Stage-related surgery for cervical spine instability in rheumatoid arthritis |
| |
Authors: | Frank Kandziora Thomas Mittlmeier Fridun Kerschbaumer |
| |
Institution: | (1) Department of Arthritis Surgery, Johann Wolfgang Goethe University Frankfurt, Frankfurt and Accident and Reconstructive Surgery, Virchow Clinic Campus, Charité University Hospital, Berlin, Germany, DE;(2) Accident and Reconstructive Surgery, Virchow Clinic Campus, Charité University Hospital, Berlin, Germany, DE;(3) Department of Arthritis Surgery, Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany , DE;(4) Accident and Reconstructive Surgery, Virchow Clinic Campus, Charité University Hospital, Augustenburgerplatz 1, D-13353 Berlin, Germany e-mail: fkandzio@charite.de, Tel.: +49-30-450 50 ext 52083, Fax: +49-30-450 52901, DE |
| |
Abstract: | Thirty-six consecutive patients with cervical spine instability due to rheumatoid arthritis (RA) were treated surgically
according to a stage-related therapeutic concept. The aim of this study was to investigate the clinical results of these procedures.
The initial change in RA of the cervical spine is atlanto-axial instability (AAI) due to incompetence of the cranio-cervical
junction ligaments, followed by development of a peridontoid mass of granulation tissue. This results in inflammatory involvement
of, and excessive dynamic forces on, the lateral masses of C1 and C2, leading to irreducible atlanto-axial kyphosis (AAK).
Finally, cranial settling (CS) accompanied by subaxial subluxation (SAS) occurs. According to these three separate pathological
and radiological lesions, the patients were divided into three therapeutic groups. Group I comprised 14 patients with isolated
anterior AAI, who were treated by posterior wire fusion. Group II comprised 15 patients with irreducible AAK, who were treated
by transoral odontoid resection. The fixation was done using anterior plating according to Harms in combination with posterior
wire fusion according to Brooks. Group III comprised seven patients with CS and additional SAS, who were treated with occipito-cervical
fusion. Pre- and postoperatively, evaluation was performed using the parameters pain (visual analog scale), range of motion
(ROM), subjective improvement and Health Assessment Questionnaire (HAQ). The neurologic deficit was defined according to
the classification proposed by Ranawat. Radiographs including lateral flexion and extension views, and MRI scans were obtained.
The average clinical and radiographic follow-up of all patients was 50.7 ± 19.3 months (range 21–96 months). No perioperative
fatality occurred. Postoperative pain was significantly relieved in all groups (P < 0.001). In group II a slight improvement in the HAQ was obtained. In groups I and II the ROM of all patients increased
significantly (average gain of motion in group I: 11.3°± 7.8° for rotation; 7.8°± 5.6° for bending; average gain of motion
in group II: 21.5°± 14.0° for rotation; 17.2°± 5.5° for bending), while it decreased significantly in group III (10.7°± 18.1°
for rotation; 6.7°± 18.5° for bending). Preoperatively 27 patients had a manifest neurologic deficit. At follow-up four patients
remained unchanged, all others improved by at least one Ranawat class. All patients, except one, showed solid bony fusion.
According to the significantly improved postoperative subjective self-assessment and the clinical and radiological parameters,
transoral plate fixation combined with posterior wire fixation after transoral odontoid resection represents an effective
reliable and safe procedure for the treatment of irreducible AAK in rheumatoid arthritis.
Received: 4 March 1999 Accepted: 19 May 1999 |
| |
Keywords: | Atlanto-axial instability Transoral approach Decompression Rheumatoid arthritis C1/C2 fusion |
本文献已被 SpringerLink 等数据库收录! |
|