Osteomyelitis of the cervical spine: a potentially dramatic disease

Osteomyelitis of the cervical spine is a rare disease, representing only 3% to 6% of all cases of vertebral osteomyelitis. In contrast with other locations of spinal infections, osteomyelitis of the cervical spine can be a much more dramatic and rapidly deteriorating process, leading to early neurologic deficit. Thus, the disease must be diagnosed quickly and appropriate therapy initiated as soon as possible. The clinical course, therapy, and outcome of 15 patients treated for osteomyelitis of the cervical spine are presented. Nine of 15 patients presented with a neurologic deficit at the time of diagnosis. Surgical treatment consisted of radical debridement of the infected bone and either immediate bone grafting and stabilization as a one-step procedure or interval antibiotic treatment before bone grafting and surgical stabilization as a second procedure. A favorable outcome was achieved by early and aggressive surgical intervention, including complete resolution of neurologic deficits in more than 50% of the patients and complete bony fusion in all but one patient. The authors prefer additional posterior rather than anterior stabilization alone to perform fusion over a shorter distance involving only the infected segments.     

The efficacy of anterior cervical plating in the management of symptomatic pseudoarthrosis of the cervical spine.

STUDY DESIGN: A retrospective review of 16 consecutive patients treated with anterior resection of the pseudoarthrosis, autogenous iliac crest bone grafting, and stabilization with an anterior cervical plate. OBJECTIVES: To determine the efficacy of anterior cervical plating used to manage symptomatic pseudoarthrosis of the cervical spine and obtain safe radiographic fusion and improved clinical results. SUMMARY OF BACKGROUND DATA: It is generally recognized that the clinical outcome of anterior cervical discectomy and fusion correlates with rates of fusion. There is debate in the literature as to how the patient with symptomatic cervical pseudoarthrosis should be addressed. Recent reports would support a posterior approach rather than a revision anterior approach. METHODS: Sixteen consecutive patients with symptomatic pseudoarthrosis of the cervical spine were treated with anterior resection of the pseudoarthrosis, autogenous iliac crest bone grafting, and stabilization with an anterior cervical plate. The average follow-up period was 51 months, and patients were assessed using physical examinations, questionnaires, and flexion-extension lateral radiographs. RESULTS: In all, 75% of the patients reported improvement of their symptoms, and 69% of patients returned to work. Fusions were graded I or II in 81% of the patients. No patient demonstrated radiographic instability, and none required revision surgery. Involvement with workers' compensation litigation negatively affected the clinical outcome. CONCLUSIONS: Patients in whom symptomatic cervical pseudoarthrosis develops after cervical anterior discectomy and fusion may be managed successfully with anterior resection of the pseudoarthrosis, autogenous bone grafting, and an anterior cervical plate. Successful clinical results regarding return to work status and general satisfaction with the surgical procedure depend not only on obtaining a successful radiographic fusion, but also on patient selection.     

Adjuvant Posterior Stabilization in the Management of Tuberculous Spondylitis of the Dorsal and Lumbar Spine

Objective Posterior instrumentation and stabilization allowing early mobilization, shortened hospital stay and maintenance of correction after debridement and bone grafting for tuberculous spondylitis through an anterior approach. Indications Tuberculous spondylitis requiring anterior drainage, debridement and decompression, as well as interbody fusion. Significant bone loss of vertebral body. Kyphosis > 25° Concomitant posterior column disease. Contraindications Poor general health precluding such an extensive intervention. Superinfection of tubercoulous sinus on the back. Surgical Technique The first stage consists of anterior debridement and bone grafting. During the second stage, preferably performed at the same sitting, a posterior stabilization is done. At the level of the thoracic spine and for all patients with osteoporosis irrespective of the level, a sublaminar wiring (Hartshill) is performed. At the lumbar spine pedicular screw fixation and Steffee plating are done in the absence of osteoporosis. Results Between June 1993 and December 1996 25 patients (nine men, 16 women, average age 38.5 years) with tuberculous spondylitis underwent this two-stage procedure. Average length of follow-up 16.9 months. A preoperative neurologic deficit seen in 15 patients persisted only in two. The overall loss of correction amounted to 6.5°. The average time of fusion was 6 months. No implant failures were recorded. A screw pull-out secondary to infection accompanied by loss of correction occurred in one patient. Another patient experienced a transient neurologic deficit.     

