Abstract
Cervical spine involvement in rheumatoid arthritis (RA) is common and can lead to severe pain, irreversible neurological deterioration and even death. It presents a challenge to the treating physician as the pain, neurological symptoms and instability cannot be equated with each other.
RA of the cervical spine follows the same pathophysiology as in the peripheral joints and leads to instability due to atlanto-axial subluxation, mid- and lower cervical spine instability and basilar invagination. The clinical presentation is variable and neurological assessment is difficult due to peripheral disease. Patients with minimal symptoms can have major life-threatening instability.
Treatment goals are to prevent irreversible neurological deficit, alleviate intractable pain and to avoid death due to cord compression.
Timing of surgical interventions is extremely important. It is generally recommended to address the instability (usually C1/C2) early in order to avoid more extensive fixation and fusion. Surgical stabilization is challenging because of suboptimal bone quality, increased risks of infection and difficult post-operative rehabilitation but generally leads to favourable outcomes. Referral of patients to specialist rheumatology centres and screening of cervical spine with flexion-extension radiographs and MRI scans seems optimal to avoid patients presenting with major deformity, instability and advanced myelopathy. Surgical treatment of the rheumatoid cervical spine is very demanding and should therefore be performed at centres where cervical spine surgery is performed on a regular basis. In our experience, even advanced neurological deficit can significantly improve following well-executed surgery.
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Allaire SH, Prashker MJ, Meenan RF. The costs of rheumatoid arthritis. Pharmacoeconomics. 1994;6(6):513–22.
Bayley E, Zia Z, Kerslake R, Klezl Z, Boszczyk BM. Lamina-guided lateral mass screw placement in the sub-axial cervical spine. Eur Spine J. 2010;19(4):660–4.
Boden SD, Dodge LD, Bohlman HH, Rechtine GR. Rheumatoid arthritis of the cervical spine. A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am. 1993;75(9):1282–97.
Brattström H, Granholm L. Atlanto-axial fusion in rheumatoid arthritis. A new method of fixation with wire and bone cement. Acta Orthop Scand. 1976;47(6):619–28.
Casey ATH, Crockard AH, Pringle J, O’Brien MF, Stevens JM. Rheumatoid arthritis of the cervical spine: Current techniques for management. Orthop Clin North Am. 2002;33:291–309.
Clark CR, Goetz DD, Menzes AH. Athrodesis of the cervical spine in rheumatoid arthritis. J Bone Joint Surg Am. 1989;71:381–92.
Conaty JP, Mongan ES. Cervical fusion in rheumatoid arthritis. J Bone Joint Surg Am. 1981;63(8):1218–27.
Conlon PW, Isdale IC, Rose BS. Rheumatoid arthritis of the cervical spine. An analysis of 333 cases. Ann Rheum Dis. 1966;25(2):120–6.
Da Sylva D, Doran MF, Crowson CS, O’Fallon WM, Matteson EL. Declining use of orthopedic surgery in patiens with rheumatoid arthritis? Results of long-term, population-based assessment. Arthritis Rheum. 2003;49:216–20.
Dreyer SJ, Boden SD. Natural history of rheumatoid arthritis of the cervical spine. Clin Orthop Relat Res. 1999;366:98–106.
Dvorak J, Grob D, Baumgartner H, Gschwend N, et al. Functional evaluation of the spinal cord by magnetic resonance imaging in patients with rheumatoid arthritis and instability of upper cervical spine. Spine. 1989;14(10):1057–64 (Phila Pa 1976).
Gallie WE. Fractures and dislocations of the spine. Am J Surg. 1939;46:495–9.
Goel A, Laheri V, Harms J, Melcher P. Posterior C1-C2 fusion with polyaxial screw and rod fixation. Spine. 2001;26:2467–71. Spine (Phila Pa 1976). 2002 Jul 15; 27(14): 1589–90.
Grassi W, De Angelis R, Cervini C. Corticosteroid prescribing in rheumatoid arthritis and psoriatic arthritis. Clin Rheumatol. 1998;17(3):223–6.
Grassi W, De Angelis R, Lamanna G, Cervini C. The clinical features of rheumatoid arthritis. Eur J Radiol. 1998;27(Suppl 1):S18–24.
Grob D, Magerl F, McGowan DP. Spinal pedicle fixation: reliability and validity of roentgenogram- based assessment and surgical factors on successful screw placement. Spine. 1990;15(3):251 (Phila Pa 1976).
Hamilton JD, Gordon M-M, McInnes IB, Johnston RA, Madhok R, Capell HA. Improved medical and surgical management of cervical spine disease in patients with rheumatoid arthritis over 10 years. Ann Rheum Dis. 2000;59:434–8.
Harms J, Posterior MRP. C1–C2 fusion with polyaxial screw and rod fixation. Spine. 2001;26(22):2467–71 (Phila Pa 1976).
Hoshino Y, Kurokawa T, Nakamura K, Seichi A, Miyoshi K. A report on the safety of unilateral vertebral artery ligation during cervical spine surgery. Spine. 1996;21(12):1454–7.
