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THU0213 The importance of screening and spinal instrumentation in patients with instability of upper cervical spine due to rheumatoid arthritis
  1. Z Klezl1,
  2. M Vesela2,
  3. J Fousek1,
  4. K Pavelka2
  1. 1Department of Orthopedics and Traumatology, Central Military Hospital
  2. 2Rheumatology Institute, Prague, Czech Republic


Background Instability of cervical spine is one of the most challenging fields in patients with rheumatoid arthritis (RA). Although most of the patients can be treated conservatively, some experience intractable pain with pronounced neurological symptoms. Sudden death has been reported in 10% of cases.

Objectives Aim of this study was to determine the importance of screening of patients with RA and cervical spine instrumentation, which restores spinal stability before onset of cervical myelopathy.

Methods We retrospectively evaluated 17 patients surgically treated for instability of the upper cervical spine during 1996 – 2001. Average age was 53.2 years (22 – 72), average duration of the disease was 14 years (3 – 24), 16 patients were women. There were 4 patients with cranial settling combined with atlanto-axial or/and subaxial instability and 13 with atlanto-axial instability; one of these patients had associated lateral atlanto-axial instability. Screening included electrophysiological examination, dynamic x-rays, in cases of significant instability MRI is performed in order to determine possible compression of the dural sac by pannus as described by Dvorak. The indications for surgery are: growing neurological deficit or pain, cranial settling, lateral subluxation of C1-C2 more than 2 mm and retrodental interval in patients with atlanto-axial subluxation 14 mm or less. Four different instrumentations were used, Ransford loop with sublaminar wires and cables, transarticular screws with wire loop, double sublaminar loop (Brooks) and Cervifix. All patients were using soft collar postoperatively, the one with Brooks procedure was placed into halo-vest for 6 weeks.

Results Patients were evaluated using functional rating score and the Visual Analogue Scale with the mean follow up 14.3 months (6‑46). Marked improvement was found in both evaluations.

Complications included cerebrospinal fluid leak, which required revision, delayed wound healing, injury to vertebral artery and delayed union of spinal fusion. Although they required longer hospital stay, they were not clinically significant.

Conclusion Our results support the need for careful screening of patients with RA, which reveals instability associated with early neurological signs. Indication for surgery should be done before the onset of cervical myelopathy. Internal fixation with Cervifix, Ransford loop and transarticular fixation according to Magerl were satisfactory in maintaining stability of the upper cervical spine before healing of the fusion. Stability of the Brooks procedure was not satisfactory and therefore the patient had to be placed into halo-vest orthosis.

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