Adjuvante dorsale Stabilisierung der thorakalen und lumbalen Wirbelsäule bei tuberkulöser Spondylitis

Objective Posterior instrumentation and stabilization allowing early mobilization, shortened hospital stay and maintenance of correction after debridement and bone grafting for tuberculous spondylitis through an anterior approach. Indications Tuberculous spondylitis requiring anterior drainage, debridement and decompression, as well as interbody fusion. Significant bone loss of vertebral body. Kyphosis > 25°. Concomitant posterior column disease. Contraindications Poor general health precluding such an extensive intervention. Superinfection of tuberculous sinus on the back. Surgical Technique The first stage consists of anterior debridement and bone grafting. During the second stage, preferably performed at the same sitting, a posterior stabilization is done. At the level of the thoracic spine and for all patients with osteoporosis irrespective of the level, a sublaminar wiring (Hartshill) is performed. At the lumbar spine pedicular screw fixation and Steffee plating are done in the absence of osteoporosis. Results Between June 1993 and December 1996 25 patients (nine men, 16 women, average age 38.5 years) with tuberculous spondylitis underwent this two-stage procedure. Average length of follow-up 16.9 months. A preoperative neurologic deficit seen in 15 patients persisted only in two. The overall loss of correction amounted to 6.5°. The average time to fusion was 6 months. No implant failures were recorded. A screw pull-out secondary to infection accompanied by loss of correction occurred in one patient. Another patient experienced a transient neurologic deficit.     

A technique of posterior cervical fusion for instability of the cervical spine

A technique of posterior cervical spine fusion (the "Dewar procedure") that allows immediate stabilization of the spine requiring only minimal external support is described. The procedure was performed in 16 patients with unstable fractures or fracture-dislocations of the cervical spine. All patients went on to develop solid fusion. Twelve patients incurred neurologic deficit due to their injury, and those with root involvement all recovered following fusion. Patients rendered quadriplegic as a result of their accident did not show any useful neurologic recovery but were able to start rehabilitation earlier and avoid the complications of nonoperative treatment. There were no significant complications related to surgery.     

Circumferential fusion for the management of acute cervical spine trauma.

Combined, single-stage anterior and posterior approaches for acute surgical management of cervical spine injury allows for early restoration of anatomic alignment and decompression. Six patients underwent single-stage anterior decompression and posterior instrumentation and fusion at Vanderbilt University Medical Center between 1984-1989. There was no late deformity. Five patients had incomplete neurologic deficits, and each improved a minimum of one Frankel classification. One patient had complete neurologic deficit at the C5 level. The procedure is lengthy, with an average time under anesthesia of 7.7 hs. Since this procedure allows for immediate mobilization, it should be considered for the management of cervical spine fractures with both anterior and posterior column instability.     

Anterior debridement,decompression, bone grafting,and instrumentation for lower cervical spine tuberculosis

