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Siempis T, Tsakiris C, Anastasia Z, Alexiou GA, Voulgaris S, Argyropoulou MI. Radiological assessment and surgical management of cervical spine involvement in patients with rheumatoid arthritis. Rheumatol Int 2023; 43:195-208. [PMID: 36378323 PMCID: PMC9898347 DOI: 10.1007/s00296-022-05239-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/21/2022] [Indexed: 11/16/2022]
Abstract
The purpose of the present systematic review was to describe the diagnostic evaluation of rheumatoid arthritis in the cervical spine to provide a better understanding of the indications and options of surgical intervention. We performed a literature review of Pub-med, Embase, and Scopus database. Upon implementing specific inclusion and exclusion criteria, all eligible articles were identified. A total of 1878 patients with Rheumatoid Arthritis (RA) were evaluated for cervical spine involvement with plain radiographs. Atlantoaxial subluxation (AAS) ranged from 16.4 to 95.7% in plain radiographs while sub-axial subluxation ranged from 10 to 43.6% of cases. Anterior atlantodental interval (AADI) was found to between 2.5 mm and 4.61 mm in neutral and flexion position respectively, while Posterior Atlantodental Interval (PADI) was between 20.4 and 24.92 mm. 660 patients with RA had undergone an MRI. A pannus diagnosis ranged from 13.33 to 85.36% while spinal cord compression was reported in 0-13% of cases. When it comes to surgical outcomes, Atlanto-axial joint (AAJ) fusion success rates ranged from 45.16 to 100% of cases. Furthermore, the incidence of postoperative subluxation ranged from 0 to 77.7%. With regards to AADI it is evident that its value decreased in all studies. Furthermore, an improvement in Ranawat classification was variable between studies with a report improvement frequency by at least one class ranging from 0 to 54.5%. In conclusion, through careful radiographic and clinical evaluation, cervical spine involvement in patients with RA can be detected. Surgery is a valuable option for these patients and can lead to improvement in their symptoms.
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Affiliation(s)
- Timoleon Siempis
- Department of Neurosurgery, Medical School, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Charalampos Tsakiris
- Department of Neurosurgery, Medical School, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Zikou Anastasia
- Department of Radiology, Medical School, University of Ioannina, Ioannina, Greece
| | - George A Alexiou
- Department of Neurosurgery, Medical School, University of Ioannina, School of Medicine, Ioannina, Greece.
| | - Spyridon Voulgaris
- Department of Neurosurgery, Medical School, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Maria I Argyropoulou
- Department of Radiology, Medical School, University of Ioannina, Ioannina, Greece
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Zoli A, Leone F, Zoli A, Visocchi M. Rheumatoid Diseases Involving the Cervical Spine I. History, Definition, and Diagnosis: New Trends and Technologies. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:197-202. [PMID: 38153469 DOI: 10.1007/978-3-031-36084-8_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
The cervical spine might be involved in several conditions: congenital, traumatic, and chronic inflammatory and or degenerative rheumatic disorders. Among the inflammatory rheumatic conditions that can affect the cervical spine, rheumatoid arthritis (RA) is the most common, affecting up to 86% of patients and leading to cervical spine instability and subsequent myelopathy. Other inflammatory diseases include juvenile idiopathic arthritis (JIA) and the spondyloarthritis group (SpA), including psoriatic arthritis. Since many patients do not show symptoms of cervical involvement, diagnosis is often delayed. Radiographs are the first line imaging modality used to detect such involvement, but MRI and CT are superior in terms of early diagnosis and surgical planning.In this review, we provide an overview of cervical involvement in RA, JIA, and SpA.
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Affiliation(s)
- Andrea Zoli
- UOC di Reumatologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Flavia Leone
- UOC di Reumatologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Angelo Zoli
- UOC di Reumatologia, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Traditional and modern management strategies for rheumatoid arthritis. Clin Chim Acta 2020; 512:142-155. [PMID: 33186593 DOI: 10.1016/j.cca.2020.11.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 12/20/2022]
Abstract
Rheumatoid arthritis (RA) is a serious disorder of the joints affecting 1 or 2% of the population aged between 20 and 50 years worldwide. RA is the foremost cause of disability in developing and Western populations. It is an autoimmune disease-causing inflammation and pain involving synovial joints. Pro-inflammatory markers, including cytokines, such as interleukin -1 (IL-1), IL-6, IL-7, IL-8, and tumor necrosis factor-α (TNF-α) are involved in RA. RA treatment involves TNF-α blockade, B cell therapy, IL-1 and IL-6 blockade, and angiogenesis inhibition. Synthetic drugs available for the treatment of RA include disease-modifying anti-rheumatic drugs (DMARD), such as cyclophosphamide, sulfasalazine, methotrexate, nonsteroidal anti-inflammatory drugs (NSAIDs), and intramuscular gold. These agents induce adverse hepatorenal effects, hypertension, and gastric ulcers. We found that patients diagnosed with chronic pain, as in RA, and those refractory to contemporary management are most likely to seek traditional medicine. Approximately 60-90% of patients with arthritis use traditional medicines. Therefore, the efficacy and safety of these traditional medicines need to be established. The treatment for RA entails a comprehensive multidisciplinary strategy to reduce pain and inflammation and to restore the activity of joints. The potential medicinal plants exhibiting anti-arthritic and anti-rheumatic pharmacological activity are reviewed here.
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Risk of the high-riding variant of vertebral arteries at C2 is increased over twofold in rheumatoid arthritis: a meta-analysis. Neurosurg Rev 2020; 44:2041-2046. [PMID: 33106959 PMCID: PMC8338830 DOI: 10.1007/s10143-020-01425-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/01/2020] [Accepted: 10/16/2020] [Indexed: 10/31/2022]
Abstract
Rheumatoid arthritis (RA) might lead to atlantoaxial instability requiring transpedicular or transarticular fusion. High-riding vertebral artery (HRVA) puts patients at risk of injuring the vessel. RA is hypothesized to increase a risk of HRVA. However, to date, no relative risk (RR) has been calculated in order to quantitatively determine a true impact of RA as its risk factor. To the best of our knowledge, this is the first attempt to do so. All major databases were scanned for cohort studies combining words "rheumatoid arthritis" and "high-riding vertebral artery" or synonyms. RA patients were qualified into the exposed group (group A), whereas non-RA subjects into the unexposed group (group B). Risk of bias was explored by means of Newcastle-Ottawa Scale. MOOSE checklist was followed to ensure correct structure. Fixed-effects model (inverse variance) was employed. Four studies with a total of 308 subjects were included in meta-analysis. One hundred twenty-five subjects were in group A; 183 subjects were in group B. Mean age in group A was 62,1 years, whereas in group B 59,9 years. The highest risk of bias regarded "comparability" domain, whereas the lowest pertained to "selection" domain. The mean relative risk of HRVA in group A (RA) as compared with group B (non-RA) was as follows: RR = 2,11 (95% CI 1,47-3,05), I2 = 15,19%, Cochrane Q = 3,54 with overall estimate significance of p < 0,001. Rheumatoid arthritis is associated with over twofold risk of developing HRVA, and therefore, vertebral arteries should be meticulously examined preoperatively before performing craniocervical fusion in every RA patient.
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Huang J, Wang X, Nie Q, Zhang C, Wu H, Jian F. A Novel Construct Incorporating C2 Unilateral Pedicle and Contralateral Translaminar Screws for Occipitocervical Internal Fixation: An In Vitro Biomechanical Study. World Neurosurg 2020; 149:e1166-e1173. [PMID: 33715837 DOI: 10.1016/j.wneu.2020.10.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Occipitocervical fixation using bilateral C2 pedicle screws (C0-C2BiPS) and occipitocervical fixation using bilateral C2 translaminar screws (C0-C2BiLS) provide satisfactory stability. Bilateral fixation is not feasible for cases of C2 unilateral pedicle morphology abnormality and ipsilateral laminectomy. This study proposed and evaluated novel occipitocervical fixation using C2 unilateral pedicle screw and contralateral translaminar screws (C0-C2PSLS). METHODS In 6 human cadaveric specimens, an in vitro experiment was performed with 2.0-Nm moment control in flexion-extension, lateral bending, and axial rotation to investigate biomechanical stability. Neutral zone and range of motion (ROM) between the occiput (C0) and C2 were measured in the intact state, after destabilization, and after sequential stabilization using C0-C2BiPS, C0-C2BiLS, and C0-C2PSLS constructs. RESULTS Flexion-extension ROM of the intact specimens at C0-C2 was 27.4° ± 2.4°. Instrumentation with C0-C2PSLS, C0-C2BiPS, and C0-C2BiLS reduced flexion-extension ROM to 3.7° ± 1.3°, 4.7° ± 1.4°, and 4.5° ± 1.4°, respectively. In lateral bending, ROM values were 7.0° ± 0.6°, 4.5° ± 1.4°, 4.2° ± 1.4°, 2.7° ± 1.0°, respectively. In axial rotation, ROM values were 65.3° ± 5.7°, 2.5° ± 0.5°, 1.4° ± 0.5°, and 0.9° ± 0.6°, respectively. Comparing destabilized and intact specimens, all 3 constructs significantly reduced ROM and neutral zone values in flexion-extension, lateral bending, and axial rotation (P < 0.05). Direct comparisons between the 3 constructs revealed no significant difference (P > 0.05). CONCLUSIONS Novel C0-C2PSLS provides similar stabilization effect as C0-C2BiPS and C0-C2BiLS constructs and has potential for clinical use, especially for cases of C2 unilateral pedicle morphology abnormality and ipsilateral laminectomy.
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Affiliation(s)
- Juying Huang
- School of Biomedical Engineering, Capital Medical University, Beijing, China; Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Xingwen Wang
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Qingbin Nie
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Can Zhang
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Hao Wu
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Fengzeng Jian
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China.
