Atlantoaxial stabilization in rheumatoid arthritis

Stephen M. PapadopoulosSection of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and Division of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona

Search for other papers by Stephen M. Papadopoulos in
Current site
Google Scholar
PubMed
Close
 M.D.
,
Curtis A. DickmanSection of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and Division of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona

Search for other papers by Curtis A. Dickman in
Current site
Google Scholar
PubMed
Close
 M.D.
, and
Volker K. H. SonntagSection of Neurosurgery, University of Michigan, Ann Arbor, Michigan; and Division of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona

Search for other papers by Volker K. H. Sonntag in
Current site
Google Scholar
PubMed
Close
 M.D.
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $525.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $624.00
USD  $45.00
USD  $525.00
USD  $624.00
Print or Print + Online Sign in

✓ Atlantoaxial subluxation in patients with rheumatoid arthritis is common. Operative stabilization is clearly indicated when signs and symptoms of spinal cord compression occur. However, many recommend early operative fusion before evidence of appreciable neural compression occurs because 1) the myelopathy in these patients may be irreversible; 2) the overall prognosis is poor once symptoms of cord compression are present; and 3) the risk of sudden death associated with atlantoaxial subluxation is increased even in asymptomatic patients. The authors believe that rheumatoid arthritis patients in relatively good health without advanced multisystem disease and less than 65 years of age should be considered for operative stabilization if mobile atlantoaxial subluxation is greater than 6 mm. Seventeen patients with severe rheumatoid arthritis and atlantoaxial subluxation treated with a posterior arthrodesis are presented. A new method of fusion, devised by the senior author (V.K.H.S.), was utilized in all cases. Indications for operative therapy in these patients included evidence of spinal cord compression in 11 patients (65%) and mobile atlantoaxial subluxation greater than 6 mm but no signs or symptoms of cord compression in six patients (35%). Thirteen patients developed a stable osseous fusion, two patients a well-aligned fibrous union, one patient a malaligned fibrous union, and one patient died prior to evaluation of fusion stability.

The details of the operative technique and management strategies are presented. Several technical advantages of this method of fusion make this approach particularly useful in patients with rheumatoid arthritis. Because of multisystem involvement of this disease, a high rate of osseous fusion is often difficult to achieve.

  • Collapse
  • Expand
  • 1.

    Bland JH: Rheumatoid arthritis of the cervical spine. J Rheumatol 3:319341, 1974 Bland JH: Rheumatoid arthritis of the cervical spine. J Rheumatol 3:319–341, 1974

    • Search Google Scholar
    • Export Citation
  • 2.

    Brooks AL, & Jenkins EB: Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg (Am) 60:279284, 1978 Brooks AL, Jenkins EB: Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg (Am) 60:279–284, 1978

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Clark CR, , Goetz DD, & Menezes AH: Arthrodesis of the cervical spine in rheumatoid arthritis. J Bone Joint Surg (Am) 71:381392, 1989 Clark CR, Goetz DD, Menezes AH: Arthrodesis of the cervical spine in rheumatoid arthritis. J Bone Joint Surg (Am) 71:381–392, 1989

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Conaty JP, & Mongan ES: Cervical fusion in rheumatoid arthritis. J Bone Joint Surg (Am) 63:12181227, 1981 Conaty JP, Mongan ES: Cervical fusion in rheumatoid arthritis. J Bone Joint Surg (Am) 63:1218–1227, 1981

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Cybulski GR, , Stone JL, & Crowell RM, et al: Use of Halifax interlaminar clamps for posterior C1–C2 arthrodesis. Neurosurgery 22:429431, 1988 Cybulski GR, Stone JL, Crowell RM, et al: Use of Halifax interlaminar clamps for posterior C1–C2 arthrodesis. Neurosurgery 22:429–431, 1988

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Davis FW Jr, & Markley HE: Rheumatoid arthritis with death from medullary compression. Ann Intern Med 35:451454, 1951 Davis FW Jr, Markley HE: Rheumatoid arthritis with death from medullary compression. Ann Intern Med 35:451–454, 1951

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Dickman CA, , Sonntag VKH, & Papadopoulos SM, et al: The interspinous method of posterior atlantoaxial arthrodesis. J Neurosurg 74, February, 1991 Dickman CA, Sonntag VKH, Papadopoulos SM, et al: The interspinous method of posterior atlantoaxial arthrodesis. J Neurosurg 74, February, 1991

    • Search Google Scholar
    • Export Citation
  • 8.