Background contextCervical spine tuberculosis (TB) is uncommon, accounting for 3% to 5% of spinal TB. Although the development of anti-TB chemotherapy decreases the mortality rate significantly, it may not be applicable for all situations, especially for those with risk of instability, progression of neurologic deficit, and failure of medical treatment.PurposeTo evaluate the efficacy of anterior instrumentation after debridement and bone grafting in patients with lower cervical TB over a 5-year period at a single institution.Study designA retrospective study examining the results of anterior debridement, decompression, bone grafting, and instrumentation for lower cervical spine TB.Patient sampleThe procedure was performed in 25 patients.Outcome measuresThe clinical outcomes of infection activity, deformity, pain, and neurologic function were evaluated using erythrocyte sedimentation rate value and C-reactive protein value, kyphotic angle, visual analog scale pain score, and Frankel grade, respectively.MethodsBetween 2005 and 2010, 25 patients (18 males and seven females; average age, 39 years) with lower cervical spine tuberculosis (C3–C7) underwent anterior debridement, decompression, bone grafting, and instrumentation. The average follow-up period was 37.4 months (range 24–57 months). The medical records and radiographic findings of the patients were reviewed.ResultsThere were three patients who had involvement of one vertebra, 18 had two vertebrae of involvement, and four had three vertebrae of involvement. Before surgery, there were three patients with Frankel grade B, five with grade C, 12 with grade D, and five with grade E. During the last follow-up examination, in 20 patients with neurological deficit, 11 patients improved one grade, six patients improved two grades, one patient improved three grades, and the neurologic status remained unchanged in two patients. Stable bone union was observed in all cases and the average time required for fusion was 6.8 months. The kyphosis Cobb angle improved from the preoperative average of 15.48° (range 0°–55°) to a postoperative average of ?4.8° (range ?12° to 4°) and there was no significant correction loss during the follow-up period. During the follow-up period, there were no grafts or instrumentation-related stabilization problems. There was no other recurrence of TB infection.ConclusionsAnterior debridement, decompression, bone grafting, and instrumentation are safe and effective methods in the surgical management of lower cervical spine tuberculosis.     

Lower cervical spine trauma: classification and operative treatment

Injuries to the subaxial cervical spine (C3-7) occur mostly from traffic accidents and in recreational activities. Such lesions that appear on roentgenological or magnetic resonance images must be classified according to stability. Neurologic deficits, accompanying injuries, and the patient's general condition play major roles in the choice of therapy. Fracture and fracture dislocations should be reduced as soon as possible, as neurologic regeneration and successful reduction are closely time related. The classification developed by Magerl et al. for thoracic and lumbar spine can also be used for the lower cervical spine. Stable injuries without neurologic deficits can generally be treated functionally and, sometimes, with external immobilization. Unstable injuries should be stabilized and treated surgically. Ventral intercorporal spondylodesis is a proven, standard surgical technique for open reduction, decompression, and fusion. Disc and whole or partial vertebral resection along with intercorporal fusion with autologous iliac crest bone grafting and plate osteosynthesis enables successful stabilization of almost all mono- and bisegmental lesions. Dorsal surgery is indicated only in case of a compressed spinal canal and/or neuroforamens due to destroyed posterior elements or remaining instability following ventral plate spondylesis.     

Verletzungen der unteren Halswirbelsäule

Injuries to the subaxial cervical spine (C3–7) occur mostly from traffic accidents and in recreational activities. Such lesions that appear on roentgenological or magnetic resonance images must be classified according to stability. Neurologic deficits, accompanying injuries, and the patient’s general condition play major roles in the choice of therapy. Fracture and fracture dislocations should be reduced as soon as possible, as neurologic regeneration and successful reduction are closely time related. The classification developed by Magerl et al. for thoracic and lumbar spine can also be used for the lower cervical spine. Stable injuries without neurologic deficits can generally be treated functionally and, sometimes, with external immobilization. Unstable injuries should be stabilized and treated surgically. Ventral intercorporal spondylodesis is a proven, standard surgical technique for open reduction, decompression, and fusion. Disc and whole or partial vertebral resection along with intercorporal fusion with autologous iliac crest bone grafting and plate osteosynthesis enables sucessful stabilization of almost all mono- and bisegmental lesions. Dorsal surgery is indicated only in case of a compressed spinal canal and/or neuroforamens due to destroyed posterior elements or remaining instability following ventral plate spondylesis.     

