Evaluation of posterior long fusion versus conservative treatment for the progressive rheumatoid cervical spine

[The rheumatic cervical spine]

BACKGROUND

The cervical spine is one of the main sites of manifestation in rheumatoid arthritis outside of the extremities. It can have a decisive influence on disease course via the occurrence of mechanical instabilities as well as neurologic symptoms. Both adequate diagnosis and the corresponding surgical treatment represent a challenge for the involved physicians.

MATERIALS AND METHODS

This review presents relevant diagnostic strategies and possibilities for surgical intervention which aim to avoid potentially fatal neurologic symptoms. Basic literature and expert opinions are also discussed.

RESULTS AND CONCLUSION

Through target-oriented surgical management, as well as tight clinical and radiologic monitoring during conservative and surgical therapy, potentially fatal disease courses can be avoided.

Pooled data analysis on anterior versus posterior approach for rheumatoid arthritis at the craniovertebral junction

OBJECT

Rheumatoid arthritis (RA) is one of the most debilitating autoimmune diseases affecting the craniovertebral junction (CVJ). Patients predominantly present with myelopathic symptoms and intractable neck pain. The surgical approach traditionally has been either a combined anterior and posterior approach or a posterior-only approach. In this article, the authors review pooled data from the literature and discuss the benefits of the two types of approaches.

METHODS

A search of the PubMed database was conducted using key words that describe spine deformities in RA and specific spinal interventions. The authors evaluated the neurological outcomes based on the Ranawat scale in both the groups through chi-square analysis. Multiple logistic regression was carried out to further examine for potential confounders. Any adverse sequalae resulting from either approach were also documented. Because all the procedures performed via a transoral approach in the analyzed articles also involved posterior fixation, for convenience of comparison, the combined procedures are referred to as "anterior approach" or "anterior-posterior" in the present study.

RESULTS

The search yielded 233 articles, of which 11 described anterior approaches and 14 evaluated posterior approaches. The statistical analysis showed that patients treated with a posterior approach fared better than those treated with an anterior (combined) approach. It was noted that those patients in whom the cervical subluxations were reducible on traction predominantly underwent posterior approaches.

CONCLUSIONS

CVJ instability is a serious complication of RA that requires surgical intervention. Although the anterior-posterior combined approach can provide direct decompression, it is associated with morbidity, and the analysis showed no statistically significant benefit to patients. In contrast, the posterior approach has been shown to provide statistically significant superiority with respect to stabilization and subsequent pannus reduction. Surgical approaches are undertaken based on the reducibility of subluxations with traction and the vector of compressive force. However, the choice of surgical approach should be based on the individual patient's pathology.

Distal Junctional Disease after Occipitothoracic Fusion for Rheumatoid Cervical Disorders: Correlation with Cervical Spine Sagittal Alignment

Study Design Retrospective radiographic study. Objective We have performed occipitothoracic (OT) fusion for severe rheumatoid cervical disorders since 1991. In our previous study, we reported that the distal junctional disease occurred in patients with fusion of O-T4 or longer due to increased mechanical stress. The present study further evaluated the association between the distal junctional disease and the cervical spine sagittal alignment. Methods Among 60 consecutive OT fusion cases between 1991 and 2010, 24 patients who underwent O-T5 fusion were enrolled in this study. The patients were grouped based on whether they developed postoperative distal junctional disease (group F) or not (group N). We measured pre- and postoperative O-C2, C2-C7, and O-C7 angles and evaluated the association between these values and the occurrence of distal junctional disease. Results Seven (29%) of 24 patients developed adjacent-level vertebral fractures as distal junctional disease. In group F, the mean pre- and postoperative O-C2, C2-C7, and O-C7 angles were 12.1 and 16.8, 7.2 and 11.2, and 19.4 and 27.9 degrees, respectively. In group N, the mean pre- and postoperative O-C2, C2-C7, and O-C7 angles were 15.9 and 15.0, 4.9 and 5.8, and 21.0 and 20.9 degrees, respectively. There were no significant differences between the two groups. The difference in the O-C7 angle (postoperative angle - preoperative angle) in group F was significantly larger than that in group N (p = 0.04). Conclusion Excessive correction of the O-C7 angle (hyperlordotic alignment) is likely to cause postoperative distal junctional disease following the OT fusion.

