Pooled data analysis on anterior versus posterior approach for rheumatoid arthritis at the craniovertebral junction

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OBJECT

Rheumatoid arthritis (RA) is one of the most debilitating autoimmune diseases affecting the craniovertebral junction (CVJ). Patients predominantly present with myelopathic symptoms and intractable neck pain. The surgical approach traditionally has been either a combined anterior and posterior approach or a posterior-only approach. In this article, the authors review pooled data from the literature and discuss the benefits of the two types of approaches.

METHODS

A search of the PubMed database was conducted using key words that describe spine deformities in RA and specific spinal interventions. The authors evaluated the neurological outcomes based on the Ranawat scale in both the groups through chi-square analysis. Multiple logistic regression was carried out to further examine for potential confounders. Any adverse sequalae resulting from either approach were also documented. Because all the procedures performed via a transoral approach in the analyzed articles also involved posterior fixation, for convenience of comparison, the combined procedures are referred to as “anterior approach” or “anterior-posterior” in the present study.

RESULTS

The search yielded 233 articles, of which 11 described anterior approaches and 14 evaluated posterior approaches. The statistical analysis showed that patients treated with a posterior approach fared better than those treated with an anterior (combined) approach. It was noted that those patients in whom the cervical subluxations were reducible on traction predominantly underwent posterior approaches.

CONCLUSIONS

CVJ instability is a serious complication of RA that requires surgical intervention. Although the anterior-posterior combined approach can provide direct decompression, it is associated with morbidity, and the analysis showed no statistically significant benefit to patients. In contrast, the posterior approach has been shown to provide statistically significant superiority with respect to stabilization and subsequent pannus reduction. Surgical approaches are undertaken based on the reducibility of subluxations with traction and the vector of compressive force. However, the choice of surgical approach should be based on the individual patient's pathology.

ABBREVIATIONS AADI = anterior atlantodental interval; CVJ = craniovertebral junction; PADI = posterior atlantodental interval; RA = rheumatoid arthritis.

OBJECT

Rheumatoid arthritis (RA) is one of the most debilitating autoimmune diseases affecting the craniovertebral junction (CVJ). Patients predominantly present with myelopathic symptoms and intractable neck pain. The surgical approach traditionally has been either a combined anterior and posterior approach or a posterior-only approach. In this article, the authors review pooled data from the literature and discuss the benefits of the two types of approaches.

METHODS

A search of the PubMed database was conducted using key words that describe spine deformities in RA and specific spinal interventions. The authors evaluated the neurological outcomes based on the Ranawat scale in both the groups through chi-square analysis. Multiple logistic regression was carried out to further examine for potential confounders. Any adverse sequalae resulting from either approach were also documented. Because all the procedures performed via a transoral approach in the analyzed articles also involved posterior fixation, for convenience of comparison, the combined procedures are referred to as “anterior approach” or “anterior-posterior” in the present study.

RESULTS

The search yielded 233 articles, of which 11 described anterior approaches and 14 evaluated posterior approaches. The statistical analysis showed that patients treated with a posterior approach fared better than those treated with an anterior (combined) approach. It was noted that those patients in whom the cervical subluxations were reducible on traction predominantly underwent posterior approaches.

CONCLUSIONS

CVJ instability is a serious complication of RA that requires surgical intervention. Although the anterior-posterior combined approach can provide direct decompression, it is associated with morbidity, and the analysis showed no statistically significant benefit to patients. In contrast, the posterior approach has been shown to provide statistically significant superiority with respect to stabilization and subsequent pannus reduction. Surgical approaches are undertaken based on the reducibility of subluxations with traction and the vector of compressive force. However, the choice of surgical approach should be based on the individual patient's pathology.

ABBREVIATIONS AADI = anterior atlantodental interval; CVJ = craniovertebral junction; PADI = posterior atlantodental interval; RA = rheumatoid arthritis.

