What Does Medically Clearing Your Patient With Rheumatic Disease For Surgery Entail?

Patients with rheumatic diseases face a variety of potential surgical complications as a result of either the disease itself or the medications used to manage it.

More than 25% of those with arthritic disease are likely to undergo an orthopedic procedure within 10 to 20 years of initial diagnosis.1 Many of these patients are older and disproportionately prone to fatal complications. In fact, 20% of elderly patients die within the first year after surgery for hip fracture, compared with 9% of age-matched patients without fracture who undergo orthopedic surgery.2

Preoperative assessment of older adults undergoing elective surgery has been reported to improve postoperative outcome3; however, there are no evidence-based recommendations for the perioperative management of those with rheumatic disease, and rheumatologists assessing patients for appropriateness for surgery must make their decisions based on evidence that is both fractured and inconsistent. Continuity of care requires that both the surgeon and the anesthesiologist be as knowledgeable as the rheumatologist about medical conditions that can influence surgical outcomes for those with arthritic disease.

A thorough patient history and physical examination can reveal important information regarding joint mobility and range of motion. For example, patients with rheumatoid arthritis (RA) or ankylosing spondylitis (AS) may have cervical spine involvement, with instability arising from atlantoaxial or subaxial subluxation. Involvement of the temporomandibular joint may limit jaw opening, and therefore may influence the choice of airway management. 

Among patients with AS, extensive ligamentous calcification, heterotrophic ossification, and rigid cervical spine may present technical challenges for the anesthesiologist during endotracheal intubation. Restricted chest excursion may further complicate both intraoperative and postoperative care because of an increased risk for infection. Currently, there is no consensus regarding the role of plain x-rays in the evaluation of cervical spine instability in those with RA, despite that between 17% and 86% of those with RA have evidence of cervical spine disease 5 years after diagnosis.4

Of primary concern is the possibility of iatrogenic spinal cord injury while positioning the head and neck during the intubation phase of the surgical procedure.1 Cricoarytenoid arthritis is very common among those with RA and creates concerns about complicated intubation or obstructed airway after surgery. These complications present considerable risks to the patient undergoing surgery and significant challenges for the anesthesiologist, particularly if endotracheal intubation is required.2 Avoiding sudden movements of the neck and torso is critical in these patients.5 Rheumatologists must provide the surgical team with specific information about the patient’s arthritic disease, clinical manifestations, and joint limitations.

Comprehensive laboratory evaluation is important if blood transfusion is warranted, to screen for antirheumatic drug side effects, and to assess medical comorbidities. The results of these tests should be shared with the surgical team to reduce surgical morbidity and mortality.5 The inflammatory process associated with diseases such as RA and systemic lupus erythematosus (SLE) increases the risk for cardiac morbidity and mortality6; therefore, those at risk should undergo preoperative cardiac risk stratification. 

Additionally, pulmonary complications, including fibrosis, bronchitis, and pleuritis, can affect RA and interfere with the perioperative course. Serial pulmonary function testing is recommended to allow for earlier detection of problematic ventilation.5 Current recommendations suggest following the American College of Cardiology/American Heart Association guidelines regarding use of underlying disease as a risk modifier.5