Adjacent-level failures after occipito-thoracic fusion for rheumatoid cervical disorders

INTRODUCTION

The natural history of cervical spine lesions in rheumatoid arthritis (RA) is variable. We have actively performed occipito-thoracic fusion for severe destructive rheumatoid cervical disorders and reported its clinical results and complications. In our previous study, the most frequent complication was the adjacent-level failures caused by the fragile spine. The objective of this study was to determine risk factors for adjacent-level failures after occipito-thoracic fusion.

MATERIALS AND METHODS

Subjects were 35 RA patients (31 females and 4 males) who underwent occipito-thoracic fusion using RRS Loop Spinal System(®) (Robert Reid Inc. Tokyo, Japan), and the incidence and characteristics of adjacent-level failures were investigated. Furthermore, the adjacent-level failures were divided into two types according to their levels, fracture at the lowest level of the fusion area and that at the level inferior to the fusion area, and the characteristics of each type were evaluated.

RESULTS AND CONCLUSION

Nine (26%) of 35 patients suffered adjacent-level failures (10 vertebral fractures). Adjacent-level failures occurred when the distance of fixation was "O-T4" or longer. The long fusion might cause adjacent-level failures due to greater mechanical stress. Seven fractures occurred at the lowest level of the fusion area, and all of them were cured without symptoms by conservative treatment. Three fractures occurred at the level inferior to the fusion area, and one of them needed additional surgery due to sudden paraplegia resulting from collapse of the adjacent vertebra. After occipito-thoracic fusion, burst fractures at the level inferior to the fusion area might cause sudden paraplegia, and therefore a careful observation should be required for patients with these fractures.

Mid-term results of computer-assisted cervical reconstruction for rheumatoid cervical spines

STUDY DESIGN

A retrospective single-center study. We routinely have used C1-C2 transarticular and cervical pedicle screw fixations to reconstruct highly destructed unstable rheumatoid arthritis (RA) cervical lesions. However, there is little data on mid-term results of surgical reconstruction for rheumatoid cervical disorders, particularly, cervical pedicle screw fixation.

OBJECTIVES

The purpose of this study was to evaluate the mid-term surgical results of computer-assisted cervical reconstruction for such lesions.

METHODS

Seventeen subjects (4 men, 13 women; mean age, 61 ± 9 years) with RA cervical lesions who underwent C1-C2 transarticular screw fixation or occipitocervical fixation, with at least 5 years follow-up were studied. A frameless, stereotactic, optoelectronic, CT-based image-guidance system, was used for correct screw placement. Variables including the Japanese Orthopaedic Association (JOA) score, Ranawat class, EuroQol (EQ-5D), atlantodental interval, and Ranawat values before, and at 2 and 5 years after surgery, were evaluated. Furthermore, screw perforation rates were evaluated.

RESULTS

The lesions included atlantoaxial subluxation (AAS, n = 6), AAS + vertical subluxation (VS, n = 7), and AAS + VS + subaxial subluxation (n = 4). There was significant neurological improvement at 2 years after surgery, as evidenced by the JOA scores, Ranawat class, and the EQ-5D utility weight. However, at 5 years after surgery, there was a deterioration of this improvement. The Ranawat values before, and at 2 and 5 years after surgery, were not significantly different. Major screw perforation rate was 2.1 %. No neural and vascular complications associated with screw insertion were observed.

CONCLUSIONS

Subjects with rheumatoid cervical lesions who underwent C1-C2 transarticular screw fixation or occipitocervical fixation using a pedicle screw had significantly improved clinical parameters at 2 years after surgery. However, there was a deterioration of this improvement at 5 years post surgery.

Cervical spine instability in rheumatoid arthritis

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.

Neurological improvement and prognosis after occipito-thoracic fusion in patients with mutilating-type rheumatoid arthritis

INTRODUCTION

Mutilating-type rheumatoid arthritis, the most aggressive type of rheumatoid arthritis, is frequently associated with destructive cervical involvement, both at the high-cervical and subaxial levels, causing significant neurological deficit, and their natural course of the disease and the survival are discouraging. For such cases, we have been actively performing occipito-thoracic fusion since 1991. Although medical treatment for rheumatoid patients has represented a marked improvement, it could not treat all of these patients because of several reasons. Therefore, it is still important to evaluate the past treatment results.