Katz WA, Bland JH. Shoulder, neck and thorax. In: Diagnosis and management of rheumatoid disease. 2nd ed. Philadelphia: JB Lippincott Co, 1988, p. 88–120.
Uchida K, Nakajima H, Sato R, Baba H. Multivariate analysis of the neurological outcome of surgery for cervical compressive myelopathy. J Orthop Sci. 2005;10(6):564–73.
Larson E-M, Holtas S, Zygmunt S. Pre and postoperative MR imaging of the craniocervical junction in rheumatoid arthritis. Am J Roentgenol. 1989;152:561–6.
Lipson SJ. Rheumatoid arthritis in the cervical spine. Clin Orthop Relat Res. 1989;239:121–7.
Makoto Y, Masashi N, Shunsuke F, Takashi N. Comparison of the Anatomical Risk for Vertebral Artery Injury Associated With the C2-Pedicle Screw and Atlantoaxial Transarticular Screw. Spine. 2006;31(15):E513–7.
Markenson JA. Worldwide trends in the socioeconomic impact and long-term prognosis of rheumatoid arthritis. Semin Arthritis Rheum. 1991;21(2 Suppl 1):4–12.
Matsunaga S, Ijiri K, Koga H. Results of a longer than 10-year follow-up of patients with rheumatoid arthritis treated by occipitocervical fusion. Spine. 2000;25(14):1749–53 (Phila Pa 1976).
Moskovich R, Crockard HA, Shott S. Occipito-cervical stabilization for myelopathy in patiens with rheumatoid arthritis. J Bone Joint Surg Am. 2000;82A:349–65.
Nurick S. The pathogenesis of the spinal cord disorder associated with cervical spondylosis. Brain. 1972;95(1):87–100.
Oda T, Fujiwara K, Yonenobu K, Azuma B, Ochi T. Natural course of cervical spine lesions in rheumatoid arthritis. Spine. 1995;20(10):1128–35 (Phila Pa 1976).
Omura K, Hukuda S, Katsuura A, Saruhashi Y, Imanaka T, Imai S. Evaluation of posterior long fusion versus conservative treatment for the progressive rheumatoid cervical spine. Spine. 2002;27(12):1336–45 (Phila Pa 1976).
Pastor D. The use of electrical stimulation and exercise to increase muscle strength in a patient after surgery for cervical spondylotic myelopathy. Physiother Theory Pract. 2010;26(2):134–42.
Pincus T. Long-term outcomes in rheumatoid arthritis. Br J Rheumatol. 1995;34(2):59–73.
Rana NA. Natural history of atlanto-axial subluxation in rheumatoid arthritis. Spine. 1989;14(10):1054–6 (Phila Pa 1976).
Ranawat CS, O’Leary P, Pellicci P. Tsairis P Cervical spine fusion in rheumatoid arthritis. J Bone Joint Surg Am. 1979;61(7):1003–10.
Riew KD, Hilibrand A, Palumbo MA. Diagnosing basilar invagination in the rheumatoid patient. J Bone Joint Surg Am. 2001;83:194–200.
Sherk HH. Atlantoaxial instability and acquired basilar invagination in rheumatoid arthritis. Orthop Clin North Am. 1978 Oct;9(4):1053–63.
Singh A, Choi D, Crockard A. Use of walking data in assessing operative results for cervical spondylotic myelopathy: long-term follow-up and comparison with controls. Spine. 2009;34(12):1296–300 (Phila Pa 1976).
Solanki GA, Crockard HA. Peroperative determination of safe superior transarticular screw trajectory through the lateral mass. Spine. 1999;24(14):1477–82 (Phila Pa 1976).
Van der Heijde DM, van Riel PL, van Rijswijk MH, et al. Influence of prognostic features on the final outcome in rheumatoid arthritis: a review of the literature. Semin Arthritis Rheum. 1988;17(4):284–92.
Vetti N, Alsing R, Kråkenes J, Rørvik J, Gilhus NE, Brun JG, Espeland A. MRI of the transverse and alar ligaments in rheumatoid arthritis: feasibility and relations to atlantoaxial subluxation and disease aktivity. Neuroradiology. 2010;52:215–23.
Ward MM. Decreases in rates of hospitalization for manifestations of severe rheumatoit arthritis. Arthritis Rheum. 2004;50:1122–31.
Weinblatt ME. Rheumatoid arthritis: treat now, not later! Ann Intern Med. 1996;124(8):773–4.
Wright NM, Lauryssen C. Vertebral artery injury in C1–2 transarticular screw fixation. J Neurosurg. 1998;88:634–40.
Zeidman SM, Ducker TB, Raycroft J. Trends and complications in cervical spine surgery: 1989–1993. J Spinal Disord. 1997;10(6):523–6.
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Klezl, Z., Stulik, J. (2014). Surgical Treatment of the Cervical Spine in Rheumatoid Arthritis. In: Bentley, G. (eds) European Surgical Orthopaedics and Traumatology. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-34746-7_24
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