Rheumatoid arthritis (RA) is a debilitating systemic autoimmune disease that predominantly affects synovial joints. Craniovertebral junction (CVJ) involvement is seen in 36%–88% of patients.1,2,4,13,22,32,40 The pathophysiology of the inflammatory disorder often starts with synovitis, followed by formation of a pannus, which is characterized by inflammatory infiltrate (T cells, B cells, and cytokines) and digestive enzymes (matrix metalloproteinases, collegenases). Given the erosive and bulky nature of the pannus and its dangerous location at CVJ, the probability of potential fatal complications such as cervical spine instability, blockage of vertebral arteries, and direct spinal cord compression is likely to increase as the disease progresses. A number of spinal deformities have been associated with RA. Atlantoaxial (C1–2) instability is the most common clinical manifestation, and it may lead to atlantoaxial subluxation or basilar invagination/cranial settling.

Spinal surgery is often indicated when patients present with intractable neck pain or progressive neurological symptoms. The surgical procedures are generally categorized into two groups: 1) combined anterior and posterior approaches and 2) posterior-only approach. The principle behind the anterior approach is to achieve direct decompression of the anterior cervical pathology, and the goal of the posterior approach is to stabilize the alignment of the vertebral column with immobilization to reduce pannus formation.14 Direct decompression via C-1 laminectomy may also be carried out if the vector of pressure is greater posteriorly. To date, there is no general consensus on which approach is the best for patients with RA. In this review, we aim to provide an overview of different spinal interventions and attempt to derive a surgical management algorithm that is tailored specifically to rheumatoid abnormalities at the CVJ.

Methods

A comprehensive search of the English-language literature for the years 1975–2014 was performed on PubMed using combinations of the following phrases that describe spine deformities (“atlantoaxial subluxation”, “basilar invagination”, “cranial settling”, “subaxial subluxation”, “rheumatoid arthritis”) and spinal interventions (“spine surgery”, “ anterior approach”, “posterior approach, transoral”, “fusion”, “fixation”). Additional articles were located by cross-referencing articles encountered initially through the PubMed searches. Each index article was analyzed in detail, specifically focusing on the clinical outcome following either anterior or posterior approach. Since all the transoral procedures being done were complemented with posterior fixation, the combined approach is referred to in this paper, for convenience of comparison, as “anterior approach” or “anterior-posterior approach.” Inclusion criteria comprised articles (case reports, case series, meta-analyses, clinical trials, literature reviews, molecular studies, animal models, and guidelines) originating from peer-reviewed literature and discussing the surgical management, outcomes, and complications of RA at the CVJ. Analyses were performed with SPSS 22.0 software. A chi-square test was used in simple comparison of approaches (anterior vs posterior) with respect to neurological outcome, while multivariate logistic regression was performed to assess the influence of confounding factors.

Results

Study Selection

Our PubMed search yielded 233 articles for screening and with the application of our inclusion criteria we narrowed the results to 25 articles (11 primarily on combined anterior-posterior approach and 14 on posterior-only approach). Of these 25 articles, 17 met the criteria for inclusion in our pooled data analysis. The detailed study selection flowchart is shown in Fig. 1.

FIG. 1
FIG. 1

Flow diagram representing the search criteria for selecting the articles. Out of 489 articles identified in the PubMed database and evaluated for this study, only 17 met the criteria for inclusion in the pooled data analysis.

Study Characteristics

The 11 combined anterior-posterior approach manuscripts included 674 patients (Table 1) and the 14 posterior-only manuscripts included 592 patients (Table 2). Anterior approaches consisted primarily of transoral approaches while posterior approaches comprised occipitocervical, atlantoaxial, and subaxial fusion with laminectomy. The transoral approach was always supplemented with posterior fixation in the studies included in this analysis. For the convenience of categorizing the approaches, the combined anterior-posterior approach will be referred as “anterior approach” and posterior-only fusion as “posterior approach” for the rest of the paper.