METHODS

We investigated the neurological improvement and prognosis in 51 mutilating-type rheumatoid arthritis patients who underwent occipito-thoracic fusion between 1991 and 2010. The neurological status was evaluated using modified Ranawat classification; class IIIB was subdivided into IIIBa (able to sit upright) and IIIBb (bedridden).

RESULTS

The preoperative neurologic status was IIIBa in 19 patients and IIIBb in 17 patients. 15 of the 19 patients with class IIIBa improved to being able to walk (79 %), whereas only 3 of the 17 patients with class IIIBb improved to being able to walk (18 %) after surgery. Of the 51 patients, 28 died during follow-up; the mean age at death was 67.2 years. The postoperative 5- and 10-year survival rates were 60.3 and 26.4 %, respectively.

CONCLUSION

The neurological improvement and prognosis after surgery was poorer in class IIIBb patients than in the other patient groups. Occipito-thoracic fusion can improve the neurological symptoms and prognosis. However, early surgical intervention is recommended, before a patient becomes bedridden (class IIIBb).

Rheumatoid vertical and subaxial subluxation can be prevented by atlantoaxial posterior screw fixation

PURPOSE

Literature has described a risk for subsequent vertical subluxation (VS) and subaxial subluxation (SAS) following atlantoaxial subluxation in rheumatoid patients; however, the interaction of each subluxation and the radiographic findings for atlantoaxial fixation has not been described. The purpose of this study was to evaluate the effects of two different posterior atlantoaxial screw fixation on the development of subluxation in patients with rheumatoid atlantoaxial subluxation.

METHODS

Between 1996 and 2006, rheumatoid patients treated with transarticular fixation and posterior wiring (TA) or C1 lateral mass-C2 pedicle screw fixations (SR) in the Nagoya Spine Group hospitals, a multicenter cooperative study group, were included in this study. VS, SAS, craniocervical sagittal alignment, and range of motion (ROM) at the atlantoaxial adjacent segments were investigated to determine whether posterior atlantoaxial screw fixation is a prophylactic or a risk factor for the development of VS and SAS.

RESULTS

The mean follow-up was 7.2 years (4-12). No statistically significant difference was observed among the patients treated with either of the procedure during the follow-up period. Of 34 patients who underwent posterior atlantoaxial screw fixation, SAS was observed in 26.5 % during the follow-up period; however, VS was not observed. Postoperative C2-7 angle, and Oc-C1 and C2-3 ROM were significantly different between patients with and without postoperative SAS. The incidence of SAS was 38.9 % for TA and 12.5 % for SR; statistically significant differences were observed in the postoperative C1-2 and C2-7 angles, and C2-3 ROM.

CONCLUSIONS

Atlantoaxial posterior screw fixation may be an appropriate prophylactic intervention for VS and SAS if the atlantoaxial joint develops bony fusion following physiological alignment. Compared to TA, SR provided optimal atlantoaxial angle and prevented lower adjacent segment degeneration, thereby reducing SAS.

Occipitocervicothoracic stabilization in pediatric patients

OBJECT

Although rarely encountered, pediatric patients with severe cervical spine deformities and instability may occasionally require occipitocervicothoracic instrumentation and fusion. This case series reports the experience of 4 pediatric centers in managing this condition. Occipitocervical fixation is the treatment of choice for craniocervical instability that is symptomatic or threatens neurological function. In children, the most common distal fixation level with modern techniques is C-2. Treated patients maintain a significant amount of neck motion due to the flexibility of the subaxial cervical spine. Distal fixation to the thoracic spine has been reported in adult case series. This procedure is to be avoided due to the morbidity of complete loss of head and neck motion. Unfortunately, in rare cases, the pathological condition or highly aberrant anatomy may require occipitocervical constructs to include the thoracic spine.

METHODS

The authors identified 13 patients who underwent occipitocervicothoracic fixation. Demographic, radiological, and clinical data were gathered through retrospective review of patient records from 4 institutions.

