Francis H Shen, Dino Samartzis, Louis G Jenis, Howard S An
Rheumatoid arthritis: evaluation and surgical management of the cervical spine.
Spine J. 2004 Nov-Dec;4(6):689-700. doi: 10.1016/j.spinee.2004.05.001.
Abstract/Text
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.
Hoan Vu Nguyen, Steven C Ludwig, Jeffery Silber, Daniel E Gelb, Paul A Anderson, Lawrence Frank, Alexander R Vaccaro
Rheumatoid arthritis of the cervical spine.
Spine J. 2004 May-Jun;4(3):329-34. doi: 10.1016/j.spinee.2003.10.006.
Abstract/Text
BACKGROUND CONTEXT: Rheumatoid arthritis affects over 2 million patients in the United States. It is the most common inflammatory disorder of the cervical spine. The natural history is variable. Women tend to be more commonly involved than men. Atlantoaxial instability is the most common form of cervical involvement and may occur either independently or concomitantly with cranial settling and subaxial instability. Cervical spine involvement can be seen in up to 86% of patients and neurologic involvement in up to 58%. Myelopathy is rare but when present portends a poor prognosis. What is frustrating for clinicians treating these patients is that pain cannot be equated with instability or instability with neurologic symptoms. The goal is to identify patients at risk before the development of neurologic symptoms. Both radiographic and nonradiographic risk factors play an important role in the surgical decision-making process.
PURPOSE: We will describe the current concepts in rheumatoid arthritis of the cervical spine. Emphasis is placed on the natural history, anatomy, pathophysiology and decision-making process.
STUDY DESIGN: A review of the current concepts of rheumatoid arthritis of the cervical spine.
METHODS: MEDLINE search of all English literature published on rheumatoid arthritis of the cervical spine.
RESULTS: Rheumatoid arthritis of the cervical spine was first described by Garrod in 1890. The prevalence has been estimated to be 1% to 2% of the world's adult population. Despite its prevalence, the etiology of rheumatoid arthritis remains unknown. Because of its potentially debilitating and life-threatening sequelae in advanced disease, rheumatoid arthritis in the cervical spine today remains a high priority to diagnose and treat.
CONCLUSIONS: Many aspects of the natural history and pathophysiology of the rheumatoid spine remain unclear. The timing of operative intervention in patients with radiographic instability and no evidence of neurologic deficit is an area of considerable controversy. Continued surveillance into the natural history of the rheumatoid spine is required.
Naoki Shoda, Atsushi Seichi, Katsushi Takeshita, Hirotaka Chikuda, Takashi Ono, Hiroyuki Oka, Hiroshi Kawaguchi, Kozo Nakamura
Sleep apnea in rheumatoid arthritis patients with occipitocervical lesions: the prevalence and associated radiographic features.
Eur Spine J. 2009 Jun;18(6):905-10. doi: 10.1007/s00586-009-0975-z. Epub 2009 Apr 14.
Abstract/Text
Since sleep apnea is a risk factor for high mortality of rheumatoid arthritis (RA) patients, this study examined the prevalence in RA patients with occipitocervical lesions, and the associated radiographic features. Twenty-nine RA patients requiring surgery for progressive myelopathy due to occipitocervical lesions (3 males, 26 females, average age 65 years) were preoperatively evaluated. Twenty-three (79%) had sleep apnea defined as apnea-hypopnea index >5 events per hour measured by a portable monitoring device, and all of them were classified as the obstructive type. Among gender, age, bone mass index (BMI), and radiographic parameters related to occipitocervical lesions: atlantodental interval (ADI), cervical angles (O/C1, C1/2, and C2/6), and cervical lengths (O-C2 and O-C6), the ADI and cervical lengths were shown to be significantly associated with the presence of sleep apnea by parametric statistical analysis. Since there were positive correlations between the ADI and cervical lengths by Pearson's test, we performed a multivariate logistic regression analysis after adjustment for confounding factors and found that small ADI was the principle parameter associated with sleep apnea. We therefore conclude that the prevalence of sleep apnea is higher than that in a general RA population that was reported previously, and believe that occipitocervical lesions are an independent risk factor for this condition. Small ADI and short neck, secondary to the vertical translocation by RA, may cause obstructive sleep apnea, probably through mechanical or neurological collapse of the upper airway.
Hiromi Ataka, Takaaki Tanno, Tomohiro Miyashita, Shiroh Isono, Masashi Yamazaki
Occipitocervical fusion has potential to improve sleep apnea in patients with rheumatoid arthritis and upper cervical lesions.
Spine (Phila Pa 1976). 2010 Sep 1;35(19):E971-5. doi: 10.1097/BRS.0b013e3181c691df.
Abstract/Text
STUDY DESIGN: Case series.
OBJECTIVE: To analyze factors that contribute to the development of sleep apnea in patients with rheumatoid arthritis (RA) and upper cervical lesions.
SUMMARY OF BACKGROUND DATA: No large prospective study has analyzed the association between sleep apnea and upper cervical involvement resulting from RA. Furthermore, only 1 report in the literature describes a case of sleep apnea accompanying rheumatoid vertical subluxation of the odontoid process.
