Extended report
Improved medical and surgical management of cervical spine
disease in patients with rheumatoid arthritis over 10 years
Jennifer D Hamiltona, Margaret-Mary Gordona, Iain B McInnesa, Robin A Johnstonb, Rajan Madhoka, Hilary A Capella
a Centre for Rheumatic
Diseases, Glasgow Royal Infirmary, Glasgow, Scotland, UK, b Institute of Neurological
Sciences, Southern General Hospital, Glasgow, Scotland, UK
Correspondence to: Dr J D Hamilton, Centre for Rheumatic Diseases, Glasgow Royal Infirmary, 84 Castle St, Glasgow G4 0SF, UK E-mail: jendh{at}emailmsn.com
Accepted for publication 22 November 1999
OBJECTIVES
(1) To
compare clinical outcome and symptomatology of rheumatoid cervical
myelopathy between patients managed conservatively and surgically. (2)
To determine if surgical outcome has improved since the series
published from this unit in 1987. (3) To examine the role of magnetic
resonance imaging (MRI) in the diagnosis of cervical myelopathy.
METHODSPatients
undergoing MRI of the cervical spine between 1991 and 1996 were
identified. Case records were reviewed retrospectively.
RESULTS111 patients
with RA underwent 124 MRI scans. The median age at onset of cervical
spine symptoms was 58 years (range 16-87) with median disease duration
of 16 years (range 1-59). 18 (16%) required surgery immediately after
MRI. 93 (84%) were managed conservatively, 9 of whom (10%) later
required surgery. 2/7 deaths in the conservative group were directly
related to cervical myelopathy. Patients requiring surgery were more
likely to report paraesthesia, weakness, unsteadiness and to exhibit
extensor plantar reflexes, gait disturbance, and reduced power. MRI
findings did not correlate with clinical features. When compared with
the 1974-82 cohort, fewer patients had severe myelopathy (Ranawat
grade IIIB) before surgery (34% versus 7%). Early postoperative
mortality improved from 9% to 0% and surgical complication rate fell
from 50% to 22%. 89% of patients in the 1991-96 cohort reported
subjective improvement in overall function.
CONCLUSIONIn this
series surgical outcome has improved. The major factor in this more
favourable outcome is probably that patients presenting with rheumatoid
cervical myelopathy are now referred for surgery at an earlier stage of
disease. Clinical findings correlate poorly with MRI findings,
therefore clinical history should remain the key to determining the
need for MRI.
© 2000 by Annals of the Rheumatic Diseases
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