TABLE 1

Characteristics of studies describing an anterior approach*

Authors & YearType of StudyNo. of PtsMean Age in Yrs (range)Female/MaleFU (mos)Type of Surgery†Diagnosis
Menezes et al., 1985Retrospective45Transoral in 7; posterior fixation in 38BI, AAS, SAS
Crockard et al., 1986Retrospective1457.8 (19–78)11:318TransoralAAS
Spetzler et al., 1988Retrospective13TransoralBI
Hadley et al., 1989Retrospective215424TransoralBI
Crockard et al., 1990Retrospective68TransoralAAS
Casey et al., 19966Prospective13462.9 (22–82)110:24Transoral in 91; posterior fixation in 43BI
Casey et al., 19965Prospective5564.744:11Transoral & posterior fixationBI
Casey et al., 1997‡Prospective11662.3 (60.6–63.9)92:2445.3Transoral in 67; posterior fixation in 49BI (71 irreducible)
Kerschbaumer et al, 2000Retrospective1561.6(31–82)12:350.7TransoralBI in 8 (coexisting pannus in 3; ondontoid fracture in 1); pannus compression in 5 (coexisting pannus compression in 1); odontoid fracture alone in 1
Nannapaneni et al., 2005Retrospective3266.81 (36–85)25:739Transoral in 21; posterior fixation in 11AAS (coexisting BI in 6; BI & SAS in 3; SAS in 5)
Choi & Crockard, 2013Retrospective & prospective533(216 w/ RA)46.343%:57%62.1TransoralBI, congenital malformation, chordoma
AAS = atlantoaxial subluxation; BI = basilar invagination; FU = follow-up; pts = patients; SAS = subaxial subluxation; – = data unavailable.* Gray shading indicates studies that were included in the pooled data analysis.† The transoral approach was always supplemented with posterior fixation in the studies included in this analysis.‡ Similar studies by same authors and based on same database.
TABLE 2

Characteristics of studies describing a posterior approach*

Authors & YearType of StudyNo. of PtsMean Age in Yrs (range)Female/MaleFU (mos)Type of SurgeryDiagnosis
Ranawat et al., 1979Retrospective3362 (42–85)21:1254 (12–96)Posterior fusion (occipitocervical in 12; atlantoaxial in 13); anterior fusion in 5AAS in 13; BI in 1; SAS in 7; AAS & SAS in 7; SAS & BI in 3
Thompson & Meyer, 1985Retrospective1253 (25–68)10:236 (7–84)Posterior fusion (occipitocervical in 2; atlantoaxial in 10)AAS
Larsson & Toolanen, 1986Retrospective3454 (29–72)20:936Posterior fusion (occipitocervical in 6; atlantoaxial in 28)AAS in 28; BI in 6
Clarketal., 1989Retrospective4157(34–82)36:540 (23–74)Posterior fusion (occipitocervical in 16; atlantoaxial in 20); transoral in 2; anterior cervical vertebrectomy in 1AAS in 20; BI in 5; SAS in 4
Santavirta et al., 1991Retrospective3856 (35–77)30:8Posterior fusionAAS in 27; BI in 2; SAS in 10
Chan et al., 1992Retrospective1954.214:560Posterior fusion (occipitocervical in 16; atlantoaxial in 20)AAS
Eyres et al., 1998Retrospective2664.521:5Posterior fusionAAS in 13; SAS in 7; BI in 6; AAS & SAS in 4
Christensson et al., 2000Retrospective8265 (36–81)61:217Posterior fusion (atlantoaxial in 53 & occipitocervical in 19)AAS in 66; SAS in 27; BI in 10
Omura et al., 2002Retrospective1161.5(46–74)11:039.8 (14–62)Posterior fusion (occipitocervical)AAS in 1; SAS in 1; AAS, SAS & BI in 3
Tanaka et al., 2005Retrospective26536:20Posterior fusion (atlantoaxial)AAS
Clarke et al., 2006Retrospective516140:1196Posterior fusion (atlantoaxial in 31; subaxial in 17; occipitocervical in 3)AAS in 33; SAS in 8; BI in 2
Ronkainen et al., 2006Retrospective8661.890(60–120)Posterior fusion (atlantoaxial in 78; occipitocervical in 3)AAS
Kotil, 2012Retrospective1557.46:9Posterior fusionAAS in 2; SAS in 8; AAS & BI in 5
Miyamoto et al., 2013Retrospective11861.086:3264(1–180)Posterior fusion (atlantoaxial in 28; occipitocervical in 41); anterior fusion in 5BI, AAS, BI
* Gray shading indicates studies that were included in the pooled data analysis.