RESULTS

Patients ranged from 1 to 14 years of age. There were 7 girls and 6 boys. Diagnoses included Klippel-Feil, Larsen, Morquio, and VATER syndromes as well as postlaminectomy kyphosis and severe skeletal dysplasia. Four patients were neurologically intact and 9 had myelopathy. Five children were treated with preoperative traction prior to instrumentation; 5 underwent both anterior and posterior spinal reconstruction. Two patients underwent instrumentation beyond the thoracic spine. Allograft was used anteriorly, and autologous rib grafts were used in the majority for posterior arthrodesis. Follow-up ranged from 0 to 43 months. Computed tomography confirmed fusion in 9 patients; the remaining patients were lost to follow-up or had not undergone repeat imaging at the time of writing. Patients with myelopathy either improved or stabilized. One child had mild postoperative unilateral upper-extremity weakness, and a second child died due to a tracheostomy infection. All patients had severe movement restriction as expected.

CONCLUSIONS

Occipitocervicothoracic stabilization may be employed to stabilize and reconstruct complex pediatric spinal deformities. Neurological function can be maintained or improved. The long-term morbidity of loss of cervical motion remains to be elucidated.

Clinical output of the rheumatoid cervical spine in patients with mutilating-type joint involvement: for better activities of daily living and longer survival

STUDY DESIGN

Retrospective study.

OBJECTIVE

To gain an insight for the final clinical output of surgically managed cervical lesions in seropositive rheumatoid arthritis (RA) patients with mutilating-type joint involvement (mutilating-RA patients), these patients was followed up until either death or complete bedridden.

SUMMARY OF BACKGROUND DATA

There has been no study reporting the final clinical output of surgically managed cervical lesion in mutilating-RA patients. In our previous study, we reported short- to middle-term result of such patient. The present study further traced those patients and reports the final clinical output.

METHODS

Seventeen seropositive mutilating-RA patients extracted from 504 RA patients were enrolled. Eleven patients underwent surgical treatments, whereas six patients did not. All patients, who underwent operation, have received occipitocervical or occipitocervicothoracic fusion. Neck pain, neurological symptoms and ADL score were completely followed up (i.e., follow-up period>10 years).

RESULTS

The six patients of non-operated group worsened ADL score and resulted in either complete bedridden or death within 3 years. Contrary, 11 operated patients either improved or maintained ADL until their death. Survival rate in 6.2 years was 0% in non-operated group and 27% in operated group, respectively. The present study suggests that the seropositive mutilating-RA patients worsen cervical lesions once they become affected, and are likely to lose their ADL activity.

CONCLUSION

Once seropositive mutilating-RA patients develop major spinal involvement(s), they are likely to undergo a life-threatening stage of the disease during the next 5-10 years. Surgical intervention is advocated not only to treat the neurological compromise but also to sustain their ADL levels during end stage of disease. The sustained ADL, in turn, may contribute to the longevity of these patients by preventing other major life-threatening events.

Neurologic outcome of surgical and conservative treatment of rheumatoid cervical spine subluxation: a systematic review

OBJECTIVE

Rheumatoid arthritis commonly involves the upper cervical spine and can cause significant neurologic morbidity and mortality. However, there is no consensus on the optimal timing for surgical intervention: whether surgery should be performed prophylactically or once neurologic deficits have become apparent.

METHODS

A systematic review of the literature was performed to analyze neurologic outcome (Ranawat) and survival time (Kaplan-Meier) after surgical or conservative treatment using the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation system) criteria.

RESULTS

Twenty-five observational studies were selected. No randomized controlled trials (RCTs) could be found. All of the studies had a high risk of bias. Twenty-three studies reported the neurologic outcome after surgery for 752 patients. Neurologic deterioration rarely occurred in Ranawat I and II patients. Ranawat III patients did not fully recover. The 10-year survival rates were 77%, 63%, 47%, and 30% for Ranawat I, II, IIIA, and IIIB, respectively. The Ranawat IIIB patients had a significantly worse outcome. Another 185 patients treated conservatively were described in 7 studies. Neurologic deterioration rarely occurred in Ranawat I patients, but was almost inevitable in Ranawat II, IIIA, and IIIB patients. The Kaplan-Meier analysis showed a 10-year overall survival rate of 40%.

CONCLUSION

There are no RCTs that compared surgery with conservative treatment. In observational studies, surgical neurologic outcomes were better than conservative treatment in all patients with cervical spine involvement, and in asymptomatic patients with no neurologic impairment (Ranawat I) the outcomes were similar; however, the evidence is weak. Survival time of surgical and conservative treatment could not be compared.

