- Radiographic Changes of Cervical Spine in JRA:
- Rheumatoid Arthritis:
- Transverse Ligament Rupture:
- cerival spine involvement is common in RA (up to 90%) & is more common w/ long standing disease and multiple joint involvement;
- significant subluxations will occur in about 32%;
- neurologic deterioration can be irreversible, so it is essential to look for subtle signs of early neurologic involvement or myelopathy;
- most common presentations:
- atlantoaxial subluxation: (most common and may occur in up to 40%)
- atlanto-axial impaction (basilar invagniation);
- lower cervical spine:
- joints of Lushka & facet joints are affected by RA;
- pannus may trepass into the intervertebral disc, anterior longitudinal ligament, and posterior longitudinal ligament;
- subluxation may occur at multiple levels, but the middle cervical motion segments are most commonly involved.
- lower C-spine is more common in males, w/ steroid use, w/ sero-pos. RA, w/ RA nodules, & w/ severe RA;
- note that in the lower central cervical spine with less room for the cord caudally, less severe subluxation may
cause more severe myelopathic symptoms;
- lower cervical spine is the most common form of myelopathy;
- posterior fusion & wiring may be required for subluxation > 4 mm w/ intractable pain and neurologic comprimise;
- note that it is to be expected that there is also increased motion leading to subluxation adjacent to fused segments.
- Clinical Presentation:
- most common presentation is atlantoaxial subluxation C1-C2 instability w/ associated neurologic signs
& symptoms & neck pain;
- radiculopathy and myelopathic symptoms may be confused with flareup of peripheral joint disease or another neurologic disorder;
- peripheral neuropathy such as carpal tunnel syndrome is common in rheumatoid arthritis, but should not be confused with
the more generalized symptoms of C1-2 disease.
- neck pain, decrease ROM, crepitation, and occipital HA are common sx;
- neurologic impairment in pts w/ RA usually occurs very gradually and may cause decreased pain sensation and hyperreflexia early;
- Radiographic Work Up;
- Cross Table Lateral:
- flexion and extension MRI may be indicated to help assess cord involvement;
- MRI will also help evaluate possible encroachment of the cervical canal by synovial pannus;
- this process may be heralded by destruction of facet joints as seen on x-ray;
- Indications for Surgery:
- space available for the cord:
- spinal cord compression w/ < 14 mm of room either at upper or lower cervical spine or with basilar invagination,
is an indication for operative stabilization, regardless of patient symptoms;
- ADI of > 7 to 10 mm or posterior space of < 14 mm is a contraindication to elective surgery in other areas of body until the C-spine is stabilized first;
- instability is present when 3.5 mm ADI difference on flex/ext views,
- 7 mm difference may imply disruption of the alar ligaments;
- difference of > 9 mm is assoc w/ increase in neurologic injury & will usually require posterior fusion and wiring;
- neurologic impairment and/or instability are indications for treatment;
- the mortality rate of untreated myelopathy is approximately 50%;
- Surgical Options:
- posterior cervical fusion;
- anterior cervical fusion;
- surgery is less successful in pts with servere Ranawat IIIb lesions (non ambulatory with objective weakness);
- complications include pseudoarthrosis and recurring myelopathy;
- incidence decreased by extending the fusion to occiput w/ wire fixation
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