation following lumbar discectomy.


      Patients undergoing lumbar discectomy were identified from the PearlDiver MSpine dataset. The subset of those with versus without RA were identified and matched 1:4 based on patient age, sex, and ECI scores. The incidence of 90-day adverse events in the two groups was determined and compared by univariate and multivariate analyses. Subgroup analysis was performed based on RA medications being taken.


      Matched lumbar discectomy patients with RA (n=2,149) and without RA (n=8,485) were identified. Controlling for patient age, sex, and ECI, those with RA were at significantly higher odds of any (odds ratio [OR] 3.30), severe (OR 2.78), and minor (OR 3.30) adverse events (p<.0001 for all).
      Stratifying by medications being taken (and relative to those without RA), there was increasing odds of all adverse events (AAE) based on potency of medications (no biologic or disease modifying antirheumatic drugs [DMARDs] OR 2.33, DMARDs only OR 3.86, biologic±DMARDs OR 5.69 (p<.0001 for all). Despite this, no statistically significant difference in 5-year survival from subsequent lumbar surgery was found between those with versus without RA (p=.1000).


      Lumbar discectomy patients with RA were found to be at significantly higher risk for 90-day adverse events following lumbar discectomy, and this was incrementally greater for those on increasingly suppressive medications. Lumbar discectomy patients with RA bear specific consideration and perioperative monitoring when considered for lumbar discectomy.


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      1. Butler AJ DIC. Discectomy. StatPearls [serial on the Internet]. 2022.