Neurological Outcome

Neurological outcome was assessed based on the Ranawat classification. Improvement in neurological outcome was defined as improvement of at least 1 Ranawat class above the preoperative assessment. Among the 25 articles that discussed the use of anterior or posterior approaches, 4 anterior approach articles and 11 posterior approach articles reported Ranawat classification data; 68% of patients treated with an anterior approach demonstrated neurological improvement, whereas 98% of patients treated with a posterior approach showed neurological improvement. When anterior versus posterior approach was the sole factor considered, the odds ratio for neurological improvement was 0.579 (95% CI 0.379–0.886) as summarized in Fig. 2. In our multivariate analysis, when anterior versus posterior approach was adjusted for factors such as sex, mean age, preoperative neurological status, and length of follow-up, there was no significant correlation with neurological outcome. The pooled data describing the percent change in postoperative Ranawat classification from preoperative Ranawat classification were also analyzed, as shown in Figs. 3 and 4.

FIG. 2
FIG. 2

Bar diagram summarizing the comparative neurological improvement in patients treated with anterior versus posterior approaches. About 68% of patients who underwent an anterior approach demonstrated neurological improvement in comparison with 98% of patients who underwent a posterior approach. Neuro = neurological.

FIG. 3
FIG. 3

Analysis of the pooled data demonstrating the neurological outcome based on the Ranawat criteria for the anterior approach. It is easily appreciated that the more severe the disease is, the less is the possibility of improvement.

FIG. 4
FIG. 4

Analysis of the pooled data demonstrating the neurological outcome based on the Ranawat criteria for the posterior approach. Ranawat scores have shown better improvement in the posterior approach.

Complications following an anterior or a posterior approach are described in Table 3 and Table 4, respectively.

TABLE 3

Complications following an anterior approach

Authors & YearSepsisRespiratory*Cervical InfectionCardiac Failure/MIDysphagiaCSF LeakPseudarthrosisSAS/ASD
Ranawat et al., 19797.1%7.1%NRNRNRNR4/2814.3
Thompson & Meyer, 1985NR8.3%NRNRNRNR8.3%NR
Larsson & Toolanen, 1986NR2.9%NRNRNRNR14%NR
Clark et al., 1989NR7.3%7.3%2.4%NRNRNRNR
Santavirta et al., 19915.3%2.6%2.6%7.9%NRNRNRNR
Chan et al., 19925.3%5.3%5.3%5.3%5.3%NRNRNR
Eyres et al., 1998NRNR3.8%NRNRNRNRNR
Christennson et al., 2000NRNR3.7%1.2%NR1.2%NRNR
Omura et al., 2002NRNR9.1%NRNRNRNRNR
Tanaka et al., 2005NR07.7%NRNRNRNRNR
Clarke et al., 2006NRNRNRNRNRNRNR39.3%
Ronkainen et al., 2006NR2.3%NRNRNRNRNRNR
Miyamoto et al., 2013NRNRNRNRNRNR4.3%NR
ASD = adjacent segment disease; MI = myocardial infarction; NR = not reported. * Pneumonia, respiratory insufficiency.
TABLE 4

Complications following a posterior approach

Author & YearPharyngeal InfectionCervical Wound InfectionVA Occlusion w/ Brainstem StrokeRespiratory*CSF LeakMeningitisSepticemia
Menezes et al., 19850NRNRNRNRNRNR
Crockard et al., 19860NRNRNRNRNRNR
Menezes & VanGilder, 19887.0%NRNRNRNRNRNR
Spetzler et al., 1988NRNR7.7%7.7%NRNRNR
Hadley et al., 1989NR4.7%4.7%9.5%0NRNR
Crockard et al., 1990NRNRNR5.9%8.8%2.9%1.4%
Casey et al., 19974.3%0.9%NR19.8%NR2.6%NR
Nannapanenel et al., 20053.1%12.5%
Choi & Crockard, 201302.1%NR10.8%00.5%1.1%
VA = vertebral artery.* Pneumonia, pulmonary embolus, atelectasis.