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Shlobin NA, Dahdaleh NS. Cervical spine manifestations of rheumatoid arthritis: a review. Neurosurg Rev 2020; 44:1957-1965. [PMID: 33037539 DOI: 10.1007/s10143-020-01412-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/20/2020] [Accepted: 10/05/2020] [Indexed: 02/07/2023]
Abstract
Rheumatoid arthritis (RA) is a progressive autoimmune inflammatory disease affecting 1% of the population with three times as many women as men. As many as 86% of patients suffering from RA have cervical spine involvement. Synovial inflammation in the cervical spine causes instability and injuries including atlantoaxial subluxation, retroodontoid pannus formation, cranial settling, and subaxial subluxation. While many patients with cervical spine involvement are asymptomatic, symptomatic patients often present with nonspecific symptoms resulting from inflammation and additional secondary symptoms that are due to compression of the brainstem, cranial nerves, vertebral artery, and spinal cord. Radiographs are the imaging modality used most often, while MRI and CT are used for assessment of neural element involvement and surgical planning. Multiple classification systems exist. Early diagnosis and treatment of cervical spine involvement is critical. Surgical management is indicated when patients experience symptoms from cervical involvement that result in biomechanical instability and, or a neurological deficit. Atlantoaxial instability managed with atlantoaxial fusion, retroodontoid pannus with neural element compression is managed with posterior decompression and atlantoaxial fusion or occipitocervical fusion. Cranial settling is managed can be managed with anterior decompression and posterior fusion or with dorsal only approaches. Subaxial subluxation is managed with circumferential fusion or posterior only decompression and fusion. Patients with atlantoaxial instability have better functional and neurologic outcomes. RA patients have higher complication rates and more frequent need for revision surgery than the general population of spine surgery patients.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair Street, Suite 2210, Chicago, IL, 60611, USA.
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair Street, Suite 2210, Chicago, IL, 60611, USA
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Gous E, Ally MMTM, Meyer PWA, Suleman FE. Simple Erosion Narrowing Score of the hands as a predictor of cervical spine subluxation in rheumatoid arthritis. SA J Radiol 2020; 24:1876. [PMID: 32832120 PMCID: PMC7433238 DOI: 10.4102/sajr.v24i1.1876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/13/2020] [Indexed: 11/17/2022] Open
Abstract
Background Involvement of the cervical spine is common in patients with rheumatoid arthritis and can lead to devastating or even fatal consequences. Currently no guidelines exist as to whether radiographs of the cervical spine should be included in follow-up visits. Objectives To determine whether the Simple Erosion Narrowing Score (SENS) of the hands correlate with the presence of cervical spine subluxation in patients with rheumatoid arthritis. Method This was a retrospective, observational, cross-sectional study. A total of 56 rheumatoid arthritis patients with hand radiographs and lateral radiographs of the cervical spine were evaluated. The SENS of the hands and the presence of cervical spine subluxation were compared. The SENS of the hands was correlated with the prevalence of cervical spine subluxation, as was the erosion and joint space narrowing scores of the hands. Results A correlation between the SENS of the hands and the prevalence of cervical spine subluxation was confirmed. A higher prevalence of cervical spine subluxation correlated with an increase in the SENS of the hands (p = 0.0002). The erosion and joint space narrowing scores of the hands also correlated with the prevalence of cervical spine subluxation (p = 0.0001). Conclusion This study confirmed that a correlation exists between cervical spine subluxation, peripheral joint space erosions and joint space narrowing in patients with rheumatoid arthritis and SENS may therefore be used as a predictor of cervical spine disease.
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Affiliation(s)
- Eric Gous
- Department of Radiology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Mahmood M T M Ally
- Department of Rheumatology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Pieter W A Meyer
- Department of Medical Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Farhana E Suleman
- Department of Radiology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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Xu S, Liang Y, Meng F, Zhu Z, Liu H. Risk prediction of degenerative scoliosis combined with lumbar spinal stenosis in patients with rheumatoid arthritis: a case-control study. Rheumatol Int 2020; 40:925-932. [PMID: 31919576 DOI: 10.1007/s00296-019-04508-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 12/27/2019] [Indexed: 10/25/2022]
Abstract
The purpose of this study is to compare incidence of degenerative scoliosis (DS) in patients who diagnosed lumbar spinal stenosis (LSS) with or without rheumatoid arthritis (RA) and identify the risk factors of DS severity in RA patients. 61 LSS patients with RA (RA group) and 87 demographic-matched LSS patients without RA (NoRA group) from January 2013 to April 2018 were enrolled. The extracted information includes RA-related parameters such as Steinbrocker classification, disease-modifying anti-rheumatic drugs (DMARDs), and DS-related information such as Cobb angle, apical vertebra, along with osteoporosis and history of total knee arthroplasty (TKA). Comparisons between RA and NoRA group and between DS and non-DS subgroup with RA were performed, as well as the risk factors on DS severity in RA patients. The incidence of DS in RA group was 42.6%, larger than that of NoRA group (P = 0.002). The mean Cobb angle between the two groups was of no difference (P = 0.076). The apical vertebrae were both mainly focused on L3 and L4 vertebrae in both groups with no significant difference on the distribution of apical vertebrae (P = 0.786). Female took a larger proportion in DS subgroup than that of NoDS subgroup in patients with RA (P = 0.039), while Steinbrocker classification was irrelevant to the occurrence of DS and Cobb angle. Multiple regression analysis showed that TKA was a risk factor for the severity of Cobb angle (P = 0.040). The incidence of DS in LSS patients with RA is higher than non-RA patients. RA patients performed TKA sustained less severity of DS.
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Affiliation(s)
- Shuai Xu
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, P.R. China
| | - Yan Liang
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, P.R. China
| | - Fanqi Meng
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, P.R. China
| | - Zhenqi Zhu
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, P.R. China
| | - Haiying Liu
- Department of Spinal Surgery, Peking University People's Hospital, Peking University, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, P.R. China.
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Mueller K, MacConnell A, Berkowitz F, Voyadzis JM. Morphological classification of the tubercle of insertion of the transverse atlantal ligament: A computer tomography-based anatomical study of 200 subjects. Neuroradiol J 2019; 32:426-430. [PMID: 31290720 DOI: 10.1177/1971400919857211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND AND PURPOSE The atlantal tubercle is the attachment point of the transverse atlantal ligament, the main stabilizer of the atlantoaxial complex. No system of classification of the tubercle exists in the literature. We aimed to develop a morphologically based classification system of the atlantal tubercle to aid clinicians who deal with craniocervical pathology. MATERIALS AND METHODS A retrospective review of computed tomography (CT) scans of the cervical spine was performed. The morphology of the atlantal tubercle was classified into four variants: rounded (classical), pointed, flattened, and hypoplastic. Age, presence, and morphological type were recorded. RESULTS A total of 200 CT scans were identified and reviewed. The tubercle was present bilaterally in all patients. Patients were equally distributed over various age ranges. The following morphological types were recorded: rounded (227/400; 56.8%), pointed (13/400; 3.3%), flattened (126; 31.5%), and hypoplastic (34/400; 8.5%). The same type was seen bilaterally in 68% (135/200) of patients. Morphological types appear equally on the right and left side of the atlas. CONCLUSIONS The first morphologically based classification system of the atlantal tubercle utilizing CT is presented. Morphology type, especially hypoplastic type, may confer an increased risk for subsequent need for posterior fusion.
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Affiliation(s)
- Kyle Mueller
- Department of Neurosurgery, Medstar Georgetown University Hospital, USA
| | | | - Frank Berkowitz
- Department of Neuroradiology, Medstar Georgetown University Hospital, USA
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Iwata A, Abumi K, Takahata M, Sudo H, Yamada K, Endo T, Iwasaki N. Late Subaxial Lesion after Overcorrected Occipitocervical Reconstruction in Patients with Rheumatoid Arthritis. Asian Spine J 2018; 13:181-188. [PMID: 30424593 PMCID: PMC6454272 DOI: 10.31616/asj.2018.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/27/2018] [Indexed: 12/02/2022] Open
Abstract
Study Design Retrospective case-control study, level 4. Purpose To clarify the risk factors for late subaxial lesion after occipitocervical (O-C) reconstruction. We examined cases requiring fusion-segment-extended (FE) reconstruction in addition to/after O-C reconstruction. Overview of Literature Patients with rheumatoid arthritis (RA) frequently require O-C reconstruction surgery for cranio-cervical lesions. Acceptable outcomes are achieved via indirect decompression using cervical pedicle screws and occipital plate–rod systems. However, late subaxial lesions may develop occasionally following O-C reconstruction. Methods O-C reconstruction using cervical pedicle screws and occipital plate–rod systems was performed between 1994 and 2007 in 113 patients with RA. Occipito-atlanto-axial (O-C2) reconstruction was performed for 89 patients, and occipito-subaxial cervical (O-under C2) reconstruction was performed for 24 patients. We reviewed the cases of patients requiring FE reconstruction (fusion extended group, FEG) and 26 consecutive patients who did not require FE reconstruction after a follow-up of >5 years (non-fusion extended group, NEG) as controls. Results FE reconstructions were performed for nine patients at an average of 45 months (range, 24–180 months) after O-C reconstruction. Of the 89 patients, three (3%) underwent FE reconstruction in cases of O-C2 reconstruction. Of the 24 patients, five (21%) underwent FE reconstruction in cases of O-under C2 reconstruction (p=0.003, Fisher exact test). Age, sex, RA type, and neurological impairment stage were not significantly different between FEG and NEG. O-under C2 reconstruction, larger correction angle (4° per number of unfixed segment), and O-C7 angle change after O-C reconstruction were the risk factors for late subaxial lesions on radiographic assessment. Conclusions Overcorrection of angle at fusion segments requiring O-C7 angle change was a risk factor for late subaxial lesion in patients with RA with fragile bones and joints. Correction should be limited, considering the residual mobility of the cervical unfixed segments.
