Patients with systemic lupus erythematosus face significantly higher rates of postoperative complications, increased healthcare utilization, and elevated two-year revision rates following single-level cervical or lumbar fusion surgery, according to data from a retrospective cohort study using PearlDiver that identified patients older than 18 years who underwent single-level anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), or lumbar fusion between 2010 and 2022.
Surgical Risks and Complications After Spinal Fusion in Lupus Patients
Systemic lupus erythematosus is a chronic autoimmune disorder marked by autoantibody production, resulting in aberrant inflammation that impacts multiple organ systems. Systemic lupus erythematosus (lupus) is a chronic (long-lasting) autoimmune disease that can affect many parts of the body. Lupus occurs when the immune system, which normally helps protect the body from infection and disease, attacks its own tissues, causing inflammation and, in some cases, permanent tissue damage that can be widespread—affecting the skin, joints, heart, lung, kidneys, circulating blood cells, and brain. While surgery involving instrumentation like cervical or lumbar fusion presents complex clinical challenges, recent data highlights distinct postoperative risks for this patient population.
Patients were assessed for age, sex, and Elixhauser Comorbidity Index and were matched in a 1:4 ratio based on SLE status, with medical and surgical complications, postoperative healthcare utilization, two-year surgical outcomes, and mortality rates evaluated. Patients with SLE who undergo single-level anterior cervical discectomy and fusion, posterior cervical fusion, or lumbar fusion experience significantly higher rates of 90-day medical and surgical complications and healthcare utilization than their non-SLE counterparts. Furthermore, patients with SLE exhibit higher two-year revision rates following lumbar fusion procedures. The data indicates that systemic lupus erythematosus serves as an important marker of perioperative risk, driving up overall healthcare utilization after surgery.
Immunomodulatory Therapy and Subgroup Outcomes in Lumbar Fusion
Beyond the underlying autoimmune condition itself, medication management plays a critical role in surgical recovery. Immunosuppressive agents impede wound healing and increase the risk of postoperative infection. Corticosteroids are known to impact bone density, with one study finding a dose-dependent relationship between glucocorticoid use and spinal bone loss in patients with SLE.
A subgroup analysis was performed in patients with SLE with and without immunomodulatory therapy (IMT) within 90 days of lumbar fusion. In the lumbar fusion subgroup analysis, patients with SLE on IMT had higher rates of:
- Cerebrovascular accidents with an odds ratio of 1.87 (p = 0.020)
- Atelectasis with an odds ratio of 1.75 (p = 0.006)
- 30-day emergency department visits with an odds ratio of 2.44 (p < 0.001)
- 90-day emergency department visits with an odds ratio of 1.34 (p < 0.001)
- 30-day readmissions with an odds ratio of 1.57 (p < 0.001)
Bone Health, Autoimmune Factors, and Next Steps for Research
Patients with SLE are at increased risk of diminished bone quality compared with the general population due to systemic, serological, metabolic, hormonal, and possibly genetic contributors. Li EK et al. found that patients with lupus have a higher prevalence of vertebral fractures and lower bone mineral density (BMD) compared with healthy controls, with 60% of participants with SLE having osteopenia in the lumbar spine. Ruaro B et al. demonstrated that patients with SLE had significantly lower lumbar spine trabecular bone scores and BMD compared with controls. Another study found a high prevalence of vertebral deformities in premenopausal patients with SLE despite normal BMD in some cases, indicating that density scores may not always correlate with bone health within the spinal column in this population.
These underlying structural vulnerabilities compound the surgical challenges of spinal fusion. While there is no cure for SLE, certain medical treatments and lifestyle changes can help lessen symptoms, though surgical planning requires careful evaluation of perioperative vulnerabilities. Additional research is needed to identify mitigation strategies and better understand the perioperative risks associated with immunomodulatory therapy in this population.