    Gallie WE: Fractures and dislocations of the cervical spine. Am J Surg 46:495499, 1939 Gallie WE: Fractures and dislocations of the cervical spine. Am J Surg 46:495–499, 1939

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Garrod AE: A Treatise on Rheumatism and Rheumatoid Arthritis. London: C Griffin, 1890 Garrod AE: A Treatise on Rheumatism and Rheumatoid Arthritis. London: C Griffin, 1890

    • Search Google Scholar
    • Export Citation
  • 10.

    Griswold DM, , Albright JA, & Schiffman E, et al: Atlanto-axial fusion for instability. J Bone Joint Surg (Am) 60:285292, 1978 Griswold DM, Albright JA, Schiffman E, et al: Atlanto-axial fusion for instability. J Bone Joint Surg (Am) 60:285–292, 1978

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11.

    Heywood AWB, , Learmonth ID, & Thomas M: Cervical spine instability in rheumatoid arthritis. J Bone Joint Surg (Br) 70:701707, 1988 Heywood AWB, Learmonth ID, Thomas M: Cervical spine instability in rheumatoid arthritis. J Bone Joint Surg (Br) 70:701–707, 1988

    • Search Google Scholar
    • Export Citation
  • 12.

    Kourtopoulos H, & von Essen C: Stabilization of the unstable upper cervical spine in rheumatoid arthritis. Acta Neurochir 91:113115, 1988 Kourtopoulos H, von Essen C: Stabilization of the unstable upper cervical spine in rheumatoid arthritis. Acta Neurochir 91:113–115, 1988

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13.

    Lipson SJ: Rheumatoid arthritis in the cervical spine. Clin Orthop 239:121127, 1989 Lipson SJ: Rheumatoid arthritis in the cervical spine. Clin Orthop 239:121–127, 1989

    • Search Google Scholar
    • Export Citation
  • 14.

    Marks JS, & Sharp J: Rheumatoid cervical myelopathy. Q J Med 50:307319, 1981 Marks JS, Sharp J: Rheumatoid cervical myelopathy. Q J Med 50:307–319, 1981

    • Search Google Scholar
    • Export Citation
  • 15.

    Martel W, & Abell MR: Fatal atlanto-axial luxation in rheumatoid arthritis. Arthritis Rheum 6:224231, 1963 Martel W, Abell MR: Fatal atlanto-axial luxation in rheumatoid arthritis. Arthritis Rheum 6:224–231, 1963

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16.

    Mathews JA: Atlanto-axial subluxation in rheumatoid arthritis — a 5-year follow-up study. Ann Rheum Dis 33:526531, 1974 Mathews JA: Atlanto-axial subluxation in rheumatoid arthritis — a 5-year follow-up study. Ann Rheum Dis 33:526–531, 1974

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    McCarron RF, & Robertson WW: Brooks fusion for atlantoaxial instability in rheumatoid arthritis. South Med J 81:474476, 1988 McCarron RF, Robertson WW: Brooks fusion for atlantoaxial instability in rheumatoid arthritis. South Med J 81:474–476, 1988

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18.

    McGraw RW, & Rusch RM: Atlanto-axial arthrodesis. J Bone Joint Surg (Br) 55:482489, 1973 McGraw RW, Rusch RM: Atlanto-axial arthrodesis. J Bone Joint Surg (Br) 55:482–489, 1973

    • Search Google Scholar
    • Export Citation
  • 19.

    Meijers KAE, , Cats A, & Kremer HPH, et al: Cervical myelopathy in rheumatoid arthritis. Clin Exp Rheumatol 2:239245, 1984 Meijers KAE, Cats A, Kremer HPH, et al: Cervical myelopathy in rheumatoid arthritis. Clin Exp Rheumatol 2:239–245, 1984

    • Search Google Scholar
    • Export Citation
  • 20.

    Meijers KAE, , van Beusekom GT, & Luyendijk W, et al: Dislocation of the cervical spine with cord compression in rheumatoid arthritis. J Bone Joint Surg (Br) 56:668680, 1974 Meijers KAE, van Beusekom GT, Luyendijk W, et al: Dislocation of the cervical spine with cord compression in rheumatoid arthritis. J Bone Joint Surg (Br) 56:668–680, 1974

    • Search Google Scholar
    • Export Citation
  • 21.