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Affiliation(s)
- Akira Iwata
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kuniyoshi Abumi
- Sapporo Orthopaedic Hospital-Center for Spinal Disorders, Sapporo, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideki Sudo
- Department of Advanced Medicine for Spine and Spinal Cord Disorders, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Katsuhisa Yamada
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tsutomu Endo
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Rheumatoid Arthritis Affecting the Upper Cervical Spine: Biomechanical Assessment of the Stabilizing Ligaments. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6131703. [PMID: 29181398 PMCID: PMC5664273 DOI: 10.1155/2017/6131703] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 08/29/2017] [Accepted: 09/13/2017] [Indexed: 01/31/2023]
Abstract
Diameters of anterior and posterior atlantodental intervals (AADI and PADI) are diagnostically conclusive regarding ongoing neurological disorders in rheumatoid arthritis. MRI and X-ray are mostly used for patients' follow-up. This investigation aimed at analyzing these intervals during motion of cervical spine, when transverse and alar ligaments are damaged. AADI and PADI of 10 native, human cervical spines were measured using lateral fluoroscopy, while the spines were assessed in neutral position first, in maximal inclination second, and in maximal extension at last. First, specimens were evaluated under intact conditions, followed by analysis after transverse and alar ligaments were destroyed. Damage of the transverse ligament leads to an increase of the AADI's diameter about 0.65 mm in flexion and damage of alar ligaments results in significant enhancement of 3.59 mm at mean. In extension, the AADI rises 0.60 mm after the transverse ligament was cut and 0.90 mm when the alar ligaments are damaged. After all ligaments are destroyed, AADI assessed in extension closely resembles AADI at neutral position. Ligamentous damage showed an average significant decrease of the PADI of 1.37 mm in the first step and of 3.57 mm in the second step in flexion, while it is reduced about 1.61 mm and 0.41 mm in the extended and similarly in the neutrally positioned spine. Alar and transverse ligaments are both of obvious importance in order to prevent AAS and movement-related spinal cord compression. Functional imaging is necessary at follow-up in order to identify patients having an advanced risk of neurological disorders.
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A Retrospective Analysis of Subaxial Subluxation After Atlanto-axial Arthrodesis in Patients With Rheumatoid Arthritis Based on Annual Radiographs Obtained for 5 Years. Clin Spine Surg 2017; 30:E598-E602. [PMID: 28525484 DOI: 10.1097/bsd.0000000000000277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE The purpose of this study was to investigate the incidence of subaxial subluxation (SAS) after atlanto-axial arthrodesis in rheumatoid arthritis (RA) patients using annual radiographs obtained for 5 years and clarify the characteristics of SAS after surgery. SUMMARY OF BACKGROUND DATA Rheumatoid SAS has been reported to occur after atlanto-axial arthrodesis. Many authors have noted that excessive correction of the atlanto-axial angle (AAA) results in a decrease in subaxial lordosis, thereby inducing SAS; therefore, we paid special attention to acquiring a suitable AAA in patients with atlanto-axial arthrodesis. METHODS Twenty-five patients with AAS treated with surgery were reviewed. In all patients, lateral cervical radiographs were obtained in neutral, maximal flexion, and maximal extension positions every year for 5 years after surgery. We investigated the occurrence and progression of SAS using these annual radiographs. RESULTS There were no significant differences between preoperative and postoperative value in AAA and subaxial angle (SAA), respectively. Before surgery, SAS was found in 10 patients. The occurrence and progression of SAS after surgery was found in 12 cases (SAS P+ group). There were no significant differences in age, sex, or the duration of RA between the SAS P+ group and the remaining 13 cases. We also found no differences in the preoperative and postoperative AAA and SAA between the 2 groups. CONCLUSIONS Although SAA was maintained after atlanto-axial arthrodesis in RA-AAS patients, 12 of 25 patients (48%) with AAS developed SAS after atlanto-axial fusion. Further surgery was not needed for SAS up to 5 years after the initial surgery. We did not find any relationship between the occurrence of SAS and the AAA and SAA before and after surgery. Therefore, our findings suggest that proper reduction of AAA in patients with atlanto-axial arthrodesis does not affect the occurrence of SAS at 5 years after surgery.
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Lee JY, Im SB, Jeong JH. Use of a C1-C2 Facet Spacer to Treat Atlantoaxial Instability and Basilar Invagination Associated with Rheumatoid Arthritis. World Neurosurg 2016; 98:874.e13-874.e16. [PMID: 27916724 DOI: 10.1016/j.wneu.2016.11.115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 11/21/2016] [Accepted: 11/22/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease that often affects the craniovertebral junction. RA is associated with atlantoaxial instability and basilar invagination; the detailed presentations vary. Surgical treatment of atlantoaxial instability and basilar invagination caused by RA is challenging due to anatomic complexity and poor bone quality. The prevailing procedure is posterior occipitocervical fixation after transoral decompression or posterior decompression followed by occipitocervical fixation. However, these surgical modalities inevitably severely limit neck motion and cause dysesthesia of the C2 dermatome. CASE DESCRIPTION We report our surgical experience with a C1-C2 facet spacer, specifically the usual cervical cage containing an autologous bone chip combined with a C1 lateral mass screw and a C2 pedicle without resection of C2 roots. The facet space was maintained on the 3-year follow-up radiograph. CONCLUSIONS This method effectively reduces BI and allows AAI fixation without significantly compromising neck motion or causing C2 dermatome dysesthesia.
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Affiliation(s)
- Jin-Young Lee
- Department of Neurosurgery, School of Medicine, Soonchunhyang University Hospital, Bucheon-si, Gyeonggi-do, South Korea
| | - Soo-Bin Im
- Department of Neurosurgery, School of Medicine, Soonchunhyang University Hospital, Bucheon-si, Gyeonggi-do, South Korea.
| | - Je-Hoon Jeong
- Department of Neurosurgery, School of Medicine, Soonchunhyang University Hospital, Bucheon-si, Gyeonggi-do, South Korea
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Suhodolčan L, Mihelak M, Brecelj J, Vengust R. Operative stabilization of the remaining mobile segment in ankylosed cervical spine in systemic onset - juvenile idiopathic arthritis: A case report. World J Orthop 2016; 7:458-462. [PMID: 27458558 PMCID: PMC4945514 DOI: 10.5312/wjo.v7.i7.458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/05/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023] Open
Abstract
We describe a case of a 19-year-old young man with oligoarthritis type of juvenile idiopathic arthritis, who presented with several month duration of lower neck pain and progressive muscular weakness of all four limbs. X-rays of the cervical spine demonstrated spontaneous apophyseal joint fusion from the occipital condyle to C6 and from C7 to Th2 with marked instability between C6 and C7. Surgical intervention began with anterolateral approach to the cervical spine performing decompression, insertion of cage and anterior vertebral plate and screws, followed by posterior approach and fixation. Care was taken to restore sagittal balance. The condition was successfully operatively managed with multisegmental, both column fixation and fusion, resulting in pain cessation and resolution of myelopathy. Postoperatively, minor swallowing difficulties were noted, which ceased after three days. Patient was able to move around in a wheelchair on the sixth postoperative day. Stiff neck collar was advised for three months postoperatively with neck pain slowly decreasing in the course of first postoperative month. On the follow-up visit six months after the surgery patient exhibited no signs of spastic tetraparesis, X-rays of the cervical spine revealed solid bony fusion at single mobile segment C6-C7. He was able to gaze horizontally while sitting in a wheelchair. Signs of myelopathy with stiff neck and single movable segment raised concerns about intubation, but were successfully managed using awake fiber-optic intubation. Avoidance of tracheostomy enabled us to perform an anterolateral approach without increasing the risk of wound infection. Regarding surgical procedure, the same principles are obeyed as in management of fracture in ankylosing spondylitis or Mb. Forestrier.
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Joaquim AF, Ghizoni E, Tedeschi H, Appenzeller S, Riew KD. Radiological evaluation of cervical spine involvement in rheumatoid arthritis. Neurosurg Focus 2015; 38:E4. [PMID: 25828498 DOI: 10.3171/2015.1.focus14664] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cervical spine involvement commonly occurs in patients with rheumatoid arthritis (RA), especially those with inadequate treatment or severe disease forms. The most common site affected by RA is the atlantoaxial joint, potentially resulting in atlantoaxial instability, with cervical pain and neurological deficits. The second most common site of involvement is the subaxial cervical spine, often with subluxation, resulting in nerve root or spinal cord compression. In this paper, the authors review the most commonly used plain radiographic criteria to diagnose cervical instabilities seen with RA. Finally, we discuss the advantages and disadvantages of cervical CT and MRI in the setting of cervical involvement in RA.
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Rastegar K, Ghalaenovi H, Babashahi A, Shayanfar N, Jafari M, Jalalian M, Fattahi A. Cervical Spine Involvement: A Rare Manifestation of Reiter's Syndrome. Open Rheumatol J 2014; 8:82-8. [PMID: 25360183 PMCID: PMC4212507 DOI: 10.2174/1874312901408010082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 08/04/2014] [Accepted: 08/26/2014] [Indexed: 11/22/2022] Open
Abstract
Spine involvement is less common in Reiter's syndrome than in other seronegative spondyloarthropathies. Also, cervical spine involvement rarely occurs in Reiter's syndrome and other spondyloarthropathies. This paper reports a rare case of Reiter's syndrome in which there was cervical spine involvement that presented clinically as an atlanto-axial rotatory subluxation. Reiter's Syndrome (RS) is one of the most common types of seronegative spondyloarthropathies (SSAs) that presents clinically with a triad of symptoms, i.e., conjunctivitis, urethritis, and arthritis. This case highlighted the importance of radiographs of the lateral cervical spine and dynamic cervical imaging for all patients who have Reiter's syndrome with cervical spine symptoms to ensure that this dangerous abnormality is not overlooked.