Incidence of and risk factors for complications associated with halo-vest immobilization: a prospective, descriptive cohort study of 239 patients

BACKGROUND

Since high rates of serious complications, such as death and pneumonia, during halo-vest immobilization have been reported, there has been a tendency of restraint with regard to the use of the halo vest. However, the rate of complications in a high-volume center with sufficient experience is unknown. Our objective was to determine the incidence of and risk factors associated with complications during halo-vest immobilization.

METHODS

During a five-year period, a prospective cohort study was performed in a single, level-I trauma center that was also a tertiary referral center for spinal disorders. Data from all patients undergoing halo-vest immobilization were collected prospectively, and every complication was recorded. The primary outcome was the presence or absence of complications. Univariate regression analysis and regression modeling were used to analyze the results.

RESULTS

In 239 patients treated with halo-vest immobilization, twenty-six major, seventy-two intermediate, and 121 minor complications were observed. Fourteen patients (6%) died during the treatment, although only one death was related directly to the immobilization and three were possibly related directly to the immobilization. Twelve patients (5%) acquired pneumonia during halo-vest immobilization. Patients older than sixty-five years did not have an increased risk of pneumonia (p = 0.543) or halo vest-related mortality (p = 0.467). Halo vest-related complications ranged from three patients (1%) with incorrect initial placement of the halo vest to twenty-nine patients (12%) with a pin-site infection. Pin-site infection was significantly related to pin penetration through the outer table of the skull (odds ratio, 4.34; 95% confidence interval, 1.22 to 15.51; p = 0.024). In 164 trauma patients treated only with halo-vest immobilization, cervical fractures with facet joint involvement or dislocations were significantly related to radiographic loss of alignment during follow-up (odds ratio, 2.81; 95% confidence interval, 1.06 to 7.44; p = 0.031).

CONCLUSIONS

There are relatively low rates of mortality and pneumonia during halo-vest immobilization, and elderly patients do not have an increased risk of pneumonia or death related to halo-vest immobilization. Nevertheless, the total number of minor complications is substantial. This study confirms that awareness of and responsiveness to minor complications can prevent subsequent development of serious morbidities and perhaps reduce mortality.

Mediastinal migration of distal occipito-thoracic instrumentation

We present the occurrence and management of mediastinal migration of the distal aspect of a posterior occipito-thoracic screw-rod construct. No similar occurrence was found in the literature. This event occurred following an emergency tracheotomy (requiring neck hyperextension) in a patient with severe rheumatoid arthritis, who had previously undergone decompression and an Occiput-T2 instrumented fusion for cranio-cervical and sub-axial cervical spine instability. Imaging showed fracture-subluxation of T1/2 and T2/3 with the bilateral C7, T1 and T2 screws in the mediastinum causing tracheal and esophageal compression. Removal of the instrumentation, decompression (T2 corpectomy) and construct revision down to T10 was safely performed from a posterior approach. Severe osteoporosis, some pre-existing screw loosening and hyperextension of the neck were the predisposing factors of this near catastrophic event. By staying directly posterior to the rod and following the fibrous tract already created, the instrumentation was safely removed from the mediastinum.

Long-term incidence of subaxial cervical spine instability following cervical arthrodesis surgery in patients with rheumatoid arthritis

OBJECTIVE

Cervical spine deformities are well-known complications of RA. A 5- to 20-year follow-up of 51 consecutive rheumatoid patients who underwent posterior cervical arthrodesis is presented to evaluate the recurrence of instability and need for further surgery.

METHODS

We conducted a retrospective review of the clinical features of 11 men and 40 women with an established diagnosis of RA and associated cervical deformities who underwent cervical spine surgery at the Mayo Clinic (Rochester, MN) between 1979 and 1990. Their mean age was 61 +/- 10 years (SD), and their duration of RA averaged 21 +/- 8.9 years (SD). There were 22 patients who presented with myelopathy, 7 with radiculopathy, and 22 with instability/neck pain. There were 33 patients with AAS, 2 with SMO process into the foramen magnum, 8 with SAS, and 8 with combinations of these. Preoperative reduction was followed by decompression and fusion using wiring techniques and autologous bone graft. Postoperative halo orthosis was provided for at least 3 months. The mean follow-up was 8.3 +/- 6 years (SD).

