Perez-Roman Roberto J, Govindarajan Vaidya, Levi David J, Luther Evan, Levi Allan D
J Neurosurg Spine. 2022 Apr 1;37(3):350-356. doi: 10.3171/2022.2.SPINE226. Print 2022 Sep 1.
With an increasing number of disease-modifying drugs available to manage rheumatoid arthritis (RA), spine surgeons have anecdotally noted decreased rates of cervical spine surgical procedures in this population. Although these medications have been shown to mitigate RA progression and its systemic effects on joint destruction, there are currently no large-scale studies of RA patients that suggest the use of these disease-modifying drugs has truly coincided with a decline in cervical spine surgery.
Patients with RA who underwent cervical spinal fusion from 1998 to 2021 performed by the senior author were retrospectively reviewed. The cohort was stratified into 3 categories based on procedure level: 1) occipitocervical, 2) atlantoaxial, and 3) subaxial. The number of surgical procedures per year in each subgroup was evaluated to determine treatment trends over time. National (Nationwide) Inpatient Sample (NIS) data on both RA and non-RA patients who underwent cervical fusion were analyzed to assess for surgical trends over time and for differences in likelihood of surgical intervention between RA and non-RA patients over the epoch.
From 1998 to 2021, the number of overall cervical fusions performed in RA patients significantly declined (-0.13 procedures/year, p = 0.01) in this cohort, despite an overall significant increase in cervical fusions in non-RA patients over the same period. NIS analysis of cervical fusions across all patients similarly demonstrated a significant increase in cervical fusions over the same epoch (19,278 cases/year, p < 0.0001). When normalized for changes in population size, the incidence of new surgical procedures was lower in patients with RA regardless of surgical technique. Anterior cervical fusion was the most common approach used over the epoch in both RA and non-RA patients; correspondingly, RA patients were significantly less likely to undergo anterior cervical fusion (OR 0.655, 95% CI -0.4504 to -0.3972, p < 0.0001).
At the authors' institution, there was a clear decline in the number of cervical fusions performed to treat the 3 most common forms of cervical spine pathology in RA patients (basilar impression, atlantoaxial instability, and subaxial cervical deformity). Although national trends suggest an increase in total cervical fusions in both RA and non-RA patients, the incidence of new procedures in patients with RA was significantly lower than in patients without RA, which supports the anecdotal results of spine surgeons nationally.
随着越来越多的改善病情药物可用于治疗类风湿性关节炎（RA），脊柱外科医生凭经验注意到该人群颈椎手术率有所下降。尽管这些药物已被证明可减轻RA的进展及其对关节破坏的全身影响，但目前尚无针对RA患者的大规模研究表明使用这些改善病情药物与颈椎手术的真正减少相吻合。
对1998年至2021年由资深作者实施颈椎融合手术的RA患者进行回顾性研究。根据手术节段将队列分为3类：1）枕颈，2）寰枢椎，3）下颈椎。评估每个亚组每年的手术例数，以确定随时间的治疗趋势。分析全国住院患者样本（NIS）中接受颈椎融合手术的RA患者和非RA患者的数据，以评估随时间的手术趋势以及该时期RA患者和非RA患者手术干预可能性的差异。
1998年至2021年，该队列中RA患者的总体颈椎融合例数显著下降（-0.13例/年，p = 0.01），尽管同期非RA患者的颈椎融合例数总体显著增加。对所有患者颈椎融合手术的NIS分析同样显示，在同一时期颈椎融合例数显著增加（19278例/年，p < 0.0001）。按人口规模变化进行标准化后，无论手术技术如何，RA患者新手术的发生率均较低。颈椎前路融合术是该时期RA患者和非RA患者最常用的手术方法；相应地，RA患者接受颈椎前路融合术的可能性显著较低（OR 0.655，95% CI -0.4504至-0.3972，p < 0.0001）。
在作者所在机构，用于治疗RA患者三种最常见颈椎病变形式（基底凹陷、寰枢椎不稳和下颈椎畸形）的颈椎融合例数明显下降。尽管全国趋势表明RA患者和非RA患者的颈椎融合总数均有所增加，但RA患者新手术的发生率显著低于非RA患者，这支持了全国脊柱外科医生的经验性结果。