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Affiliation(s)
- Khodakaram Rastegar
- Neurosurgery ward of Rasool-e-Akram Hospital Complex, Department of Neurosurgery, Iran University of Medical Science, Tehran, Iran
| | - Hossein Ghalaenovi
- Neurosurgery ward of Rasool-e-Akram Hospital Complex, Department of Neurosurgery, Iran University of Medical Science, Tehran, Iran
| | - Ali Babashahi
- Neurosurgery ward of Rasool-e-Akram Hospital Complex, Department of Neurosurgery, Iran University of Medical Science, Tehran, Iran
| | - Nasrin Shayanfar
- Pathology ward of Rasool-e-Akram Hospital Complex, Department of Pathology, Iran University of Medical Science, Tehran, Iran
| | - Mohammad Jafari
- Medical Doctor, Resident of Neurosurgery, Neurosurgery Ward of Rasool-e-Akram Hospital Complex, Department of Neurosurgery, Iran University of Medical Science, Tehran, Iran
| | | | - Arash Fattahi
- Medical Doctor, Resident of Neurosurgery, Neurosurgery Ward of Rasool-e-Akram Hospital Complex, Department of Neurosurgery, Iran University of Medical Science, Tehran, Iran
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Grande MD, Grande FD, Carrino J, Bingham CO, Louie GH. Cervical spine involvement early in the course of rheumatoid arthritis. Semin Arthritis Rheum 2014; 43:738-44. [DOI: 10.1016/j.semarthrit.2013.12.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 12/05/2013] [Accepted: 12/06/2013] [Indexed: 02/01/2023]
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Pruthi N, Dawn R, Ravindranath Y, Maiti TK, Ravindranath R, Philip M. Computed tomography-based classification of axis vertebra: choice of screw placement. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1084-91. [PMID: 24563273 DOI: 10.1007/s00586-014-3240-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 02/05/2014] [Accepted: 02/06/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of the study was to: (1) introduce a new CT-based parameter: free facet area and provide its normative data; (2) standardize the method of measuring isthmus width and height of the axis vertebra; (3) propose a new grading system to predict the difficulty in inserting transarticular and C2 pedicle screws. METHODS Spiral CT scans of 47 adult dry axis vertebrae were studied. The methods of measuring isthmus width, isthmus height and free facet area are described. RESULTS The mean isthmus width was 5.04 mm on the right side and 5.42 mm on the left side. The mean isthmus height was 5.21 mm on the right side and 5.45 mm on the left side. Mean free facet area was 61.23 % on the right side and 70.18 % on the left side. A novel grading system is proposed on the basis of these three parameters. As per this grading system, 40.4 % of the sides were found to be difficult for transarticular and 24.5 % sides for C2 pedicle screw insertion (total score 2, 3, 4). A Management protocol is suggested on the basis of the grading system. CONCLUSION Inserting a transarticular screw was more frequently difficult as compared to pedicle screw. A new CT-based parameter (free facet area) and an efficient grading have been proposed to help surgeons choose the appropriate screw options, appreciate the complex anatomy of this region and compare data across various studies.
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Affiliation(s)
- Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore, 560 029, Karnataka, India,
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Affiliation(s)
- Masashi Neo
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
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Yeom JS, Buchowski JM, Kim HJ, Chang BS, Lee CK, Riew KD. Risk of vertebral artery injury: comparison between C1-C2 transarticular and C2 pedicle screws. Spine J 2013; 13:775-85. [PMID: 23684237 DOI: 10.1016/j.spinee.2013.04.005] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 02/10/2013] [Accepted: 04/03/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT To our knowledge, no large series comparing the risk of vertebral artery injury by C1-C2 transarticular screw versus C2 pedicle screw have been published. In addition, no comparative studies have been performed on those with a high-riding vertebral artery and/or a narrow pedicle who are thought to be at higher risk than those with normal anatomy. PURPOSE To compare the risk of vertebral artery injury by C1-C2 transarticular screw versus C2 pedicle screw in an overall patient population and subsets of patients with a high-riding vertebral artery and a narrow pedicle using computed tomography (CT) scan images and three-dimensional (3D) screw trajectory software. STUDY DESIGN Radiographic analysis using CT scans. PATIENT SAMPLE Computed tomography scans of 269 consecutive patients, for a total of 538 potential screw insertion sites for each type of screw. OUTCOME MEASURES Cortical perforation into the vertebral artery groove of C2 by a screw. METHODS We simulated the placement of 4.0 mm transarticular and pedicle screws using 1-mm-sliced CT scans and 3D screw trajectory software. We then compared the frequency of C2 vertebral artery groove violation by the two different fixation methods. This was done in the overall patient population, in the subset of those with a high-riding vertebral artery (defined as an isthmus height ≤ 5 mm or internal height ≤ 2 mm on sagittal images) and with a narrow pedicle (defined as a pedicle width ≤ 4 mm on axial images). RESULTS There were 78 high-riding vertebral arteries (14.5%) and 51 narrow pedicles (9.5%). Most (82%) of the narrow pedicles had a concurrent high-riding vertebral artery, whereas only 54% of the high-riding vertebral arteries had a concurrent narrow pedicle. Overall, 9.5% of transarticular and 8.0% of pedicle screws violated the C2 vertebral artery groove without a significant difference between the two types of screws (p=.17). Among those with a high-riding vertebral artery, vertebral artery groove violation was significantly lower (p=.02) with pedicle (49%) than with transarticular (63%) screws. Among those with a narrow pedicle, vertebral artery groove violation was high in both groups (71% with transarticular and 76% with pedicle screws) but without a significant difference between the two groups (p=.55). CONCLUSIONS Overall, neither technique has more inherent anatomic risk of vertebral artery injury. However, in the presence of a high-riding vertebral artery, placement of a pedicle screw is significantly safer than the placement of a transarticular screw. Narrow pedicles, which might be anticipated to lead to higher risk for a pedicle screw than a transarticular screw, did not result in a significant difference because most patients (82%) with narrow pedicles had a concurrent high-riding vertebral artery that also increased the risk with a transarticular screw. Except in case of a high-riding vertebral artery, our results suggest that the surgeon can opt for either technique and expect similar anatomic risks of vertebral artery injury.
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Affiliation(s)
- Jin S Yeom
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-ku, Sungnam 463-707, Republic of Korea
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da Côrte FC, Neves N. Cervical spine instability in rheumatoid arthritis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24 Suppl 1:S83-91. [PMID: 23807394 DOI: 10.1007/s00590-013-1258-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 06/10/2013] [Indexed: 01/15/2023]
Abstract
Rheumatoid arthritis (RA) is the most common inflammatory disease of the cervical spine (CS). After hands and feet, CS is the most commonly involved segment, being present in more than half of the patients with RA. Especially in the CS, RA may cause degeneration of ligaments, leading to laxity, instability and subluxation of the vertebral bodies. This is often asymptomatic or symptoms are erroneously attributed to peripheral manifestations. Otherwise, this may cause compression of spinal cord (SC) and medulla oblongata leading to severe neurologic deficits and even sudden death. Owing to its potentially debilitating and life-threatening sequelae, inevitable progression once neurologic deficits occur and the poor medical condition of afflicted patients, CS involvement remains a priority in the diagnosis and its treatment will remain a challenge. The surgical approach aims a solid fixation of the upper cervical spine, giving stability, preventing neurologic deterioration and injury to the SC, leading to improved neurologic function, vascular integrity and maintenance of sagittal balance. The recent advances in surgical techniques, complete understanding of the anatomy and precise preoperative evaluation led to safer and more effective procedures that have decreased complication rates. Based on the fact that when a patient becomes myelopathic the rate of long-term mortality increases and the chance of neurologic recovery decreases, many authors agree that early surgical intervention, before the onset of neurologic deficits, gives a more satisfactory outcome. However, the timing when a prophylactic stabilization should occur is poorly defined, and so, patients with radiographic instability but without evidence of neurologic deficit are still the most difficult to manage.
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Abstract
The differential of cervical spondylotic myelopathy (CSM) is broad and includes multiple conditions that can cause and mimic myelopathy. In adults older than 55 years of age, CSM is the most common cause of myelopathy. This article summarizes the pathophysiology, clinical presentation, differential diagnosis, diagnostic evaluation, and natural history of CSM. Available treatment options and their complications are reviewed.
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Affiliation(s)
- Michel Toledano
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Choi SH, Lee SG, Park CW, Kim WK, Yoo CJ, Son S. Surgical outcomes and complications after occipito-cervical fusion using the screw-rod system in craniocervical instability. J Korean Neurosurg Soc 2013; 53:223-7. [PMID: 23826478 PMCID: PMC3698232 DOI: 10.3340/jkns.2013.53.4.223] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 02/12/2013] [Accepted: 04/08/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Although there is no consensus on the ideal treatment of the craniocervical instability, biomechanical stabilization and bone fusion can be induced through occipito-cervical fusion (OCF). The authors conducted this study to evaluate efficacy of OCF, as well as to explore methods in reducing complications. METHODS A total of 16 cases with craniocervical instability underwent OCF since the year 2002. The mean age of the patients was 51.5 years with a mean follow-up period of 34.9 months. The subjects were compared using lateral X-ray taken before the operation, after the operation, and during last follow-up. The Nurick score was used to assess neurological function pre and postoperatively. RESULTS All patients showed improvements in myelopathic symptoms after the operation. The mean preoperative Nurick score was 3.1. At the end of follow-up after surgery, the mean Nurick score was 2.0. After surgery, most patients' posterior occipito-cervical angle entered the normal range as the pre operation angle decresed from 121 to 114 degree. There were three cases with complications, such as, vertebral artery injury, occipital screw failure and wound infection. In two cases with cerebral palsy, occipital screw failures occurred. But, reoperation was performed in one case. CONCLUSION OCF is an effective method in treating craniocervical instability. However, the complication rate can be quite high when performing OCF in patients with cerebral palsy, rheumatoid arthritis. Much precaution should be taken when performing this procedure on high risk patients.
