The surgical management of the rheumatoid spine: Has the evolution of surgical intervention changed outcomes?

Radiological assessment and surgical management of cervical spine involvement in patients with rheumatoid arthritis

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.

Intraoperative Computed Tomography for C1-C2 Stabilization by Goel-Harms: Analysis of Clinical Efficacy and a Novel Classification of Screw Placement Accuracy

BACKGROUND

The introduction of intraoperative computed tomography (iCT) could improve the surgical results of C1-C2 stabilization by Goel-Harms, especially in patients with complex deformities. This study aims to investigate the impact of iCT on the accuracy of C1-C2 screw positioning and to develop a score based on multiparametric analysis of imaging data (Cervical Screw Placement Accuracy score [CSPAs]).

METHODS

Twenty-one patients were retrospectively evaluated. The data obtained with the use of an iCT were compared with the incidence of cases of malpositioning in the literature. Multiparametric imaging criteria were developed: the 82 screw positions were evaluated using the CSPA criteria and 2 additional variables. The CSPAs was obtained from the aggregation of the CSPAs criteria: optimal (CSPAs ≥8), suboptimal (CSPAs = 6-7), malpositioned (CSPAs ≤5).

RESULTS

The average incidence of malpositioning in C1-C2 arthrodesis decreased from 13% without iCT to 1.2% with the aid of iCT, considering a monoparametric value. The CSPAs analysis shows a greater discretion and higher number of well-defined categories of the accuracy of C1-C2 screw position: optimal, 80.3%; suboptimal, 17.1%; and malposition, 2.6%. A correlation was observed between the accuracy of the positioning of both right and left screws in C2. Furthermore, the anatomic site of C2 screws was found to be a predictor of cortical invasion.

CONCLUSIONS

The results suggest that the introduction of the iCT is associated with a consistent improvement of the accuracy in the positioning of the screws. A multiparametric score (CSPAs) could improve the assessment of screw placement.