DECEMBER 2020 | The Surgical Technologist | 551 Review Article Surgical Management of the Lumbar Spine in Rheumatoid Arthritis Peter Joo, BA 1 , Laurence Ge, BS 1 , and Addisu Mesfin, MD 1 Abstract Study Design: Narrative review. Objective: To provide an overview on the diagnosis and surgical management of rheumatoid involvement of the lumbar spine. Rheumatoid arthritis (RA) is a chronic inflammatory disease of synovial joints, most commonly appendicular followed by axial. Although cervical spine involvement of RA is well documented, data on lumbar spine involvement and surgical management remains limited. Methods: Using PubMed, studies published prior to November 2018 with the keywords “RA, etiology”; “RA, spine manage- ment”; “RA, surgical management”; “RA, treatment”; “RA, DMARDs”; “RA, lumbar spine”; “RA, spine surgical outcomes”; “RA, imaging” were evaluated. Results: The narrative review addresses the epidemiology, manifestations, imaging, surgical complications, and operative and nonoperative management of RA involvement of the lumbar spine. Conclusions: Rheumatoid involvement of the lumbar spine can present with lower back pain, neurogenic claudication, radiculopathy, spinal deformity, and instability. Patients with RA have significantly higher rates of vertebral fractures and complications following surgical intervention. However, in the setting of instability and spinal deformity, thoughtful surgical planning in conjunction with optimal medical management is recommended. Keywords rheumatoid arthritis, lumbar vertebrae, surgery, laminotomy, laminectomy, lumbar interbody fusion, complications, spine deformity Introduction Surgical Management of the Lumbar Spine in Rheumatoid Arthritis Epidemiology. Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease primarily involving the synovial joints with a substantial global burden of disease. 1 In the United States, it was estimated that nearly 1.36 million individuals were living with RA in 2014, with a prevalence of 0.5 % to 1 % and a 3 to 1 ratio of females to males affected. 2,3 The axial skeleton is the third most common location of RA manifesta- tion after hands and feet, with cervical spine involvement affecting 43 % to 88 % of patients with RA. 4 Although the invol- vement of this disease in the cervical spine has been well reported and studied, there are few reports of disease manifes- tation and best treatment practices for the lumbar spine. Lum- bar lesions may have been overlooked in patients with RA, since prior to the routine use of biologic medications for RA, many patients sustained cervical spine instability and associ- ated neurological deficits. 5-9 One study found that 42 % of patients with RA had both lumbar and cervical lesions. 4 Anatomy and Pathophysiology. RA is a complicated disease, with a wide range of opinions on the disease, its etiology, and its treatment. 10,11 The disease primarily affects the synovial com- partment, with the clinical manifestation of joint swelling reflecting immune activation and synovial membrane inflam- mation. 11 The triggers for the inflammation are thought to be 1 University of Rochester School of Medicine and Dentistry, Rochester, NY, USA Corresponding Author: Addisu Mesfin, Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA. Email:
[email protected] Global Spine Journal 2020, Vol. 10(6) 767-774 ª The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/2192568219886267 journals.sagepub.com/home/gsj Creative Commons Non Commercial No Derivs CC BY-NC-ND: This article is distributed under the terms of the Creative Commons Attribution-Non Commercial-NoDerivs 4.0 License (https://creativecommons.org/licenses/by-nc-nd/4.0/) which permits non-commercial use, reproduction and distribution of the work as published without adaptation or alteration, without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).