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Affiliation(s)
- Sung Ho Choi
- Department of Neurosurgery, Gachon University, Gil Hospital, Incheon, Korea
| | - Sang Gu Lee
- Department of Neurosurgery, Gachon University, Gil Hospital, Incheon, Korea
| | - Chan Woo Park
- Department of Neurosurgery, Gachon University, Gil Hospital, Incheon, Korea
| | - Woo Kyung Kim
- Department of Neurosurgery, Gachon University, Gil Hospital, Incheon, Korea
| | - Chan Jong Yoo
- Department of Neurosurgery, Gachon University, Gil Hospital, Incheon, Korea
| | - Seong Son
- Department of Neurosurgery, Gachon University, Gil Hospital, Incheon, Korea
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Cha TD, An HS. Cervical spine manifestations in patients with inflammatory arthritides. Nat Rev Rheumatol 2013; 9:423-32. [DOI: 10.1038/nrrheum.2013.40] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Lee KH, Kang DH, Lee CH, Hwang SH, Park IS, Jung JM. Inferolateral entry point for c2 pedicle screw fixation in high cervical lesions. J Korean Neurosurg Soc 2011; 50:341-7. [PMID: 22200017 DOI: 10.3340/jkns.2011.50.4.341] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Revised: 08/12/2011] [Accepted: 10/17/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this retrospective study was to evaluate the efficacy and safety of atlantoaxial stabilization using a new entry point for C2 pedicle screw fixation. METHODS Data were collected from 44 patients undergoing posterior C1 lateral mass screw and C2 screw fixation. The 20 cases were approached by the Harms entry point, 21 by the inferolateral point, and three by pars screw. The new inferolateral entry point of the C2 pedicle was located about 3-5 mm medial to the lateral border of the C2 lateral mass and 5-7 mm superior to the inferior border of the C2-3 facet joint. The screw was inserted at an angle 30° to 45° toward the midline in the transverse plane and 40° to 50° cephalad in the sagittal plane. Patients received followed-up with clinical examinations, radiographs and/or CT scans. RESULTS There were 28 males and 16 females. No neurological deterioration or vertebral artery injuries were observed. Five cases showed malpositioned screws (2.84%), with four of the screws showing cortical breaches of the transverse foramen. There were no clinical consequences for these five patients. One screw in the C1 lateral mass had a medial cortical breach. None of the screws were malpositioned in patients treated using the new entry point. There was a significant relationship between two group (p=0.036). CONCLUSION Posterior C1-2 screw fixation can be performed safely using the new inferolateral entry point for C2 pedicle screw fixation for the treatment of high cervical lesions.
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Affiliation(s)
- Kwang Ho Lee
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju, Korea
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Abstract
A total of 150,000 primary total knee arthroplasties are performed in Germany each year. There is only a limited amount of evidence-based data available on possible surgery-related differences between osteoarthritis (OA) and rheumatoid arthritis (RA) of the knee joint. The following review summarizes the recent literature on total knee arthroplasty with a focus on special features of RA patients.
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Affiliation(s)
- H-D Carl
- Abteilung für Orthopädische Rheumatologie, Friedrich-Alexander-Universität Erlangen-Nürnberg, Waldkrankenhaus St. Marien, Erlangen.
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Lui NL, Inman RD. Atlanto-axial subluxation as the initial manifestation of spondyloarthritis. Joint Bone Spine 2011; 78:415-7. [PMID: 21550278 DOI: 10.1016/j.jbspin.2011.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 03/10/2011] [Indexed: 10/18/2022]
Abstract
Patients with spondyloarthritis (SpA) typically present with inflammatory back pain, peripheral arthritis and enthesitis, often with distinctive clinical features such as psoriasis and inflammatory bowel diseases. Atlanto-axial subluxation (AAS) is a complication occurring rarely in these patients, and usually is seen in patients with longstanding, severe disease. We present three cases of AAS whose initial presentation of AAS was followed by subsequent development of signs and symptoms meeting the European Spondyloarthropathy Study Group (ESSG) classification criteria for SpA. All three patients were less than 30 years of age and had no other explanation for the AAS. Significantly, all three patients required C1/C2 surgical fusion within 1 year of symptom onset due to severe pain, though none of them developed neurologic complications related to AAS such as myelopathy. Peripheral arthritis/tendonitis, the presence of HLA-B27 gene and family history of SpA appeared to be associated with higher risk of evolution to SpA in these patients. No medical therapy has been systematically examined in this condition.
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Affiliation(s)
- Nai Lee Lui
- Department of Rheumatology and Immunology, Singapore General Hospital (SGH), Singapore
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Khaldi A, Griauzde J, Duckworth EAM. Degenerative Pannus Mimicking Clival Chordoma Resected via an Endoscopic Transnasal Approach. SKULL BASE REPORTS 2011; 1:7-12. [PMID: 23984195 PMCID: PMC3743584 DOI: 10.1055/s-0031-1275243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 08/03/2010] [Indexed: 11/24/2022]
Abstract
Lesions of the lower clivus represent a technically challenging subset of skull base disease that requires careful treatment. A 75-year-old woman with tongue atrophy was referred for resection of a presumed clival chordoma. The lesion was resected via an endoscopic transnasal transclival approach with no complications. Pathology revealed only chronic inflammatory tissue consistent with a degenerative pannus. Degenerative pannus should be included in the differential diagnosis of lower clival extradural lesions. The endoscopic transnasal transclival corridor should be considered for resection of such lesions as an alternative to larger, more morbid, traditional skull base approaches.
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Affiliation(s)
- Ahmad Khaldi
- Department of Neurosurgery at Loyola University Stritch School of Medicine, Maywood, Illinois
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Kawaguchi Y. Cervical Myelopathy. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00060-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Bahadur R, Goyal T, Dhatt SS, Tripathy SK. Transarticular screw fixation for atlantoaxial instability - modified Magerl's technique in 38 patients. J Orthop Surg Res 2010; 5:87. [PMID: 21092173 PMCID: PMC2995783 DOI: 10.1186/1749-799x-5-87] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Accepted: 11/22/2010] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Symptomatic atlantoaxial instability needs stabilization of the atlantoaxial joint. Among the various techniques described in literature for the fixation of atlantoaxial joint, Magerl's technique of transarticular screw fixation remains the gold standard. Traditionally this technique combines placement of transarticular screws and posterior wiring construct. The aim of this study is to evaluate clinical and radiological outcomes in subjects of atlantoaxial instability who were operated using transarticular screws and iliac crest bone graft, without the use of sublaminar wiring (a modification of Magerl's technique). METHODS We evaluated retrospectively 38 subjects with atlantoaxial instability who were operated at our institute using transarticular screw fixation. The subjects were followed up for pain, fusion rates, neurological status and radiographic outcomes. Final outcome was graded both subjectively and objectively, using the scoring system given by Grob et al. RESULTS Instability in 34 subjects was secondary to trauma, in 3 due to rheumatoid arthritis and 1 had tuberculosis. Neurological deficit was present in 17 subjects. Most common presenting symptom was neck pain, present in 35 of the 38 subjects.Postoperatively residual neck and occipital pain was present in 8 subjects. Neurological deficit persisted in only 7 subjects. Vertebral artery injury was seen in 3 subjects. None of these subjects had any sign of neurological deficit or vertebral insufficiency. Three cases had nonunion. At the latest follow up, subjectively, 24 subjects had good result, 6 had fair and 8 had bad result. On objective grading, 24 had good result, 11 had fair and 3 had bad result. The mean follow up duration was 41 months. CONCLUSIONS Transarticular screw fixation is an excellent technique for fusion of the atlantoaxial complex. It provides highest fusion rates, and is particularly important in subjects at risk for nonunion. Omitting the posterior wiring construct that has been used along with the bone graft in the traditional Magerl' s technique achieves equally good fusion rates and is an important modification, thereby avoiding the complications of sublaminar wire passage.
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Affiliation(s)
- Raj Bahadur
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Government Medical College and Hospital, Chandigarh, India
| | - Tarun Goyal
- Dept of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Saravdeep S Dhatt
- Dept of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sujit K Tripathy
- Dept of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
BACKGROUND Cervical spondylosis is part of the aging process and affects most people if they live long enough. Degenerative changes affecting the intervertebral disks, vertebrae, facet joints, and ligamentous structures encroach on the cervical spinal canal and damage the spinal cord, especially in patients with a congenitally small cervical canal. Cervical spondylotic myelopathy (CSM) is the most common cause of myelopathy in adults. REVIEW SUMMARY The anatomy, pathophysiology, clinical presentation, differential diagnosis, diagnostic investigation, natural history, and treatment options for CSM are summarized. Patients present with signs and symptoms of cervical spinal cord dysfunction with or without cervical nerve root injury. The condition may or may not be accompanied by pain in the neck and/or upper limb. The differential diagnosis is broad. Imaging, typically with magnetic resonance imaging, is the most useful diagnostic tool. Electrophysiologic testing can help exclude alternative diagnoses. The effectiveness of conservative treatments is unproven. Surgical decompression improves neurologic function in some patients and prevents worsening in others, but is associated with risk. CONCLUSIONS Neurologists should be familiar with this very common condition. Patients with mild signs and symptoms of CSM can be monitored. Surgical decompression from an anterior or posterior approach should be considered in patients with progressive and moderate to severe neurologic deficits.