RESULTS

There were 31 patients (61%) who underwent atlantoaxial arthrodesis, 17 patients (33%) who underwent subaxial, and 3 patients (6%) who underwent occipitocervical arthrodesis. During follow-up, 39% (13/33) of patients with AAS developed nonsymptomatic (6) or symptomatic/unstable (7) SASs subsequent to C1-C2 fusion. The latter 7 patients (21%) subsequently required extension of their arthrodesis. Adjacent segment disease was most common at the C3-C4 interspace after atlantoaxial fusion in 62% (8/13). Among the 8 patients who underwent isolated cervical fusion for SAS, 1 patient (1/8, 12%) developed adjacent instability after a fall and required extension of the previous fusion. No secondary procedure was required for the 6 patients initially stabilized by C1-(C6-T1) fusions for combinations of AAS + SAS. None of the patients initially treated by C1-C2 arthrodesis for AAS progressed to SMO.

CONCLUSIONS

The incidence of subaxial instability in patients with rheumatoid disease who underwent cervical arthrodesis may be higher than previously reported, indicating the need for continued follow-up in these patients. Adjacent segment disease may be most common at the C3-C4 level following atlantoaxial fusion. Early stabilization of the C1-C2 complex in the patients with AAS may potentially prevent progression of SMO.

Surgical outcome in rheumatoid Ranawat Class IIIb myelopathy

OBJECTIVE

Rheumatoid arthritis frequently affects the craniovertebral junction (CVJ) and may lead to severe neck pain, quadriparesis, and respiratory dysfunction. Surgery in rheumatoid nonambulatory (Ranawat Class IIIb) patients carries a significant risk. This study presents the surgical outcome of Class IIIb patients with CVJ rheumatoid myelopathy and reviews the literature.

METHODS

One hundred twelve consecutive patients with rheumatoid cervical myelopathy underwent surgical decompression and stabilization. Thirty-two of the patients (mean age, 66.81 +/- 10.25 yr) with CVJ rheumatoid arthritis were in Class IIIb, and all had atlantoaxial subluxation. A halo brace was applied before surgery and continued during surgery. Eleven patients with reducible atlantoaxial subluxation underwent direct posterior fusion. Twenty-one patients with fixed atlantoaxial subluxation underwent transoral decompression and then posterior fusion while they were under anesthesia.

RESULTS

At a mean follow-up of 39 months, four patients improved to Class II and 14 improved to Class IIIa, whereas six remained in Class IIIb. Neck pain was relieved in all patients. There was one perioperative death after transoral surgery (posterior fusion not done), and seven other patients died subsequently of causes unrelated to surgery. The morbidity of surgery included construct failure, cerebrospinal fluid leak, superficial wound or graft donor site infection, transient dysphagia, and lung infection.

CONCLUSION

A large subset of patients with CVJ rheumatoid myelopathy may reach Class IIIb. These patients have unique management considerations. Surgery (despite high morbidity) often remains the best therapeutic option available to them. Improvement of even one grade in their Ranawat score from Class IIIb to Class IIIa brought about by surgery confers on them a significant benefit in terms of their quality of life and survival.

Bone resorption of the facet joint in rheumatoid arthritis as a predictor of lower cervical myelopathy

The purpose of the present study was to identify the risk factors to predict instability of the subaxial cervical spine and cervical myelopathy based on plain radiographs. The study was performed on 99 patients with mutilating rheumatoid arthritis (RA). From plain lateral radiographs of the cervical spine over time, rheumatoid cervical spine lesions were investigated and evaluation was made on the possibility to develop cervical myelopathy. The incidence of subaxial cervical spine lesions in the patients with mutilating RA was as high as 98%. In particular, resorption of the superior facet suggests high risk to develop cervical myelopathy. The presence of spinous process erosion is also likely to reveal such a possibility. There was no statistically significant difference in the anteroposterior diameter of cervical spinal canal between the cases with cervical myelopathy and those without it. Resorption of the superior facet is the most important factor for the development of cervical myelopathy. In the cases with rheumatoid cervical spine lesions, it is necessary to take special notice of the superior facet.

