Impact of Chronic DMARD Therapy in Patients With Rheumatoid Arthritis Undergoing Surgery of the Craniovertebral Junction

STUDY DESIGN: A multi-centered retrospective review from five institutions. OBJECTIVE: The aim of this study was to determine whether continuing or withholding disease-modifying antirheumatoid drugs (DMARDs) in the perioperative period affect outcomes in rheumatoid arthritis (RA) patients undergoing arthrodesis at the craniovertebral junction SUMMARY OF BACKGROUND DATA.: RA is a chronic systemic inflammatory disease that affects the cervical spine and is treated with DMARDs. Some advocate withholding DMARDs in the perioperative period due to concern for the cytotoxic effects of these medications. However, the impact of DMARDs in the perioperative period is not well understood. METHODS: A multicenter retrospective study from five affiliated institutions was performed. Adult patients with RA on chronic DMARDs undergoing posterior arthrodesis of the craniovertebral junction (occipital-cervical or atlanto-axial arthrodesis) were identified. Patients were stratified based on whether DMARD therapy was continued (C group) or discontinued (DC group) in the perioperative period. The primary outcome was the need for reoperation and reason for reoperation. RESULTS: Thirty-nine patients met inclusion criteria, 19 in C group and 20 in DC group. Average follow-up time was 42 months. Four patients (three in DC group and one in C group) required reoperation. Two patients from the DC group required readmission secondary to RA flare-up. CONCLUSION: Our cohort of RA patients who underwent occipital-cervical and C1/C2 posterior arthrodesis showed no significant differences in surgical complications when DMARD therapy was continued or discontinued in the perioperative period. The decision to continue or discontinue DMARD therapy in the perioperative period is at the discretion of the treating physician, but we encourage physicians to counsel patients regarding this theoretical risk and their tolerance of the medications as well as the risk of RA flare-up. Factors such as overall health, disease burden, nutrition, bone quality, smoking status, and other comorbid conditions are likely to have a larger influence on perioperative complications. LEVEL OF EVIDENCE: 3.