Elsevier

The Lancet

Volume 347, Issue 9007, 13 April 1996, Pages 1004-1007
The Lancet

Articles
Surgery on the rheumatoid cervical spine for the non-ambulant myelopathic patient—too much, too late?

https://doi.org/10.1016/S0140-6736(96)90146-4Get rights and content

Abstract

Summary

Background Opinions differ on the timing of surgery for rheumatoid arthritis patients with atlanto-axial subluxation. Some clinicians wait for development of neurological signs; others favour prophylactic fusion and decompression. We examined the results of surgery in relation to neurological state at the time of operation.

Methods 134 patients underwent surgery for rheumatoid involvement of the cervical spine, after development of objective signs of myelopathy. Surgical outcomes were examined prospectively in two groups—patients who were still ambulant at the time of presentation (Ranawat class III A) and patients who had lost the ability to walk (Ranawat class III B)—by means of neurological and functional grading systems in conjunction with standard measures of postoperative morbidity and mortality.

Findings 58% of the ambulant patients attained Ranawat neurological grades I or II compared with only 20% of the non-ambulant patients (p<0·0001). The non-ambulant group also fared worse in terms of postoperative complication rate, length of hospital stay, functional outcome, and ultimately survival. Radiologically, the non-ambulant patients were characterised by a smaller cross-sectional spinal cord area.

Interpretation The strong likelihood of surgical complications, the poor survival, and the limited prospects for functional recovery in non-ambulant patients make a strong case for earlier surgical intervention. At a late stage of disease most patients will have irreversible cord damage.

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      Regarding the postoperative neurologic status, some authors noted [10,15] that ISHI before surgery did not affect the postoperative neurologic severity or the recovery rate; however, most authors [9–14,18] reported that it was related to the postoperative neurologic severity or the recovery rate. Casey et al. [5] noted that some of the more severe neurologic deficits were not reversible; however, in the current study no difference was observed between the groups regarding the number of Ranawat grade III cases after surgery. Therefore, our findings suggest that ISHI before surgery did not affect the neurologic recovery rate after surgery.

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