    Mitsui H: A new operation for atlanto-axial arthrodesis. J Bone Joint Surg (Br) 66:423426, 1984 Mitsui H: A new operation for atlanto-axial arthrodesis. J Bone Joint Surg (Br) 66:423–426, 1984

    • Search Google Scholar
    • Export Citation
  • 22.

    Morizono Y, , Sakou T, & Kawaida H: Upper cervical involvement in rheumatoid arthritis. Spine 12:721725, 1987 Morizono Y, Sakou T, Kawaida H: Upper cervical involvement in rheumatoid arthritis. Spine 12:721–725, 1987

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23.

    Pellicci PM, , Ranawat CS, & Tsairis P, et al: A prospective study of the progression of rheumatoid arthritis of the cervical spine. J Bone Joint Surg (Am) 63:342350, 1981 Pellicci PM, Ranawat CS, Tsairis P, et al: A prospective study of the progression of rheumatoid arthritis of the cervical spine. J Bone Joint Surg (Am) 63:342–350, 1981

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24.

    Ranawat CS, , O'Leary P, & Pellicci P, et al: Cervical spine fusion in rheumatoid arthritis. J Bone Joint Surg (Am) 61:10031010, 1979 Ranawat CS, O'Leary P, Pellicci P, et al: Cervical spine fusion in rheumatoid arthritis. J Bone Joint Surg (Am) 61:1003–1010, 1979

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25.

    Santavirta S, , Slatis P, & Kankaanpaa U, et al: Treatment of the cervical spine in rheumatoid arthritis. J Bone Joint Surg (Am) 70:658667, 1988 Santavirta S, Slatis P, Kankaanpaa U, et al: Treatment of the cervical spine in rheumatoid arthritis. J Bone Joint Surg (Am) 70:658–667, 1988

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26.

    Smith PH, , Benn RT, & Sharp J: Natural history of rheumatoid cervical luxations. Ann Rheum Dis 31:431439, 1972 Smith PH, Benn RT, Sharp J: Natural history of rheumatoid cervical luxations. Ann Rheum Dis 31:431–439, 1972

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27.

    Steinbrocker O, , Traeger CH, & Batterman RC: Therapeutic criteria in rheumatoid arthritis. JAMA 140:659662, 1949 Steinbrocker O, Traeger CH, Batterman RC: Therapeutic criteria in rheumatoid arthritis. JAMA 140:659–662, 1949

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28.

    Taitsman JP, & Saha S: Tensile strength of wire-reinforced bone cement and twisted stainless-steel wire. J Bone Joint Surg (Am) 59:419425, 1977 Taitsman JP, Saha S: Tensile strength of wire-reinforced bone cement and twisted stainless-steel wire. J Bone Joint Surg (Am) 59:419–425, 1977

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29.

    Thompson RC Jr, & Meyer TJ: Posterior surgical stabilization for atlantoaxial subluxation in rheumatoid arthritis. Spine 10:597601, 1985 Thompson RC Jr, Meyer TJ: Posterior surgical stabilization for atlantoaxial subluxation in rheumatoid arthritis. Spine 10:597–601, 1985

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30.

    Weissman BNW, , Aliabadi P, & Weinfeld MS, et al: Prognostic features of atlantoaxial subluxation in rheumatoid arthritis patients. Radiology 144:745751, 1982 Weissman BNW, Aliabadi P, Weinfeld MS, et al: Prognostic features of atlantoaxial subluxation in rheumatoid arthritis patients. Radiology 144:745–751, 1982

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 31.

    Zoma A, , Sturrock RD, & Fisher WD, et al: Surgical stabilization of the rheumatoid cervical spine. A review of indications and results. J Bone Joint Surg (Br) 69:812, 1987 Zoma A, Sturrock RD, Fisher WD, et al: Surgical stabilization of the rheumatoid cervical spine. A review of indications and results. J Bone Joint Surg (Br) 69:8–12, 1987

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1455 885 206
Full Text Views 291 8 0
PDF Downloads 82 6 0
EPUB Downloads 0 0 0