METHODS: The authors analyzed 8 consecutive RA patients with upper cervical lesions who underwent occipitocervical (O-C) fusion. The patients were examined with all-night polysomnography before and after surgery. Patients with apnea-hypopnea index values>or=5 were diagnosed to have sleep apnea. O-C2 angles were calculated from cervical radiographs.
RESULTS: All 8 patients were diagnosed as having sleep apnea, and most of their apneic episodes were obstructive in origin. Among the 4 patients with medullary compression, central apneic episodes comprisedCONCLUSION: All our study patients with RA and upper cervical lesions had obstructive-dominant sleep apnea. Negative O-C2 angles may result in upper airway narrowing, increasing the severity of sleep apnea. O-C fusion with correction of kyphosis at the craniovertebral junction has the potential to improve sleep apnea in RA patients.
Shunji Matsunaga, Takashi Sakou, Toshiyuki Onishi, Kyoji Hayashi, Eiji Taketomi, Nobuhiko Sunahara, Setsuro Komiya
Prognosis of patients with upper cervical lesions caused by rheumatoid arthritis: comparison of occipitocervical fusion between c1 laminectomy and nonsurgical management.
Spine (Phila Pa 1976). 2003 Jul 15;28(14):1581-7; discussion 1587.
Abstract/Text
STUDY DESIGN: A matched controlled comparative study of patients with upper cervical lesions caused by rheumatoid arthritis was performed at two different hospitals to evaluate occipitocervical fusion associated with C1 laminectomy and nonsurgical treatment.
OBJECTIVES: To evaluate the long-term results and advantages of occipitocervical fusion associated with C1 laminectomy, and to compare these results with those of nonsurgical management of patients with myelopathy related to rheumatoid arthritis.
SUMMARY OF BACKGROUND DATA: Few studies have reported the prognosis of patients with rheumatoid arthritis managed by occipitocervical fusion associated with C1 laminectomy.
METHODS: In this study, 40 patients with rheumatoid arthritis and myelopathy caused by irreducible atlantoaxial dislocation with or without upward migration of the odontoid process were studied. Of these 40 patients, 19 were treated by occipitocervical fusion using a rectangular rod associated with C1 laminectomy at one hospital, whereas 21 matched patients were treated conservatively at another hospital. The patients were observed by the same protocol to assess the radiologic and clinical results, including functional recovery and survival rate. All the patients were followed until their death.
RESULTS: The atlantodental interval was reduced immediately after surgery, and this result had been well maintained at the final follow-up assessment. Redlund-Johnell values did not vary significantly throughout the course of the study. As for neural assessment with the Ranawat classification system, improvement was found in 13 (68%) of the 19 patients who underwent surgery. The survival rate was 84% 5 years after surgery, and 37% in the first 10 years. In the patients who did not undergo surgical treatment, atlantodental interval and Redlund- Johnell values were aggravated. These patients showed no neural improvement, and aggravation was found in 16 (76%) of the 21 cases during the follow-up period. All the patients were bedridden within 3 years after the onset of myelopathy. The survival rate was 0% in the first 8 years.
CONCLUSIONS: The findings lead to the conclusion that occipitocervical fusion associated with C1 laminectomy for patients with rheumatoid arthritis is useful for decreasing nuchal pain, reducing myelopathy, and improving prognosis.
Jasper F C Wolfs, Margreet Kloppenburg, Michael G Fehlings, Maurits W van Tulder, Maarten Boers, Wilco C Peul
Neurologic outcome of surgical and conservative treatment of rheumatoid cervical spine subluxation: a systematic review.
Arthritis Rheum. 2009 Dec 15;61(12):1743-52. doi: 10.1002/art.25011.
Abstract/Text
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.
Jun Mizutani, Takeshi Matsubara, Muneyoshi Fukuoka, Nobuhiko Tanaka, Hirotaka Iguchi, Aiharu Furuya, Hideki Okamoto, Ikuo Wada, Takanobu Otsuka
Application of full-scale three-dimensional models in patients with rheumatoid cervical spine.
Eur Spine J. 2008 May;17(5):644-9. doi: 10.1007/s00586-008-0611-3. Epub 2008 Feb 5.
Abstract/Text
Full-scale three-dimensional (3D) models offer a useful tool in preoperative planning, allowing full-scale stereoscopic recognition from any direction and distance with tactile feedback. Although skills and implants have progressed with various innovations, rheumatoid cervical spine surgery remains challenging. No previous studies have documented the usefulness of full-scale 3D models in this complicated situation. The present study assessed the utility of full-scale 3D models in rheumatoid cervical spine surgery. Polyurethane or plaster 3D models of 15 full-sized occipitocervical or upper cervical spines were fabricated using rapid prototyping (stereolithography) techniques from 1-mm slices of individual CT data. A comfortable alignment for patients was reproduced from CT data obtained with the patient in a comfortable occipitocervical position. Usefulness of these models was analyzed. Using models as a template, appropriate shape of the plate-rod construct could be created in advance. No troublesome Halo-vests were needed for preoperative adjustment of occipitocervical angle. No patients complained of dysphasia following surgery. Screw entry points and trajectories were simultaneously determined with full-scale dimensions and perspective, proving particularly valuable in cases involving high-riding vertebral artery. Full-scale stereoscopic recognition has never been achieved with any existing imaging modalities. Full-scale 3D models thus appear useful and applicable to all complicated spinal surgeries. The combination of computer-assisted navigation systems and full-scale 3D models appears likely to provide much better surgical results.