Posterior Fusion in Patients with Trauma, Instability, and Tumor of the Cervical Spine

Trauma, instabilities and tumors of the cervical spine are treated with established methods of surgery. Therefore, anterior fusion is considered to be a standardized procedure for the lower cervical spine, while posterior and anterior instrumentation facilitates stabilization of the upper cervical spine. However, special situations that particularly require posterior instrumentation in traumatic lesions, tumor or other kinds of instabilities arise again and again. Neurological deficit symptoms, bone quality and related diseases fundamentally lead to a decision of posterior access and fusion. Different pathologies and corresponding reasons for posterior surgical interventions on the cervical spine are described in this paper and discussed using the current literature.     

Posterior stabilization of cervical spine fractures and subluxations using plates and screws

Posterior stabilization of cervical spine fractures and subluxations with metal plates and screws is commonly used in Europe, but has rarely been employed by neurosurgeons in North America, where stabilization has usually been achieved with wires supplemented by bone grafts or acrylic. The limitations of the more commonly used stabilization techniques include the failure to achieve rotational stability, the necessity for intact laminae, and the requirement for bone grafting. We therefore examined the efficacy of posterior cervical plating in 19 patients who had posttraumatic instability of the cervical spine between C3 and C7 without residual spinal cord compression and 1 patient who had a subluxation as a result of osteomyelitis. Two patients had no neurological deficit, 4 had partial deficits, and 14 had no neurological function below the level of injury. Operation was performed after patients were medically stable and maximal reduction of fractures was achieved (usually within 48 hours). The plates are made of vitallium and contain two or three holes 13 mm apart through which 16-mm screws are placed bilaterally into the center of the articular masses of two or three adjacent vertebrae to stabilize one or two motion segments. Bone grafting is not performed. Patients are mobilized on the day after operation in a Philadelphia collar, which is worn for 3 months. Fourteen patients had stabilization of one motion segment and 6 had stabilization over two motion segments. The mean follow-up is 9.2 months. In a single patient with ankylosing spondylitis, plate fixation failed when screws pulled out. No patient experienced neurological deterioration as a result of the operative procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Posterior cervical spine stabilization under local anesthesia

A technique is described for posterior cervical stabilization with spinous process wiring and fusion performed with the patient under local anesthesia and using corticocancellous demineralized bone matrix allograft. In patients with unstable cervical spines, posterior stabilization and fusion with local anesthesia allowed patient interaction with the surgeon during crucial parts of the operation. The technique was well tolerated and no untoward complications occurred. The technique has not been described for the neurologically intact patient with cervical spine trauma. The purpose of this report is to document the facility and advantages of this technique over traditional general anesthesia with autograft use. Nineteen patients were treated surgically at the author's institution. Local anesthesia was used in 12, and general anesthesia was used in 7. Allograft was used in 12 and autologous iliac crest graft was used in 7 patients. The indications for surgery were instability or neurologic deficit. Blood loss and operative times were favorable when compared with general anesthesia and autograft. The fusion extended by one level in 6 of 19 patients. One patient had preoperative neurologic deficit. All 19 follow-up patients were Frankel grade E. There is no need for endotracheal intubation, the patient serves as his or her own spinal cord monitor, and the surgeon is able to be aware immediately of any threat to neurological function. Demineralized bone matrix allograft has been shown to effectively induce osteogenesis by osteoinduction as well as osteoconduction. Its use eliminates the need for autograft harvesting and permits the use of local anesthesia alone for cervical spine posterior stabilization. The more neurologically intact the patient, the more this technique is indicated.(ABSTRACT TRUNCATED AT 250 WORDS)     

Progressive rotational dislocation in kyphoscoliotic deformities: presentation and treatment