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Treatment of Periodontoid Pannus With Infliximab in a Patient With Rheumatoid Arthritis. J Clin Rheumatol 2009; 15:250-1. [DOI: 10.1097/rhu.0b013e3181b18797] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Younes M, Belghali S, Kriâa S, Zrour S, Bejia I, Touzi M, Golli M, Gannouni A, Bergaoui N. Compared imaging of the rheumatoid cervical spine: Prevalence study and associated factors. Joint Bone Spine 2009; 76:361-8. [DOI: 10.1016/j.jbspin.2008.10.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2008] [Indexed: 10/21/2022]
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Ito H, Neo M, Sakamoto T, Fujibayashi S, Yoshitomi H, Nakamura T. Subaxial subluxation after atlantoaxial transarticular screw fixation in rheumatoid patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2009; 18:869-76. [PMID: 19337758 DOI: 10.1007/s00586-009-0945-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2008] [Revised: 01/31/2009] [Accepted: 03/12/2009] [Indexed: 11/30/2022]
Abstract
The most common cervical abnormality associated with rheumatoid arthritis (RA) is atlantoaxial subluxation, and atlantoaxial transarticular screw fixation has proved to be one of the most reliable, stable fixation techniques for treating atlantoaxial subluxation. Following C1-C2 fixation, however, subaxial subluxation reportedly can bring about neurological deterioration and require secondary operative interventions. Rheumatoid patients appear to have a higher risk, but there has been no systematic comparison between rheumatoid and non-rheumatoid patients. Contributing radiological factors to the subluxation have also not been evaluated. The objective of this study was to evaluate subaxial subluxation after atlantoaxial transarticular screw fixation in patients with and without RA and to find contributing factors. Forty-three patients who submitted to atlantoaxial transarticular screw fixation without any concomitant operation were followed up for more than 1 year. Subaxial subluxation and related radiological factors were evaluated by functional X-ray measurements. Statistical analyses showed that aggravations of subluxation of 2.5 mm or greater were more likely to occur in RA patients than in non-RA patients over an average of 4.2 years of follow-up, and postoperative subluxation occurred in the anterior direction in the upper cervical spine. X-ray evaluations revealed that such patients had a significantly smaller postoperative C2-C7 angle, and that the postoperative AA angle correlated negatively with this. Furthermore, anterior subluxation aggravation was significantly correlated with the perioperative atlantoaxial and C2-C7 angle changes, and these two changes were strongly correlated to each other. In conclusion, after atlantoaxial transarticular screw fixation, rheumatoid patients have a greater risk of developing subaxial subluxations. The increase of the atlantoaxial angel at the operation can lead to a decrease in the C2-C7 angle, followed by anterior subluxation of the upper cervical spine and possibly neurological deterioration.
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Affiliation(s)
- Hiromu Ito
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo, Kyoto, 606-8507, Japan.
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Miyata M, Neo M, Ito H, Yoshida M, Fujibayashi S, Nakamura T. Rheumatoid arthritis as a risk factor for a narrow C-2 pedicle: 3D analysis of the C-2 pedicle screw trajectory. J Neurosurg Spine 2008; 9:17-21. [DOI: 10.3171/spi/2008/9/7/017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Vertebral artery (VA) injury is a potentially serious complication of C-2 pedicle screw (PS) fixation. Although this surgery is frequently performed in patients with rheumatoid arthritis (RA), few studies have compared the risk of VA injury in patients with and without RA. In this study, the authors compare the morphological risk of VA injury relating to C-2 PS fixation in patients with and without RA.
Methods
A total of 110 3D CT images of the cervical spine including the axis were evaluated. Fifty patients with RA and 60 patients without RA were included in the study. The maximum PS diameter (MPSD) that could be used at C-2 without breaching the cortex was measured in 3D using a computer-assisted navigation system. A narrow-pedicle carrier was defined as a patient with an MPSD of 4 mm or less.
Results
In the RA group, 42 of 100 MPSDs were ≤ 4 mm, and 30 of 50 patients (60%) were narrow-pedicle carriers. In the non-RA group, 10 of 120 MPSDs (8%) were ≤ 4 mm, and 8 of 60 (13%) patients were narrow-pedicle carriers. The MPSD, the anteroposterior (AP) diameter of C-3, and the ratio of MPSD to the AP diameter of C-3 were significantly smaller in the RA group than in the non-RA group. Multiple logistic regression analysis showed that RA and narrow C-3 AP diameter were significant risk factors for a narrow-pedicle carrier.
Conclusions
Rheumatoid arthritis is a significant risk factor for a narrow C-2 pedicle. When performing PS placement at C-2, particularly in patients with RA, thorough preoperative evaluation of the bone architecture is very important for avoiding inadvertent injury to the VA.
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Atlantoaxial transarticular screw fixation with posterior wiring using polyethylene cable: facet fusion despite posterior graft resorption in rheumatoid patients. Spine (Phila Pa 1976) 2008; 33:1655-61. [PMID: 18594458 DOI: 10.1097/brs.0b013e31817b5c07] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A comparative retrospective study on the posterior graft union and the facet fusion in atlantoaxial transarticular screw fixation. OBJECTIVE To evaluate the posterior graft union and the facet fusion in atlantoaxial transarticular screw fixation when a polyethylene (PE) cable was used in rheumatoid and nonrheumatoid patients. SUMMARY OF BACKGROUND DATA In atlantoaxial transarticular screw fixation, metal wires or cables for posterior bone graft fixation can cause intraoperative or delayed spinal cord compression. PE cables do not have the risk, but there has been no comparative report. Also, a precise evaluation on the posterior graft union and the facet fusion has not been reported. METHODS Thirty-eight patients who submitted to atlantoaxial transarticular screw fixation and posterior bone graft without any concomitant operation were followed up for more than 2 years. The posterior graft union and the facet fusion were evaluated by functional radiographs and computed tomography scans. RESULTS Seven patients showed the posterior graft nonunion. All of them were rheumatoid patients and received PE cable wiring for posterior internal fixation. However, 5 of the 7 cases presented stable C1-C2 with the facet fusion demonstrated by functional radiographs and computed tomography scans, achieving an overall fusion rate of 95%. CONCLUSION In atlantoaxial transarticular screw fixation, the use of PE cable and rheumatoid background are 2 of the unfavorable factors for the posterior graft union. However, atlantoaxial transarticular screws can bring the facet fusion despite the posterior graft failure in such cases.
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Treatment of upper cervical spine involvement in rheumatoid arthritis patients. Mod Rheumatol 2008; 18:327-35. [PMID: 18414784 DOI: 10.1007/s10165-008-0059-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 02/12/2008] [Indexed: 10/22/2022]
Abstract
The cervical spine, especially the upper cervical spine, is a common focus of destruction by rheumatoid arthritis (RA). Because of its potentially debilitating and life-threatening sequelae, cervical spine involvement remains a priority in the diagnosis and treatment of RA. Many studies show that early surgical intervention gives a more satisfactory outcome. Surgery aims to establish spinal stability and to prevent neurological deterioration and injury to the spinal cord, leading to improved neurological function. The recent sophisticated screw-rod-plate technique allows one to obtain a solid fixation of the upper cervical spine with a high possibility of bone union even in RA patients. Although surgery of the occipitoatlantoaxial region is a challenge with many possibilities of serious complications, recent advances in the surgical technique, complete understanding of the anatomy, and precise preoperative evaluation have decreased complication rates. Early consultation with a specialized spine surgeon is mandatory once cervical involvement is suspected in an RA patient because once the patient becomes myelopathic, the rate of long-term mortality increases and the chance of neurological recovery decreases.
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Aryan HE, Newman CB, Nottmeier EW, Acosta FL, Wang VY, Ames CP. Stabilization of the atlantoaxial complex via C-1 lateral mass and C-2 pedicle screw fixation in a multicenter clinical experience in 102 patients: modification of the Harms and Goel techniques. J Neurosurg Spine 2008; 8:222-9. [PMID: 18312073 DOI: 10.3171/spi/2008/8/3/222] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Stabilization of the atlantoaxial complex has proven to be very challenging. Because of the high mobility of the C1–2 motion segment, fusion rates at this level have been substantially lower than those at the subaxial spine. The set of potential surgical interventions is limited by the anatomy of this region. In 2001 Jürgen Harms described a novel technique for individual fixation of the C-1 lateral mass and the C-2 pedicle by using polyaxial screws and rods. This method has been shown to confer excellent stability in biomechanical studies. Cadaveric and radiographic analyses have indicated that it is safe with respect to osseous and vascular anatomy. Clinical outcome studies and fusion rates have been limited to small case series thus far. The authors reviewed the multicenter experience with 102 patients undergoing C1–2 fusion via the polyaxial screw/rod technique. They also describe a modification to the Harms technique.
Methods
One hundred two patients (60 female and 42 male) with an average age of 62 years were included in this analysis. The average follow-up was 16.4 months. Indications for surgery were instability at the C1–2 level, and a chronic Type II odontoid fracture was the most frequent underlying cause. All patients had evidence of instability on flexion and extension studies. All underwent posterior C-1 lateral mass to C-2 pedicle or pars screw fixation, according to the method of Harms. Thirty-nine patients also underwent distraction and placement of an allograft spacer into the C1–2 joint, the authors' modification of the Harms technique. None of the patients had supplemental sublaminar wiring.