Nonsurgical Predictors of Neurological Improvement

Several preoperative factors, including sex, use of corticosteroids, and duration of myelopathy, were found to be not strongly associated with outcome.30,33 In our review, a multivariate analysis of the effect of age, sex, surgical technique, and follow-up period was performed to analyze the influence of these factors on neurological improvement (Table 5). Despite the significant finding in the previous univariate analysis, we found that the surgical techniques were no longer significantly correlated with outcome when the mentioned factors were added. This was probably due to the smaller sample size (n = 121) available for the analysis and possible influence of confounding factors. Interestingly, sex and follow-up period were found to be potential confounders. Female sex had a significant effect on neurological outcome (p = 0.001). It is well known that female sex is associated with a higher susceptibility to most autoimmune diseases, including RA. Meanwhile, it is logical that the longer the follow-up, the greater the chance for recovery in terms of neurological status (p = 0.003).

TABLE 5

Results of multivariate analysis*

VariableAdjusted OR for Neurological Improvementp Value
Anterior vs posterior0.5840.445
Sex (female)21.2500.001
Age (>70 yrs)1.5630.445
Preop Ranawat class (Class III)1.4710.391
Follow-up (>5 yrs)13.1060.003
* Odd ratios for neurological improvement, estimated significance for anterior versus posterior, sex, mean age, preoperative neurological status, and length of follow-up in the 121 cases included in the pooled data analysis.

In consideration of demographic factors, elderly age is significantly correlated with poor outcome.5,34 This should prompt careful selection of elderly surgical candidates and also might suggest the beneficial effect of early surgical intervention. On the other hand, high Ranawat class, especially Class IIIB (with long tract dysfunction) typically is associated with slow recovery and a high mortality rate.33,34 Casey et al.,5 in their multivariate analysis, demonstrated a high predictive value of preoperative spinal cord cross-sectional area for improvement of neurological outcome (p = 0.026). In other words, the smaller the spinal cord cross-sectional area, the worse the outcome. The spinal cord atrophy due to chronic compression and trauma most likely explains this observed phenomenon. Indeed, this led to more investigations focusing on different radiographic parameters: anterior atlantodental interval (AADI) and posterior atlantodental interval (PADI). AADI and PADI measure the space available between spinal cord and the vertebra ventrally and posteriorly. Boden et al., have observed that a PADI of at least 10 mm always resulted in improvement of 1 neurological class,3 and hence many spine experts have advocated surgery when PADI is less than 14 mm in atlantoaxial subluxation. In the same report, PADI was proven superior as both a diagnostic and a prognostic parameter when AADI failed to be as useful as PADI. On the other hand, subaxial canal diameter, which is the space available for the spinal cord below the axis, was shown to have similar finding (< 14 mm) as a useful prognostic factor in subaxial subluxation. Furthermore, vertical subluxation, as in basilar invagination, has a worse prognosis and poor motor recovery compared with horizontal subluxation. Despite the high rate of morbidity resulting from surgery, the fear of potentially life-threatening events eventually prompts most spinal surgeons to perform surgery.