STUDY DESIGN: Progressive rotational dislocation of the spine has been described as the most serious evolutive risk of kyphoscoliosis. A retrospective chart review was conducted on 11 patients with this deformity. OBJECTIVES: To delineate the clinical and radiologic characteristics of this entity to facilitate early diagnosis and treatment. The outcome after treatment was analyzed to point out the rationale for appropriate treatment. METHODS: The characteristic radiologic feature was a short sharp angled kyphosis (average 112) at the junction of two lordoscoliotic curvatures. The etiology of the spinal deformity was neurofibromatosis in four patients and various dysplastic conditions in seven patients. Two patients had congenital vertebral defects. Structural weakness of the bone was therefore a basic feature. Neurologic impairment was identified in three patients (one complete, two incomplete). Four patients had a nonunion after a previous attempt at spinal fusion: two after a combined anterior and posterior fusion with an anterior approach from the convexity and two after a posterior fusion alone. All patients underwent complete circumferential stabilization through anterior strut-grafting and posterior fusion. An anterior approach from the concavity was performed systematically with tibial strut grafts inserted in a palisade fashion. Preoperative correction of the deformity was performed by progressive controlled elongation in a Stagnara elongation cast. Cotrel-Dubousset instrumentation was used in two patients, Harrington instrumentation was used in two patients, and cast immobilization alone was used in seven patients. RESULTS: The average follow-up period was 5 years 5 months. All but one patient achieved successful spinal fusion. Loss of correction at the latest follow-up evaluation was less than 3 degrees in nine patients. The two patients with incomplete neurologic deficits were improved, but the patient with the complete deficit remained unchanged after surgery. CONCLUSIONS: Awareness of the possibility of a progressive rotational dislocation in dystrophic forms of kyphoscoliosis should allow for an early diagnosis and stabilization. The percentage of patients having a neurologic deficit in this series was significantly less important than in the initial report. Early anterior strut grafting from the concavity of the scoliotic curvature and posterior fusion is recommended.     

Vertebral artery occlusion after acute cervical spine trauma

STUDY DESIGN: A retrospective study of vertebral artery injury diagnosed during the last 6 years in our institution. OBJECTIVES: To determine the clinical and radiologic features of vertebral artery injury. SUMMARY OF BACKGROUND DATA: Extracranial occlusion of the vertebral artery associated with cervical spine fracture is uncommon and can cause serious and even fatal neurologic deficit due to back lifting and cerebellar infarction. Magnetic resonance imaging and magnetic resonance angiography are extremely helpful in the examination of acute injuries of the cervical spine. METHODS: Magnetic resonance imaging and magnetic resonance angiography were performed at the time of injury. RESULTS: The authors reviewed six patients with cervical spine fractures who were diagnosed with a unilateral occlusion of the vertebral artery by means of magnetic resonance imaging/magnetic resonance angiography. One patient had signs of vertebrobasilar insufficiency and another with complete cord lesion had cerebellar and back lifting infarctions. Surgical anterior spinal fusion was performed in five patients, and one was treated by traction and orthosis. At the time of discharge, five patients had no vertebrobasilar symptoms, and the patient who experienced vertebrobasilar territory infarctions showed no progression of the neurologic damage. CONCLUSIONS: Vertebral artery injury should be suspected in cervical trauma patients with facet joint dislocation or transverse foramen fracture. Magnetic resonance imaging/magnetic resonance angiography is a helpful test to rule out vascular injury. Vertebral artery injury affects the extracranial segment at the same level as the cervical fracture. This is a retrospective review that did not permit drawing conclusions about the effects of early surgical stabilization in the treatment of cervical spine injuries with associated vertebral artery injury; however, surgical stabilization may avoid propagation and embolization of the clot located at the site of the lesion.     