        • Rajamani PA
        • Goparaju P
        • Kulkarni AG
        • Bhojraj SY
        • Rajasekaran S
        • Chhabra HS
        • et al.
        A 2-Year outcomes and complications of various techniques of lumbar discectomy: a multicentric retrospective study.
        World Neurosurg. 2021; 156: e319-ee28
        • Weinstein JN
        • Tosteson TD
        • Lurie JD
        • Tosteson AN
        • Hanscom B
        • Skinner JS
        • et al.
        Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial.
        JAMA. 2006; 296: 2441-2450
        • Lovy AJ
        • Keswani A
        • Beck C
        • Dowdell JE
        • Parsons BO.
        Risk factors for and timing of adverse events after total shoulder arthroplasty.
        J Shoulder Elbow Surg. 2017; 26: 1003-1010
        • Fjeld OR
        • Grøvle L
        • Helgeland J
        • Smastuen MC
        • Solberg TK
        • Zwart JA
        • et al.
        Complications, reoperations, readmissions, and length of hospital stay in 34 639 surgical cases of lumbar disc herniation.
        Bone Joint J. 2019; 101-b: 470-477
        • Rosas S
        • Knio ZO
        • Gowd AK
        • Luo TD
        • Emory CL
        • O'Gara TJ
        Cost and complications of single-level lumbar decompression in those over and under 75: a matched comparison.
        Spine. 2021; 46: 29-34
        • Webb ML
        • Nelson SJ
        • Save AV
        • Cui JJ
        • Lukasiewicz AM
        • Samuel AM
        • et al.
        Of 20,376 lumbar discectomies, 2.6% of patients readmitted within 30 days: surgical site infection, pain, and thromboembolic events are the most common reasons for readmission.
        Spine (Phila Pa 1976). 2017; 42: 1267-1273
        • Browne JA
        • Cook C
        • Pietrobon R
        • Bethel MA
        • Richardson WJ.
        Diabetes and early postoperative outcomes following lumbar fusion.
        Spine (Phila Pa 1976). 2007; 32: 2214-2219
        • Chen S
        • Anderson MV
        • Cheng WK
        • Wongworawat MD.
        Diabetes associated with increased surgical site infections in spinal arthrodesis.
        Clin Orthop Relat Res. 2009; 467: 1670-1673
        • Kaye ID
        • Wagner SC
        • Butler JS
        • Sebastian A
        • Morrissey PB
        • Kepler C.
        Risk factors for adverse cardiac events after lumbar spine fusion.
        Int J Spine Surg. 2018; 12: 638-643
        • Lee NJ
        • Kothari P
        • Phan K
        • Shin JI
        • Cutler HS
        • Lakomkin N
        • et al.
        Incidence and risk factors for 30-day unplanned readmissions after elective posterior lumbar fusion.
        Spine (Phila Pa 1976). 2018; 43: 41-48
        • Burn E
        • Edwards CJ
        • Murray DW
        • Silman A
        • Cooper C
        • Arden NK
        • et al.
        The impact of rheumatoid arthritis on the risk of adverse events following joint replacement: a real-world cohort study.
        Clin Epidemiol. 2018; 10: 697-704
        • Goodman SM.
        Rheumatoid arthritis: preoperative evaluation for total hip and total knee replacement surgery.
        J Clin Rheumatol. 2013; 19: 187-192
        • Wasserman A.
        Rheumatoid arthritis: common questions about diagnosis and management.
        Am Fam Physician. 2018; 97: 455-462
        • Gillick JL
        • Wainwright J
        • Das K.
        Rheumatoid arthritis and the cervical spine: a review on the role of surgery.
        Int J Rheumatol. 2015; 2015252456
        • Radu AF
        • Bungau SG
        Management of rheumatoid arthritis: an overview.
        Cells. 2021; 10: 2857
        • Guo Q
        • Wang Y
        • Xu D
        • Nossent J
        • Pavlos NJ
        • Xu J.
        Rheumatoid arthritis: pathological mechanisms and modern pharmacologic therapies.
        Bone Res. 2018; 6: 15
        • Kato S
        • Nakamoto H
        • Matsubayashi Y
        • Taniguchi Y
        • Doi T
        • Yoshida Y
        • et al.
        Postoperative outcomes after degenerative lumbar spine surgery in rheumatoid arthritis patients -a propensity score-matched analysis.
        BMC Musculoskelet Disord. 2022; 23: 380
        • Seki S
        • Hirano N
        • Matsushita I
        • Kawaguchi Y
        • Nakano M
        • Yasuda T
        • et al.
        Lumbar spine surgery in patients with rheumatoid arthritis (RA): what affects the outcomes?.
        Spine J. 2018; 18: 99-106
        • Kammien AJ
        • Zhu JR
        • Gouzoulis MJ
        • Moore HG
        • Galivanche AR
        • Medvecky MJ
        • et al.
        Emergency department visits within 90 days of anterior cruciate ligament reconstruction.
        Orthop J Sports Med. 2022; 10 (23259671221083586)
        • Kammien AJ
        • Galivanche AR
        • Gouzoulis MJ
        • Moore HG
        • Mercier MR
        • Grauer JN.
        Emergency department visits within 90 days of single-level anterior cervical discectomy and fusion.
        N Am Spine Soc J. 2022; 10100122
        • Joo PY
        • Jayaram RH
        • McLaughlin WM
        • Ameri B
        • Kammien AJ
        • Arnold PM
        • et al.
        Four-level anterior versus posterior cervical fusions: Perioperative outcomes and five-year reoperation rates: Outcomes after four-level anterior versus posterior cervical procedures.
        N Am Spine Soc J. 2022; 10: 100115
        • Gouzoulis MJ
        • Kammien AJ
        • Zhu JR
        • Gillinov SM
        • Moore HG
        • Grauer JN.
        Single-level posterior lumbar fusions in patients with Ehlers Danlos Syndrome not found to be associated with increased postoperative adverse events or five-year reoperations.
        N Am Spine Soc J. 2022; 11100136
        • Dougados M
        • Soubrier M
        • Antunez A
        • Balint P
        • Balsa A
        Buch MH,et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA).
        Ann Rheum Dis. 2014; 73: 62-68
        • Bell J
        • Sequeira S
        • Kamalapathy P
        • Puvanesarajah V
        • Hassanzadeh H
        Rheumatoid arthritis increases risk of medical complications following posterior lumbar fusion.
        World Neurosurg. 2021; 149: e729-ee36
        • Tropea J
        • Brand CA
        • Bohensky M
        • Van Doornum S.
        Myocardial infarction and mortality following joint surgery in patients with rheumatoid arthritis: a retrospective cohort study.
        Arthritis Res Ther. 2016; 18: 69
        • Mameli A
        • Barcellona D
        • Marongiu F.
        Rheumatoid arthritis and thrombosis.
        Clin Exp Rheumatol. 2009; 27: 846-855
        • Singh S
        • Fumery M
        • Singh AG
        • Singh N
        • Prokop LJ
        • Dulai PS
        • et al.
        Comparative risk of cardiovascular events with biologic and synthetic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis: a systematic review and meta-analysis.
        Arthritis Care Res (Hoboken). 2020; 72: 561-576
        • Kong L
        • Cao J
        • Zhang Y
        • Ding W
        • Shen Y.
        Risk factors for periprosthetic joint infection following primary total hip or knee arthroplasty: a meta-analysis.
        Int Wound J. 2017; 14: 529-536
        • White RH
        • McCurdy SA
        • Marder RA.
        Early morbidity after total hip replacement: rheumatoid arthritis versus osteoarthritis.
        J Gen Intern Med. 1990; 5: 304-309
        • Giles JT
        • Bartlett SJ
        • Gelber AC
        • Nanda S
        • Fontaine K
        • Ruffing V
        • et al.
        Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in rheumatoid arthritis.
        Arthritis Rheum. 2006; 55: 333-337
        • Conforti A
        • Di Cola I
        • Pavlych V
        • Ruscitti P
        • Berardicurti O
        • Ursini F
        • et al.
        Beyond the joints, the extra-articular manifestations in rheumatoid arthritis.
        Autoimmun Rev. 2021; 20: 102735
        • Figus FA
        • Piga M
        • Azzolin I
        • McConnell R
        • Iagnocco A.
        Rheumatoid arthritis: extra-articular manifestations and comorbidities.
        Autoimmun Rev. 2021; 20102776
        • Chang CC
        • Chiou CS
        • Lin HL
        • Wang LH
        • Chang YS
        • Lin HC.
        Increased risk of acute pancreatitis in patients with rheumatoid arthritis: a population-based cohort study.
        PLoS One. 2015; 10e0135187
        • Sheĭkh Zh V
        • Krutskevich AO
        • Drebushevskiĭ NS
        • Shvaĭko SN
        • Dunaev AP
        • Alekseev VG.
        [Pulmonary cytotoxicity induced by bleomycin and methotrexate].
        Vestn Rentgenol Radiol. 2015; : 46-51
        • Bindu S
        • Mazumder S
        • Bandyopadhyay U.
        Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: a current perspective.
        Biochem Pharmacol. 2020; 180114147
        • Masson C.
        Rheumatoid anemia.
        Joint Bone Spine. 2011; 78: 131-137
        • Geervliet PC
        • Somford MP
        • Winia P
        • van den Bekerom MP.
        Long-term results of shoulder hemiarthroplasty in patients with rheumatoid arthritis.
        Orthopedics. 2015; 38: e38-e42