Perioperative outcomes associated with thoracolumbar 3-column osteotomies for adult spinal deformity patients with rheumatoid arthritis

Abstract

Spinal deformity causing spinal imbalance is directly correlated to pain and disability. Prior studies suggest adult spinal deformity (ASD) patients with rheumatoid arthritis (RA) have more complex deformities and are at higher risk for complications. In this study the authors compared outcomes of ASD patients with RA following thoracolumbar 3-column osteotomies to outcomes of a matched control cohort. All patients with RA who underwent 3-column osteotomy for thoracolumbar deformity correction performed by the senior author from 2006 to 2016 were identified retrospectively. A cohort of patients without RA who underwent 3-column osteotomies for deformity correction was matched based on multiple clinical factors. Data regarding demographics and surgical approach, along with endpoints including perioperative outcomes, reoperations, and incidence of proximal junctional kyphosis (PJK) were reviewed. Univariate analyses were used to compare patients with RA to matched controls. Eighteen ASD patients with RA were identified, and a matched cohort of 217 patients was generated. With regard to patients with RA, 11.1% were male and the mean age was 68.1 years. Vertebral column resection (VCR) was performed in 22.2% and pedicle subtraction osteotomy (PSO) in 77.8% of patients. Mean case length was 324.4 minutes and estimated blood loss (EBL) was 2053.6 ml. Complications were observed in 38.9% of patients with RA and 29.0% of patients without RA (p = 0.380), with a trend toward increased medical complications (38.9% vs 21.2%, p = 0.084). Patients with RA had a significantly higher incidence of deep vein thrombosis (DVT)/pulmonary embolism (PE) (11.1% vs 1.8%, p = 0.017) and wound infections (16.7% vs 5.1%, p = 0.046). PJK occurred in 16.7% of patients with RA, and 33.3% of RA patients underwent reoperation. Incidence rates of PJK and reoperation in matched controls were 12.9% and 25.3%, respectively (p = 0.373, p = 0.458). At follow-up, mean sagittal vertical axis (SVA) was 6.1 cm in patients with RA and 4.5 cm in matched controls (p = 0.206). Findings from this study suggest that RA patients experience a higher incidence of medical complications, specifically DVT/PE. Preoperative lower-extremity ultrasounds, inferior vena cava (IVC) filter placement, and/or early initiation of DVT prophylaxis in RA patients may be indicated. Perioperative complications, morbidity, and long-term outcomes are otherwise similar to non-RA patients. AKI = acute kidney injury; ASA = American Society of Anesthesiologists; ASD = adult spinal deformity; CSVL = central sacral vertical line; DMARDs = disease-modifying antirheumatic drugs; DVT = deep vein thrombosis; EBL = estimated blood loss; HRQOL = health-related quality of life; IVC = inferior vena cava; LOS = length of stay; LL = lumbar lordosis; ODI = Oswestry Disability Index; PE = pulmonary embolism; PI = pelvic incidence; PI-LL = PI − LL mismatch; PJK = proximal junctional kyphosis; PT = pelvic tilt; PSO = pedicle subtraction osteotomy; RA = rheumatoid arthritis; SVA = sagittal vertical axis; TK = thoracic kyphosis; UIV = upper instrumented vertebra; UTI = urinary tract infection; VAS = visual analog scale; VCR = vertebral column resection; VTE = venous thromboembolism.