Distraction extension injuries of the cervical spine

Twenty-four consecutive patients with cervical distraction extension injuries were retrospectively reviewed to study the safety and efficacy of various treatment protocols in this type of cervical spine injury. Sixteen of 24 patients with cervical distraction extension injuries underwent surgical stabilization. All patients undergoing surgical stabilization were noted to have a stable fusion at their latest follow-up. There were three instances of surgically related neurologic deterioration as a result of over-distraction of the anterior column interspace at the time of graft placement. The overall mortality rate was 42% in this aged patient population. Anterior reconstruction of the cervical spine with an anterior cervical graft and plate acting as a tension band is the ideal treatment method for stabilization of acute distraction extension injuries involving primarily the soft tissue structures (anterior longitudinal ligament and intervertebral disc). Type 2 injuries, depending on the degree of displacement and the adequacy of closed reduction, may need to be approached initially posteriorly to obtain adequate alignment, followed by an anterior reconstructive procedure. Great care should be taken during anterior graft placement to avoid over-distraction of the spine. If nonsurgical intervention is selected, close regular radiographic follow-up is necessary to detect early vertebral malalignment, which may predispose to spinal cord dysfunction. Older patients sustaining this injury have a high mortality rate.     

Management of post-traumatic cervical spine instability: operative fusion versus halo vest immobilization. Analysis of 49 cases

A 5-year retrospective analysis was conducted for all cervical spine fractures associated with neurologic deficit initially treated at the University of Michigan Hospitals. Forty-nine cases of lower cervical spine fracture (C3-C7) were reviewed. Twenty-eight patients underwent early operative fusion followed by immobilization with either halo vests, or hard cervical collars, and 20 patients were initially immobilized in halo vests only. One patient refused treatment and was kept in a hard cervical collar. The average period of immobilization was 3 months. Eight patients in the halo vest group demonstrated radiographic evidence of spinal instability following immobilization (40%). Five of these eight patients subsequently required operative stabilization. Two of these five suffered progression of neurologic deficit secondary to loss of reduction while immobilized. Spinal instability occurred in two of the 28 patients initially fused (7%) (p less than 0.01), and in the patient treated in a collar. The findings indicate: 1) the halo vest does not protect patients with cervical instability from neurological injury, nor does it absolutely immobilize the cervical spine; 2) surgery may be required to provide spinal stability, even after a 3-month orthotic treatment period; and 3) there appears to be an increased rate of spinal stability with fusion and immobilization versus immobilization alone.     

Anterior surgery for unstable lower cervical spine injuries

The authors reviewed the medical records of 53 patients with a lower cervical spine injury who were treated by anterior decompression, bone grafting, and instrumentation using an anterior cervical spine plate and screws. The average age of the patients was 36 years and the mean followup was 58 months. Twenty-six patients predominantly had anterior lesions and 27 patients predominantly had posterior lesions. Thirteen patients were neurologically intact. Fusion was achieved in all patients at an average of 3.4 months postoperatively. Radiographic followup detected 15% of hardware malposition. There were no pseudarthrosis, dysphagia, or neurologic complications. Incomplete spinal cord lesions improved on average one Frankel grade after surgery. Anterior decompression and stabilization is a safe and effective procedure for the treatment of acute lower cervical spine injuries and permits immediate postoperative mobilization of the patient.     