Yukihiro Matsuyama, Noriaki Kawakami, Hisatake Yoshihara, Taichi Tsuji, Mitsuhiro Kamiya, Yasutsugu Yukawa, Naoki Ishiguro
Long-term results of occipitothoracic fusion surgery in RA patients with destruction of the cervical spine.
J Spinal Disord Tech. 2005 Feb;18 Suppl:S101-6.
Abstract/Text
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.
Magerl F, Seemann PS: Stable Posterior Fusion of the Atlas and Axis by Transarticular Screw Fixation. Cervical Spine I. Springer-Verlag, 322-327, 1987.
J Harms, R P Melcher
Posterior C1-C2 fusion with polyaxial screw and rod fixation.
Spine (Phila Pa 1976). 2001 Nov 15;26(22):2467-71.
Abstract/Text
STUDY DESIGN: A novel technique of atlantoaxial stabilization using individual fixation of the C1 lateral mass and the C2 pedicle with minipolyaxial screws and rods is described. In addition, the initial results of this technique on 37 patients are described.
OBJECTIVES: To describe the technique and the initial clinical and radiographic results for posterior C1-C2 fixation with a new implant system.
SUMMARY OF BACKGROUND DATA: Stabilization of the atlantoaxial complex is a challenging procedure because of the unique anatomy of this region. Fixation by transarticular screws combined with posterior wiring and structural bone grafting leads to excellent fusion rates. The technique is technically demanding and has a potential risk of injury to the vertebral artery. In addition, this procedure cannot be used in the presence of fixed subluxation of C1 on C2 and in the case of an aberrant path of the vertebral artery. To address these limitations, a new technique of C1-C2 fixation has been developed: bilateral insertion of polyaxial-head screws in the lateral mass of C1 and through the pars interarticularis into the pedicle of C2, followed by a fluoroscopically controlled reduction maneuver and rod fixation.
METHODS: After posterior exposure of the C1-C2 complex, the 3.5-mm polyaxial screws are inserted in the lateral masses of C1. Two polyaxial screws are then inserted into the pars interarticularis of C2. Drilling is guided by anatomic landmarks and fluoroscopy. If necessary, reduction of C1 onto C2 can be accomplished by manipulation of the implants, followed by fixation to the 3-mm rod. For definitive fusion, cancellous bone can be added. No structural bone graft or wiring is required. In selected cases, e.g., C1-C2 subluxation or fractures in young patients in whom only temporary fixation is necessary, the instrumentation can be removed after an appropriate time. Because the joint surfaces stay intact, the patient can regain motion in the C1-C2 joints.
RESULTS: Thirty-seven patients underwent this procedure. No neural or vascular damage related to this technique has been observed. The early clinical and radiologic follow-up data indicate solid fusion in all patients.
CONCLUSION: Fixation of the atlantoaxial complex using polyaxial-head screws and rods seems to be a reliable technique and should be considered an efficient alternative to the previously reported techniques.
C Bundschuh, M T Modic, F Kearney, R Morris, C Deal
Rheumatoid arthritis of the cervical spine: surface-coil MR imaging.
AJR Am J Roentgenol. 1988 Jul;151(1):181-7. doi: 10.2214/ajr.151.1.181.
Abstract/Text
Fifteen patients with classic rheumatoid arthritis were investigated with plain films, pluridirectional tomography, and surface-coil T1-weighted MR imaging at 500/17 (TR/TE). We evaluated the atlantodental interval; basion-dental interval; density or intensity of the dens; dens erosion; cranial settling; anterior, posterior, lateral, or rotatory atlantoaxial subluxation; subaxial subluxation; ligamentous calcification or osteophytes; erosion; cystic changes; joint-space narrowing of the apophyseal articulations; and posterior spinous process erosion. In addition, the cervicomedullary angle and the neuraxis configuration were identified on MR images. To determine its normal range, the cervicomedullary angle was measured in 50 patients whose MR studies were unrelated to the craniovertebral junction. All patients with a cervicomedullary angle less than 135 degrees had evidence of brainstem compression, cervical myelopathy, or C2 root pain. Also, all patients with cervicomedullary junction compression were neurologically abnormal. MR was found to be as good as tomography in evaluating the atlantodental interval, dens erosion, ligamentous calcification or osteophytes of the upper spine, subaxial subluxation, and various subluxations that occur in the occiput-C2 area. MR was less effective than tomography in evaluating the basion-dental interval, erosion of the posterior spinous processes, apophyseal joint disease from C3 inferiorly, and cystic changes of the articular facets of C1-C2. The most clinically important parameters were well seen with MR. The data show that MR is an excellent imaging procedure for evaluating rheumatoid arthritis of the cervical spine.