Results
All but 2 patients with at least a 12-month follow-up had radiographic evidence of fusion or lack of motion on flexion and extension films. All patients with an allograft spacer demonstrated bridging bone across the joint space on plain x-ray films and computed tomography. The C-2 root was sacrificed bilaterally in all patients. A postoperative wound infection developed in 4 patients and was treated conservatively with antibiotics and local wound care. One patient required surgical debridement of the wound. No patient suffered a neurological injury. Unfavorable anatomy precluded the use of C-2 pedicle screws in 23 patients, and thus, they underwent placement of pars screws instead.
Conclusions
Fusion of C1–2 according to the Harms technique is a safe and effective treatment modality. It is suitable for a wide variety of fracture patterns, congenital abnormalities, or other causes of atlantoaxial instability. Modification of the Harms technique with distraction and placement of an allograft spacer in the joint space may restore C1–2 height and enhance radiographic detection of fusion by demonstrating a graft–bone interface on plain x-ray films, which is easier to visualize than the C1–2 joint.
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Affiliation(s)
- Henry E. Aryan
- 1Department of Neurosurgery, University of California, San Francisco Medical Center
- 2University of California, San Francisco Spine Center, San Francisco
- 3Division of Neurosurgery, University of California, San Diego Medical Center, San Diego, California; and
| | - C. Benjamin Newman
- 3Division of Neurosurgery, University of California, San Diego Medical Center, San Diego, California; and
| | | | - Frank L. Acosta
- 1Department of Neurosurgery, University of California, San Francisco Medical Center
| | - Vincent Y. Wang
- 1Department of Neurosurgery, University of California, San Francisco Medical Center
| | - Christopher P. Ames
- 1Department of Neurosurgery, University of California, San Francisco Medical Center
- 2University of California, San Francisco Spine Center, San Francisco
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Milhorat TH, Bolognese PA, Nishikawa M, McDonnell NB, Francomano CA. Syndrome of occipitoatlantoaxial hypermobility, cranial settling, and chiari malformation type I in patients with hereditary disorders of connective tissue. J Neurosurg Spine 2008; 7:601-9. [PMID: 18074684 DOI: 10.3171/spi-07/12/601] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECT Chiari malformation Type I (CM-I) is generally regarded as a disorder of the paraxial mesoderm. The authors report an association between CM-I and hereditary disorders of connective tissue (HDCT) that can present with lower brainstem symptoms attributable to occipitoatlantoaxial hypermobility and cranial settling. METHODS The prevalence of HDCT was determined in a prospectively accrued cohort of 2813 patients with CM-I. All patients underwent a detailed medical and neuroradiological workup that included an assessment of articular mobility. Osseous structures composing the craniocervical junction were investigated morphometrically using reconstructed 3D computed tomography and plain x-ray images in 114 patients with HDCT/CM-I, and the results were compared with those obtained in patients with CM-I (55 cases) and healthy control individuals (55 cases). RESULTS The diagnostic criteria for Ehlers-Danlos syndrome and related HDCT were met in 357 (12.7%) of the 2813 cases. Hereditability was generally compatible with a pattern of autosomal dominant transmission with variable expressivity. The diagnostic features of HDCT/CM-I were distinguished from those of CM-I by clinical stigmata of connective tissue disease, a greater female preponderance (8:1 compared with 3:1, p < 0.001), and a greater incidence of lower brainstem symptoms (0.41 compared with 0.11, p < 0.001), retroodontoid pannus formation (0.71 compared with 0.11, p < 0.001), and hypoplasia of the oropharynx (0.44 compared with 0.02, p < 0.001). Measurements of the basion-dens interval, basion-atlas interval, atlas-dens interval, dens-atlas interval, clivus-atlas angle, clivus-axis angle, and atlas-axis angle were the same in the supine and upright positions in healthy control individuals and patients with CM-I. In patients with HDCT/CM-I, there was a reduction of the basion-dens interval (3.6 mm, p < 0.001), an enlargement of the basion-atlas interval (3.0 mm, p < 0.001), and a reduction of the clivus-axis angle (10.8 degrees, p < 0.001), clivus-atlas angle (5.8 degrees, p < 0.001), and atlas-axis angle (5.3 degrees, p < 0.001) on assumption of the upright position. These changes were reducible by cervical traction or returning to the supine position. CONCLUSIONS The identification of HDCT in 357 patients with CM-I establishes an association between two presumably unrelated mesodermal disorders. Morphometric evidence in this cohort-cranial settling, posterior gliding of the occipital condyles, and reduction of the clivus-axis angle, clivus-atlas angle, and atlas-axis angle in the upright position-suggests that hypermobility of the occipitoatlantal and atlantoaxial joints contributes to retroodontoid pannus formation and symptoms referable to basilar impression.
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Affiliation(s)
- Thomas H Milhorat
- Department of Neurosurgery, The Chiari Institute, Harvey Cushing Institute of Neuroscience, North Shore-Long Island Jewish Health System, Manhasset, New York 11030, USA.
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Abstract
Surgery on the cervical spine runs the gamut from minor interventions done in a minimally invasive fashion on a short-stay or ambulatory basis, to major surgical undertakings of a high-risk, high-threat nature done to stabilize a degraded skeletal structure to preserve and protect neural elements. Planning for optimum airway management and anesthesia care is facilitated by an appreciation of the disease processes that affect the cervical spine and their biomechanical implications and an understanding of the imaging and operative techniques used to evaluate and treat these conditions. This article provides background information and evidence to allow the anesthesia practitioner to develop a conceptual framework within which to develop strategies for care when a patient is presented for surgery on the cervical spine.
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Affiliation(s)
- Edward T Crosby
- Department of Anesthesiology, University of Ottawa, The Ottawa Hospital-General Campus, Ottawa, Ontario K1H 8L6, Canada.
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Samartzis D, Kalluri P, Herman J, Lubicky JP, Shen FH. Superior odontoid migration in the Klippel-Feil patient. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 16:1489-97. [PMID: 17171550 PMCID: PMC2200752 DOI: 10.1007/s00586-006-0280-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Revised: 10/03/2006] [Accepted: 11/23/2006] [Indexed: 11/29/2022]
Abstract
Klippel-Feil syndrome (KFS) is an uncommon condition noted primarily as congenital fusion of two or more cervical vertebrae. Superior odontoid migration (SOM) has been noted in various skeletal deformities and entails an upward/vertical migration of the odontoid process into the foramen magnum with depression of the cranium. Excessive SOM could potentially threaten neurologic integrity. Risk factors associated with the amount of SOM in the KFS patient are based on conjecture and have not been addressed in the literature. Therefore, this study evaluated the presence and extent of SOM and the various risk factors and clinical manifestations associated therein in patients with KFS. Twenty-seven KFS patients with no prior history of surgical intervention of the cervical spine were included for a prospective radiographic and retrospective clinical review. Radiographically, McGregor's line was utilized to evaluate the degree of SOM. Anterior and posterior atlantodens intervals (AADI/PADI), number of fused segments (C1-T1), presence of occipitalization, classification-type, and lateral and coronal cervical alignments were also evaluated. Clinically, patient demographics and presence of cervical symptoms were assessed. Radiographic and clinical evaluations were conducted by two independent blinded observers. There were 8 males and 19 females with a mean age of 13.5 years at the time of radiographic and clinical assessment. An overall mean SOM of 5.0 mm (range = -1.0 to 19.0 mm) was noted. C2-C3 (74.1%) was the most commonly fused segment. A statistically significant difference was not found between the amount of SOM to age, sex-type, classification-type, AADI, PADI, and lateral cervical alignment (P > 0.05). A statistically significant greater amount of SOM was found as the number of fused segments increased (r = 0.589; P = 0.001) and if such levels included occipitalization (r = 0.616; P = 0.001). A statistically significant greater amount of SOM was also found with an increase in coronal cervical alignment (r = 0.413; P = 0.036). Linear regression modeling further supported these findings as the strongest predictive variables contributing to an increase in SOM. A 7.20 crude relative risk (RR) ratio [95% confidence interval (CI) = 1.05-49.18; risk differences (RD) = 0.52] was noted in contributing to a SOM greater than 4.5 mm if four or more segments were fused. Adjusting for coronal cervical alignment greater than 10 degrees , five or more fused segments were found to significantly increase the RR of a SOM greater than 4.5 mm (RR = 4.54; 95% CI = 1.07-19.50; RD = 0.48). The RR of a SOM greater than 4.5 mm was more pronounced in females (RR = 1.68; 95% CI = 0.45-6.25; RD = 0.17) than in males. Eight patients (29.6%) were symptomatic, of which symptoms in two of these patients stemmed from a traumatic event. However, a statistically significant difference was not found between the presence of symptoms to the amount of SOM and other exploratory variables (P > 0.05). A mean SOM of 5.0 mm was found in our series of KFS patients. In such patients, increases in the number of congenitally fused segments and in the degree of coronal cervical alignment were strongly associated risk factors contributing to an increase in SOM. Patients with four or greater congenitally fused segments had an approximately sevenfold increase in the RR in developing SOM greater than 4.5 mm. A higher RR of SOM more than 4.5 mm may be associated with sex-type. However, 4.5 mm or greater SOM is not synonymous with symptoms in this series. Furthermore, the presence of symptoms was not statistically correlated with the amount of SOM. The treating physician should be cognizant of such potential risk factors, which could also help to indicate the need for further advanced imaging studies in such patients. This study suggests that as motion segments diminish and coronal cervical alignment is altered, the odontoid orientation is located more superiorly, which may increase the risk of neurologic sequelae.