Spinal and spinal cord injuries. Therapeutic approach in Gabon

The authors present their experience with 81 cases (66.4%) of acute cervical spine injuries (C.S.I.) and 41 cases (33.6%) of acute thoracolumbar spine injuries (T.L.S.I.) treated by a multidisciplinary approach, at Jeanne Ebori Hospital (Libreville, Gabon) between the years 1981 and 1987. Traffic accidents were the leading cause of injury. The largest group consisted of patients in their third decade. The anatomic localizations were: upper cervical spine: 22 cases (27%); lower cervical spine: 56 (69%); upper thoracic spine: 11 (26.8%); lower thoracic spine or thoracolumbar area: 19 (46.3%); lumbar spine: 7 (17%). There were osteoligamental lesions in 3 cases (3.7%) of C.S.I. and 4 (9.7%) of T.L.S.I. Clinically, 44 patients (54.3%) with C.S.I. and 37 (90.2%) with T.L.S.I. had neurological deficits. Surgical indications depended upon the osseous as well as neurologic lesions. There were five important steps in the treatment of spinal injuries associated with neurological deficit: (1) immobilization, (2) medical stabilization, (3) spinal alignment (skeletal traction), (4) operative decompression if there was proven cord compression, and (5) spinal stabilization. Twenty patients (24.6%) with cervical injuries were treated conservatively (traction, collar, kinesitherapy); 53 (65.4%) underwent a surgical intervention (anterior approach - 21, posterior fusion - 30, combined approach - 2); and in 8 patients (9.8%) refraining from surgery seemed the best alternative. After lengthy multidisciplinary discussion, the authors elected not to operate on tetraplegic patients with respiratory problems that necessitated assisted ventilation, because of its fatal outcome. Of injuries to the thoracolumbar spine, 13 (31.7%) were treated conservatively (bedrest, orthopedic treatment). Twenty-eight patients (68.2%) with unstable thoracic and lumbar fractures associated with neurologic deficit required acute surgical intervention (stabilization with or without decompression of the neural elements). Laminectomy alone was performed in 5 cases, laminectomy with graft in 2, stabilization by Roy-Camille plates in 16 and by Harrington rods in 5. Most upper thoracic spine fractures were treated conservatively. Surgical intervention was increasingly possible with the availability of more material and qualified staff. There were 17 patients (21%) who died from C.S.I. (15 were tetraplegic), and 6 (14.6%) from T.L.S.I. In general, osteoligamental consolidation was satisfactory. Neurological recovery was observed only in patients with partial deficits. Most cases posed socioeconomic problems.     

Cervical spondylosis: the role of anterior instrumentation after decompression and fusion

The role of plate stabilization after anterior decompression and fusion of the cervical spine for cervical spondylosis remains controversial. This study aimed to justify the use of instrumentation to stabilize anterior cervical fusion for cervical spondylosis through a risk-benefit analysis and comparison of the results with those reported in the literature on the outcome of fusion without instrumentation. The authors retrospectively reviewed the charts and radiographs of 47 patients with symptoms secondary to cervical spondylosis who underwent anterior cervical decompression and instrumented fusion. After operation, patients were mobilized early, and neither neurologic injury nor infection developed in any patient. At an average 3.4 years after surgery, the rate of graft complications, including nonunion (4.26%), was low, whereas the rate of hardware-related morbidity was minimal (6%). An average 0.4 degrees loss of the intraoperative correction of cervical lordosis was observed at the last follow-up examination. Accelerated degenerative changes at levels adjacent to the fusion were seen in 17% of patients, but only two patients required repeat operation for persistent symptoms. The use of instrumentation to stabilize the cervical spine in patients with cervical spondylosis after anterior decompression and fusion is relatively safe. It permits early pain-free mobilization, successfully maintains sagittal cervical spine alignment, and promotes consistent and reliable spinal fusion.     

Natural history of rheumatoid arthritis of the cervical spine

This article reviews the natural history of rheumatoid arthritis involving the cervical spine with special attention given to predictors of paralysis. Understanding the natural history of rheumatoid arthritis of the cervical spine is necessary to determine the benefit of various interventions. The primary treatment goal for cervical instability is prevention of irreversible neurologic injury. The natural history of rheumatoid arthritis for a period of 10 years or more is one of significant disease progression. The natural history of cervical instability in patients with rheumatoid arthritis is more variable, with only some patients having a neurologic deficit develop. Recent studies support prophylactic stabilization of the rheumatoid cervical spine to prevent paralysis in high risk patients. However, proponents for prophylactic arthrodesis must acknowledge that not all cervical instability in rheumatoid arthritis progresses to neurologic deficit, and surgical intervention in patients with rheumatoid arthritis incurs added morbidity and mortality. Identifying the risk factors for progression of cervical instability is the first step in eliminating morbidity and mortality from spinal cord and brain stem compression. Surgical stabilization is indicated not only for those patients with paralysis, but for the subgroups of patients with cervical rheumatoid disease who are at risk for spinal cord and brain stem compression. The posterior atlantodental interval is the most reliable screening tool and predictor of progressive neurologic deficit.