![Page 1: Cervical Spine Surgery – For Patients with Rheumatoid Arthritis Wayne Cheng, MD. Assistant professor Department of Orthopaedic Surgery Loma Linda University](https://reader030.vdocuments.mx/reader030/viewer/2022032706/56649dfe5503460f94ae616a/html5/thumbnails/1.jpg)
Cervical Spine Surgery –For Patients with Rheumatoid Arthritis
Wayne Cheng, MD.Assistant professor
Department of Orthopaedic SurgeryLoma Linda University Medical Center
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Outline
The most common abnormalities. Clinical Presentation. Radiological Evaluation. Natural History. Predictor of progression and recovery. Indication for surgery Surgical Considerations
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Incidence RA affects 1% of adult
population in US. C-spine is the second
most common skeletal manifestation (15-86%).
Up to 26% of in-patients with RA may need surgical intervention.
Three most common abnormalities:– 1. AAS– 2. AAI– 3. SAS
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Atlantoaxial Subluxation (AAS)
Most common – (43 -86%)
Transverse ligament. Ant, lateral, posterior.
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Atlantoaxial Impaction Second most frequent
– (5-34%)
Other names– Basilar invagination
– Cranial settling
– Vertical subluxation
– Superior migration.
Joint incompetent: Result from bone and cartilage loss.
Impinge on the brain stem.
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Subaxial Subluxation
10-25%. Most frequent:
– C23, C34.
Incompetent ligaments,facets.
“Staircase”
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Clinical Presentation #1: Pain(40-88%) #2: Neuro(7-34%) #3: Sudden death
(10%) Earliest signs
– Pain & neck stiffness High index of suspicion
– Change in ambulation.– Long tract sign.– Vertebrobasilar SX.
• Loss of equilibrium• Tennitus,vertigo,diplopia• Visual distrubances
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Sudden Death in RA Post mortem study- 11 consecutive cases of atlanto-axial
dislocation (104 patients total). Sudden death
– 7 out 11 Correct diagnosis
– 2 out 11 Spastic SX
– only in 4/11 patients. Conclusion:
– 1. 10% incidence of fatal medulla compression.– 2. Neurological signs are not helpful to point out the risk of fatal
cord compression.
Miculowski et al., Acta Med. Scand, 1975
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Ranawat Classification
I No neural deficit. II Subjective weakness/dysesthesia III Objective weakness/long-tract signs.
• IIIA ambulatory
• IIIB not ambulatory
Ranawat et al, JBJS 1979 Vol 61A-7
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Radiological Eval - AAS
Need flexion lateral. Normal is 3mm. >10 –12 mm =
complete disruption Not reliable – May
decrease as odontoid moves superiorly.
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Radiologic Eval - AAS
PADI >14 mm = 94%
negative predictive value.
Different than space available for the cord.
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Radiologic Eval – AASMRI
neutral vs. flexion
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Radiologic Eval - AAI
Ranawat’s distance- – distance between
transverse axis of C1 and middle of pedicle of C2.
Abnormal if:– Male < 15mm.
– Female < 13 mm.
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Radiologic Eval. - AAI
McGreggor’s line. Line from hard palate
to occipt. Abnormal if dens >
4.5mm above the line.
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Radiologic Eval - AAI
Redlund-Johnell Distance between
McGregor’s line and inferior end plate of C2.
Abnormal if male < 34 mm and female < 29mm.
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Radiologic Eval - AAI
Clark Station Divide C2 into thirds
on sagittal plan. Abnormal if the
middle or lower third of C2 is at the level of arch of C1.
I
II
III
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Radiologic Eval - AAI The most specific:
Redlund-Johnell (76%)
The most sensitive: Clark Station (83%)
To achieve > 90% sensitivity+specificity– Use combination of
Clark station + Redlund-Johnell + Ranawat
When in doubt– get a MRI. Riew et al. JBJS 83A(2). 2001
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Natural History
Without cervical myelopathy
With Cervical myelopathy.
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Natural History – without myelopathy
Prospective Study of 106 patients over 5 years.
80% had radiographic progression. 36% had neurologic deterioration. Only 10% required surgery.
Pellicci et al. JBJS 63A(3) 1981
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Natural History – with myelopathy
Sunahara, Spine 22(22), 1997
21 pt with AAS, refused surgery.
All patients bedridden within 3 years.
7 patients had sudden death.
Meijers, Clinical and Exp Rheu, 1984
9 patients. All 9 patients died
within a year. 4 due to consequences
of cord compression.
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Natural History
Without cervical myelopathy
With Cervical myelopathy.
Good Bad
Predictor
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Predictor of Paralysis
PADI < 14mm. Cervicomedullary angle less than 135
degree. SAC < 13 mm on MRI Cord diameter < 6 mm.
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Predictor of Recovery
Boden:– No recovery if PADI < 10mm.– At least one neuro. Class improvement if PADI
> 10 mm. Klein:
– Duration of SX. Casey:
– Pre-op neuro. Function, cord area, degree of AAI.
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Indications for Surgery
Accepted:– Intractable pain.– Progressive neurologic impairment.– Presence of myelopathy
Controversial:– impending neurologic deficit.
• Arguments for and against.
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Surgical Consideration
Frail. Malnourished. Osteoporotic. Immunosuppressed.
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Preoperative Cervical Traction
Used for AAI and severe subluxation.
Goal: reduce subluxation and relieve compression.
Advantages.
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Airway Management
Awake fiberoptic-assisted intubation Vs. traditional.
128 patients with RA. Upper-airway obstruction after extubation
decrease from 14% to 1%.
Wattenmaker et al. JBJS 76-A(3), 1994
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Decompression Persistent neurologic deficit despite
traction. Level depend on location
– of cord impingement.
Controversial.
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StabilizationInclude all unstable levels.
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Complication
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Complication
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Complication
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Surgical Outcomes
Year Author #patients Pain relief%
Neuro. Improv %
2001 Asselt 31 62% 67%
1999 Grob 39 96 77
1998 Eyres 26 92 89
1998 Mori 25 96 67
1989 Clark 41 91 27
1987 Sakou 16 100 100
1985 Menezes 45 100 100
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CONCLUSION
High index of suspicion Majority of RA does not require surgery. Surgical indication:
– Intractable pain– Progressive neurologic deficit– Myelopathy– Impending neurologic deficit?
Careful surgical planning/team approach.
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THANK YOU