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Affiliation(s)
- Dino Samartzis
- Graduate Division, Harvard University, Cambridge, MA USA
- NIHES, Erasmus University, Rotterdam, The Netherlands
| | | | - Jean Herman
- Shriners Hospitals for Children, Chicago, IL USA
| | - John P. Lubicky
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN USA
| | - Francis H. Shen
- Shriners Hospitals for Children, Chicago, IL USA
- Department of Orthopaedic Surgery, University of Virginia, P.O. Box 800159, Charlottesville, VA 22908-0159 USA
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Ito H, Neo M, Yoshida M, Fujibayashi S, Yoshitomi H, Nakamura T. Efficacy of computer-assisted pedicle screw insertion for cervical instability in RA patients. Rheumatol Int 2006; 27:567-74. [PMID: 17094002 DOI: 10.1007/s00296-006-0256-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Accepted: 10/31/2006] [Indexed: 11/25/2022]
Abstract
We evaluated the efficacy of the computer-assisted cervical pedicle screw insertion, compared with those inserted without the help of the system on the cervix of rheumatoid arthritis (RA) patients. Eighty-six cervical pedicle screws were inserted without the help of the system. Of the 86, 59 screws were in non-RA patients with degenerative spine, and 27 were in RA patients. The accuracy of the screw insertions was evaluated by a CT-based method. Then, 25 screws were inserted with the system into the cervical spines between C2 and C6 in RA patients (Navigation group). The efficacy of the system was assessed by the CT-based method, compared with 27 screws inserted without the system (Conventional group). The screws in RA patients tended to be more deviated than those in non-RA patients. In Conventional group, four screws (15%) were placed far laterally, and two (7%), far medially. In contrast, no screw was placed far laterally or medially in Navigation group (P < 0.05).
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Affiliation(s)
- H Ito
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo, Kyoto, 606-8507, Japan.
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Yoshida M, Neo M, Fujibayashi S, Nakamura T. Comparison of the anatomical risk for vertebral artery injury associated with the C2-pedicle screw and atlantoaxial transarticular screw. Spine (Phila Pa 1976) 2006; 31:E513-7. [PMID: 16816753 DOI: 10.1097/01.brs.0000224516.29747.52] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN We evaluated the trajectories of atlantoaxial transarticular and C2-pedicle screws in 3 dimensions using computerized tomography. OBJECTIVE To compare the anatomic risk for vertebral artery injury associated with C2-pedicle and atlantoaxial transarticular screws. SUMMARY OF BACKGROUND DATA The atlantoaxial fixation technique using C1-lateral mass screws combined with C2-pedicle screws is considered a safer technique for preventing vertebral artery injury than atlantoaxial transarticular fixation. However, few reports have compared the anatomic risk of vertebral artery injury associated with C2-pedicle screws with that of transarticular screws. METHODS A total of 62 consecutive patients with cervical lesions were evaluated using 3-dimensional images reconstructed by a computer-assisted navigation system. We compared the maximum possible diameters of the atlantoaxial transarticular screw and C2-pedicle screw trajectories, and examined whether the maximum possible diameters were limited by the height or width of the bony structure in screw trajectories < or = 4 mm in diameter. RESULTS Mean maximum possible diameters did not differ significantly between the trajectories of 124 atlantoaxial transarticular and 124 C2-pedicle screws. In screw trajectories < or = 4 mm in diameter, 57.1% of transarticular screw trajectories were limited by the height of the bony structure, and all pedicle screw trajectories were limited by the width. CONCLUSIONS C2-pedicle screw placement has nearly the same anatomic risk of vertebral artery injury as transarticular screw placement. Preoperative 3-dimensional evaluation may be useful for choosing the best surgical technique.
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Affiliation(s)
- Makoto Yoshida
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Shogoin, Kyoto, Japan
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Heyde CE, Weber U, Kayser R. Die rheumatisch bedingte Instabilität der oberen Halswirbelsäule. DER ORTHOPADE 2006; 35:270-87. [PMID: 16432689 DOI: 10.1007/s00132-005-0918-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Rheumatic manifestation at the cervical spine occurs in more than 50% of all cases in the natural course of this disease. The first cervical manifestation takes place in the upper cervical spine. The initial involvement of the C1/C2 segment leads to atlantodental subluxation. Progressive destruction can result in vertical instability, which is characterized by cranial subluxation of the odontoid process with the danger of resulting stenosis and cervical myelopathy. The goal of diagnosis has to be the early recognition of these changes to establish an effective treatment protocol. Persistent pain, neurological deficits, and progressive radiological signs for instability are indications for operative stabilizing procedures. These procedures avoid progressive destruction and improve the prognosis regarding pain decrease, regression of neurological deficits, and life expectancy.
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Affiliation(s)
- C E Heyde
- Klinik für Unfall- und Wiederherstellungschirurgie, Charité, Campus Benjamin Franklin, Universitätsmedizin, Berlin.
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Wolfs JFC, Peul WC, Boers M, van Tulder MW, Brand R, van Houwelingen HJC, Thomeer RTWM. Rationale and design of The Delphi Trial – I(RCT)2: international randomized clinical trial of rheumatoid craniocervical treatment, an intervention-prognostic trial comparing 'early' surgery with conservative treatment [ISRCTN65076841]. BMC Musculoskelet Disord 2006; 7:14. [PMID: 16483360 PMCID: PMC1420300 DOI: 10.1186/1471-2474-7-14] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2005] [Accepted: 02/16/2006] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Rheumatoid arthritis is a chronic inflammatory disease, which affects 1% of the population. Hands and feet are most commonly involved followed by the cervical spine. The spinal column consists of vertebrae stabilized by an intricate network of ligaments. Especially in the upper cervical spine, rheumatoid arthritis can cause degeneration of these ligaments, causing laxity, instability and subluxation of the vertebral bodies. Subsequent compression of the spinal cord and medulla oblongata can cause severe neurological deficits and even sudden death. Once neurological deficits occur, progression is inevitable although the rapidity of progression is highly variable. The first signs and symptoms are pain at the back of the head caused by compression of the major occipital nerve, followed by loss of strength of arms and legs. The severity of the subluxation can be observed with radiological investigations (MRI, CT) with a high sensitivity.
The authors have sent a Delphi Questionnaire about the current treatment strategies of craniocervical involvement by rheumatoid arthritis to an international forum of expert rheumatologists and surgeons. The timing of surgery in patients with radiographic instability without evidence of neurological deficit is an area of considerable controversy. If signs and symptoms of myelopathy are present there is little chance of recovery to normal levels after surgery.
Design
In this international multicenter randomized clinical trial, early surgical atlantoaxial fixation in patients with rheumatoid arthritis and radiological abnormalities without neurological deficits will be compared with prolonged conservative treatment. The main research question is whether early surgery can prevent radiological and neurological progression. A cost-effectivity analysis will be performed. 250 patients are needed to answer the research question.
Discussion
Early surgery could prevent serious neurological deficits, but may have peri-operative morbidity and loss of rotation of the head and neck. The objective of this study is to identify the best timing of surgery for patients at risk for the development of neurological signs and symptoms.
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Affiliation(s)
- Jasper FC Wolfs
- Department of Neurosurgery, Leiden University Medical Center, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, The Netherlands
| | - Maarten Boers
- Department of Epidemiology and Rheumatology, VU Medical Center Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Institute for Research in Extramural Medicine (EMGO), VU Medical Center Amsterdam, The Netherlands
| | - Ronald Brand
- Department of Biostatistics, Leiden University Medical Center, The Netherlands
| | | | - Raph TWM Thomeer
- Department of Neurosurgery, Leiden University Medical Center, The Netherlands
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Shen FH, Samartzis D, Herman J, Lubicky JP. Radiographic assessment of segmental motion at the atlantoaxial junction in the Klippel-Feil patient. Spine (Phila Pa 1976) 2006; 31:171-7. [PMID: 16418636 DOI: 10.1097/01.brs.0000195347.35380.68] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective review of 33 consecutive Klippel-Feil syndrome (KFS) patients at a single institution. OBJECTIVES To assess in KFS patients the presence and degree of radiographic segmental motion at the atlantoaxial junction, factors contributing to such motion, and associated clinical manifestations. SUMMARY OF BACKGROUND DATA Studies suggest that abnormal segmentation in KFS patients may result in cervical hypermobility, increasing the risk of developing neurologic compromise and the need for surgical intervention. The use of the anterior and posterior atlantodens interval (AADI/PADI) has gained interest as a method for assessing atlantoaxial instability and for space available for the cord. Although helpful for identifying instability after trauma, these measurements are not understood in KFS patients. In addition, the effects of the fusion process associated with KFS on atlantoaxial motion and associated clinical findings have not been properly addressed. METHODS Radiographs were analyzed for the presence of occipitalization, number/location of congenitally fused segments, and the AADI and PADI. RESULTS There were 15 males and 18 females (mean age, 13.9 years). Occipitalization occurred in 48.5% of patients. A fused C2-C3 segment was noted in 72.7% of cases. More motion with respect to AADI was evident on O-C1 and C2-C3 fusion only patients, which were all asymptomatic. Overall, 24.2% of patients were symptomatic. Mean AADI and PADI difference was 2.0 mm (symptomatic: mean, 1.5 mm; asymptomatic: mean, 2.1 mm) and -1.7 mm (symptomatic: mean, -1.0 mm; asymptomatic: mean, -2.0 mm), respectively (P > 0.05). CONCLUSIONS Hypermobility of the atlantoaxial junction, as indicated by increased AADI on flexion-extension radiographs, is not necessarily associated with an increased risk for the development of symptoms or neurologic signs in the KFS patient. Occipitalization plays an integral role in the degree of motion at the atlantoaxial region. Greatest AADI values were in patients with occipitalization and a fused C2-C3 segment. The presence of symptoms was not related to the degree of AADI change. Evaluation of the PADI provides additional information for identifying patients at risk for developing symptoms. Nonetheless, KFS patients remain largely asymptomatic.
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Affiliation(s)
- Francis H Shen
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA 22908-0159, USA.
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