Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P110. The impact of chronic steroid and dmard therapy on atlanto-axial fusion rates in patients with rheumatoid arthritis: a multicenter review

Abstract

BACKGROUND CONTEXT Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of the immune system primarily affecting the synovial joints leading to progressive joint destruction with a 1%–2% worldwide prevalence. The cervical spine is commonly affected in patients with RA leading to atlantoaxial subluxation (AAS), basilar invagination (BI), and subaxial subluxation. These patients commonly require stabilization of their AAS requiring either Occipitocervical or C1–C2 arthrodesis. RA has historically been treated with steroid therapy and although this has been falling out of favor with the advent of disease modifying anti-rheumatic drugs (DMARDs); however, some patients are unable to wean from steroids. Although DMARDs have become increasingly popular for treatment of RA there is a growing concern that the cytotoxicity of these agents may compromise wound healing and arthrodesis. Currently there is little information available regarding surgical outcomes in patients on DMARDs. This study aims to identify patients with RA and AAS that underwent surgical intervention. We hypothesize that DMARDS and low dose steroids do not adversely affect patient outcome. PURPOSE To identify the sigficance of impact that chronic steroid and/or DMARD therapy has on RA patients underdoing posterior arthrodesis for atlanto-axial instability. STUDY DESIGN/SETTING Multicenter retrospective review. PATIENT SAMPLE Patients with the diagnosis of RA requiring surgery for atlanto-axial pathology. Patients undergoing occipital–cervical and atlanto-axial arthrodesis were included. OUTCOME MEASURES Primary outcome measure was return to the OR. METHODS This study was a multicentered retrospective review from seven hospitals. All patients with the diagnosis of RA that underwent cervical spine surgery were identified and reviewed. All patients that underwent C1–C2 or occipital–cervical fusion for treatment of AAS dating back to January 2008 were identified and included in the review. Perioperative medications were reviewed for use of steroids, DMARDs, bisphosphonates and hormone therapy. Patients were stratified among 2 groups, those that had their steroids or DMARDs held perioperatively and those that did not. End point measurement was return to the operating room (OR) for wound failure, pseudoarthrosis, infection, or other reasons. RESULTS A total of 40 patients were idenitifed for inclusion in the review. There were two patients in the cohort that required return to the OR, one for pseudoarthrosis and one for wound failure. The patient with pseudoarthrosis maintained their anti-RA medications in the perioperative period while the patient with wound failure had their anti-RA medications held in the perioperative period. There was note however of patients experiencing RA flare-ups when the anti-RA medications were held. CONCLUSIONS Our cohort demonstrated a 5% return to OR rate in RA patients undergoing surgery for atanto-axial instability. There was no demonstrable affect on outcome with respect to holding or continuing anti-RA medications in the peri-operative period in our cohort. The overall affect these medications in this patient population may be benign. However, more studies are warranted to further investigate the impact these medications have in the perioperative period and overall outcome.