Long-Term Results of Occipitothoracic Fusion Surgery in RA Patients with Destruction of the Cervical Spine

OBJECTIVE

This is a retrospective study of the outcome of occipitothoracic fusion surgery in rheumatoid arthritis (RA) patients with destruction of the cervical spine, designed to assess the efficacy of halo vest before surgery, the postoperative outcome, and the activities-of-daily living (ADL) problems associated with surgical management. There have been no reports regarding these issues, including surgical effect on subjacent vertebrae.

METHODS

This study included 20 RA patients with destruction of the cervical spine. All patients underwent preoperative halo vest followed by occipitothoracic fusion with an average follow-up of 5 years. The long-term clinical outcomes were analyzed using a modified Ranawat classification.

RESULTS

Before halo application, the neurologic status was assessed as IIIC in 15 patients and IIIB in 5 patients. After halo application, the neurologic status improved in all patients: IIIA in 12 patients and IIIB in 8 patients. After surgery, the neurologic status did not improve in six of the eight IIIB patients but improved to IIIA in two patients. Of the 12 IIIA patients, the neurologic status improved to II in 6 patients but did not improve in the other 6 patients. Patient satisfaction was excellent for 14 patients, good for 3 patients, and fair for only 3 patients (1 had difficulty drinking, another had back pain, and the last had low back pain associated with a compression fracture of the lumbar spine).

CONCLUSIONS

We have performed occipitothoracic fusion surgery in RA patients with destruction of the cervical spine. Preoperative halo vest was very effective for improving the neurologic status, for the general condition, and for an optimal sagittal alignment. Occipitothoracic fusion using unit rods gave satisfactory long-term clinical results compared with the prognosis of patients in whom the disease follows its natural course.

Rheumatoid arthritis: evaluation and surgical management of the cervical spine

BACKGROUND CONTEXT

Rheumatoid arthritis is a debilitating polyarthropathic degenerative condition. Eighty-six percent of patients with rheumatoid arthritis have cervical spine involvement. Often these lesions are clinically asymptomatic or symptoms are erroneously attributed to peripheral manifestation of the patient's rheumatoid disease. Because these lesions are common and missed diagnosis can result in death, early recognition is vital.

PURPOSE

The purpose of this literature review is to identify common lesions present in the rheumatoid neck and review diagnostic methods as well as treatment options for those requiring surgical intervention.

STUDY DESIGN

A review of the English medical literature with focus on more recent studies on the presentation, diagnosis, management, surgical treatment and clinical outcomes of rheumatoid arthritis of the cervical spine.

METHODS

A comprehensive literature review of the English medical literature obtained through Medline up to November 2003 was performed identifying relevant and more recent articles that addressed the presentation, evaluation, surgical management and outcomes of rheumatoid patients with cervical spine involvement.

RESULTS

If left untreated, a large percentage of rheumatoid patients with cervical spine involvement progress toward complex instability patterns resulting in significant morbidity and mortality. Once myelopathy occurs, prognosis for neurologic recovery and long-term survival is poor. In properly selected patients, anterior and/or posterior cervical procedures can prevent neurologic injuries and preserve remaining function.

CONCLUSION

Cervical spine involvement in the rheumatoid patient is common and progressive. Early diagnosis and treatment is imperative; however, surgical intervention should be considered carefully because associated morbidity and mortality is high.

Cervical Laminoplasty for Subaxial Lesion in Rheumatoid Arthritis

Expansive laminoplasty of the cervical spine was performed for 15 patients with subaxial lesion (SAL) in rheumatoid arthritis (RA) with or without symptomatic occipitocervical pathology. Clinical results were satisfactory, and radiographic evaluation revealed that the range of movement of the cervical spine decreased to 56.3%, spinal alignment was well preserved, and intervertebral slipping advanced only slightly. Therefore, expansive laminoplasty is shown to be clinically effective in decompressing the subaxial spinal cord without the need for fusion of this region, yet it avoids exacerbating or creating significant instability. We found that it can serve as a useful procedure for treating spinal cord compression caused by SAL in RA. For patients with upper cervical instability, laminoplasty with upper cervical fusion appears to be an effective option. In a case in which kyphosis was observed preoperatively, its deformity became worse after laminoplasty. Thus, it may be advisable to consider subaxial fusion in such cases.