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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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Krauss WE, Bledsoe JM, Clarke MJ, Nottmeier EW, Pichelmann MA. Rheumatoid Arthritis of the Craniovertebral Junction. Neurosurgery 2010; 66:83-95. [DOI: 10.1227/01.neu.0000365854.13997.b0] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Abstract
BACKGROUND
Rheumatoid arthritis (RA) is the most common inflammatory disease involving the spine. It has a predilection for involving the craniocervical spine. Despite widespread involvement of the cervical spine with RA, few patients need surgery. The 3 major spinal manifestations of RA in the cervical spine are basilar invagination, atlantoaxial instability, and subaxial subluxations. Surgical management of RA involving the craniovertebral junction remains a challenge despite a decline in severe cases and an improvement in surgical techniques.
METHODS
We conducted an exhaustive review of English-language publications discussing RA involving the craniovertebral junction. We paid special attention to publications detailing modern surgical management of these conditions. In addition, we outline our own surgical experience with such patients.
RESULTS
We discuss alternative surgical methods for treating basilar invagination, atlantoaxial instability, and concurrent subaxial subluxations. We detail our surgical technique for transoral odontoidectomy, occipital cervical fusion, and atlantoaxial fusion. We detail the use of spinal surgical navigation in both of these procedures.
CONCLUSION
Surgical management of RA remains a challenging field. There clearly has been a decrease in cases of mutilating RA involving the craniovertebral junction. Surgical techniques for managing these conditions have steadily improved.
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Wolfs JFC, Kloppenburg M, Fehlings MG, van Tulder MW, Boers M, Peul WC. Neurologic outcome of surgical and conservative treatment of rheumatoid cervical spine subluxation: a systematic review. ACTA ACUST UNITED AC 2010; 61:1743-52. [PMID: 19950322 DOI: 10.1002/art.25011] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Jasper F C Wolfs
- Leiden University Medical Center, Leiden, The Hague, The Netherlands.
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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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Application of full-scale three-dimensional models in patients with rheumatoid cervical spine. 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 2008; 17:644-9. [PMID: 18247063 DOI: 10.1007/s00586-008-0611-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 12/21/2007] [Accepted: 01/18/2008] [Indexed: 10/22/2022]
Abstract
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.
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Nannapaneni R, Behari S, Todd NV. Surgical outcome in rheumatoid Ranawat Class IIIb myelopathy. Neurosurgery 2006; 56:706-15; discussion 706-15. [PMID: 15792509 DOI: 10.1227/01.neu.0000156202.80185.32] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2004] [Accepted: 12/02/2004] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Ravindra Nannapaneni
- Department of Neurosurgery, Newcastle General Hospital, Newcastle upon Tyne, England
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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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Sakakima H, Ijiri K, Taketomi E, Iwao A, Kiyama R, Tawaratsumita M, Ishido Y, Komiya S, Matsuda T. The Trial Development of an Original C-Shaped Cervical Collar (Kagoshima-Sekijyuji, KS Collar) for Patients with Rheumatoid Arthritis. J Phys Ther Sci 2005. [DOI: 10.1589/jpts.17.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Kosei Ijiri
- School of Health Sciences, Faculty of Medicine, Kagoshima University
| | | | - Asako Iwao
- School of Health Sciences, Faculty of Medicine, Kagoshima University
| | - Ryoji Kiyama
- School of Health Sciences, Faculty of Medicine, Kagoshima University
| | | | | | - Seturo Komiya
- Department of Neuro-Musculoskeletal Disorder, Orthopaedic Surgery, Graduate School of Medicine and Dentistry, Kagoshima University
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Hentschel SJ, Nader R, Suki D, Dastgir A, Callender DL, DeMonte F. Craniofacial resections in the elderly: an outcome study. J Neurosurg 2004; 101:935-43. [PMID: 15597754 DOI: 10.3171/jns.2004.101.6.0935] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The elderly population is increasing in number and is healthier now than in the past. The purpose of this study was to examine complications and outcomes following craniofacial resection (CFR) in elderly patients and to compare findings with those of a matched younger cohort.
Methods. All patients 70 years of age or older undergoing CFR at the M. D. Anderson Cancer Center (elderly group) between December 1992 and July 2003 were identified by examining the Department of Neurosurgery database. A random cohort of 28 patients younger than 70 years of age (control group) was selected from the overall population of patients who underwent CFR.
There were 28 patients ranging in age from 70 to 84 years (median 74 years). Major local complications occurred in seven elderly patients (25%) and in six control patients (21%) (p = 0.75), and major systemic complications occurred in nine elderly patients (32%) and in three control patients (11%) (p = 0.05). There was one perioperative death in both groups of patients. The median duration of disease-specific survival for the elderly patients was not reached (mean 6.8 years); however, it was 8.3 years for control patients (p = 0.24). Predictors of poorer overall survival from a multivariate analysis of the elderly group included presence of cardiac disease (p = 0.005), a major systemic perioperative complication (p = 0.03), and a preoperative Karnofsky Performance Scale score less than 100 (p = 0.04).
Conclusions. In this study of elderly patients who underwent CFR, there was no difference in disease-specific survival when compared with a matched cohort of younger patients. There was, however, an increased incidence of perioperative major systemic complications in the elderly group.
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Affiliation(s)
- Stephen J Hentschel
- Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030-4009, USA
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Shen FH, Samartzis D, Jenis LG, An HS. Rheumatoid arthritis: evaluation and surgical management of the cervical spine. Spine J 2004; 4:689-700. [PMID: 15541704 DOI: 10.1016/j.spinee.2004.05.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2003] [Accepted: 05/05/2004] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Francis H Shen
- Department of Orthopedic Surgery, Rush Medical College, Rush-Presbyterian-St. Luke's Medical Center, 1725 West Harrison Street, Suite 1063 POB, Chicago, IL 60612, USA
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