Discussion

The optimal surgical approach in the treatment of the rheumatoid spine remains a controversy in spine surgery. To our knowledge, there have been only 2 studies that included analyses of type of spine surgery (anterior vs posterior) in RA patients.7,30 Casey et al.7 reported the results of a prospective study involving 116 patients with vertical translocation, a Ranawat neurological classification of at least Class II, and a mean postoperative follow-up of 62.3 months. The choice of anterior-posterior combination vs posterior-only surgery was made based on whether the compression was predominantly anterior or posterior and if the translocation was reducible with traction. A transoral procedure was carried out in 67 cases (57.8%). Neurological improvement was seen in 46% of the patients treated with a posterior approach group and 44% of those treated with an anterior approach group. However, the difference of 2 percentage points was not statistically significant. In the same study, the authors also showed higher incidence of chest infection in the anterior-approach group, but the association was not statistically significant. Nannapaneni and colleagues30 examined surgical outcome in patients with very poor preoperative neurological status (Ranawat Class IIIB) and a mean follow-up of 39 months. All the patients underwent halo placement before surgery, and if their subluxation was reducible, they had the posterior-only surgery. However, only 2 of the patients with reducible subluxations had basilar invagination. The influence of different surgical approaches on clinical outcome was not found to be statistically significant. Several articles have shown that pannus regression is also possible with posterior stabilization despite anterior location of the pannus.20,23,24,37,41,42

Transoral

Fang and Ong were among the first to use a transoral approach in treating atlantoaxial instability.17 It can be categorized into 3 different types: 1) transoral-transpalatal approach, 2) transoral-transpharyngeal or standard transoral, and 3) transmandibular with split. The standard transoral approach provides exposure from the lower third of the clivus to C-2. Due to the common rheumatoid spine pathology at CVJ, the standard transoral approach has been mainly employed in direct ventral decompression from the mass effect exerted by the pannus and odontoid peg compression on the spinal cord at the CVJ. The decompression is achieved mainly via odontoidectomy, and posterior fixation is carried out on the same day to correct the craniocervical instability resulting from the procedure. Choi et al.9 described a decreasing trend in the use of transoral procedures in a series of 479 patients over 3 decades. This might be explained by the evolution of medical treatment (i.e., disease-modifiying antirheumatic drugs) and the advancement of surgical approaches, especially the dorsal route of fixation and fusion.

Endoscopy

More recently, endoscopic transnasal procedures have gained popularity for odontoid resection. These minimally invasive techniques address various limitations of open transoral approaches. Avoidance of a transmaxillary procedure is probably the major advantage, as the splitting of the palate is known to be associated with a high incidence of morbidity.9 However, Choi et al. pointed out the relatively high incidence of CSF leak associated with the endoscopic technique (22%–25%) compared with the conventional one (1.3%).

Atlantoaxial Fusion

Historically, a posterior fusion mainly comprised of various wiring construct techniques, which include Gallie, Brooks, and Sonntag-Dickman techniques. During the 1st decades of the 21st century, there has been a trend of increasing use of transarticular screws in correcting atlantoaxial subluxation. Unlike the conventional wiring techniques, the placement of transarticular screws from the pars interarticularis of C-2 into the lateral mass of C-1 can provide immediate rigid internal fixation.

Occipitocervical Fusion

Extension of fusion or fixation to the occipital bone is commonly carried out in patients with basilar invagination. This is the type of fusion that has always been employed following anterior odontoidectomy to correct the secondary instability.

Limitations of This Study

The major limitation of our analysis was the small number of qualifying studies that included long-term follow-up. In addition, our analysis was based almost entirely on retrospective studies. It included only 1 prospective study, and we did not find any randomized clinical trial in the current literature.

Conclusions

Numerous factors, including reducibility of the deformity, the direction of greatest compression, preoperative neurological status, and the patient's age, need to be considered before deciding to carry out either approach. In 1980, Menezes et al. proposed an algorithm (Fig. 5) for surgical treatment of CVJ pathology based on most of the factors mentioned.28 Our findings reinforced the principle of management as illustrated in the algorithm and also added several extra factors (i.e., preoperative neurological status) for consideration when choosing either approach.

FIG. 5
FIG. 5

Treatment algorithm of Menezes et al., which assists the surgeon in decision making depending on the physical examination and radiological findings and the reducibility of the deformity. Decompr. = decompression; 1° = primary. From Menezes et al.28 Published with permission.

In our analysis, we showed that 66% of those with Class IIIB myelopathy improved to at least 1 class above in the anterior-approach group during postoperative follow-up while compared with 46% in the posterior-approach group. There was no case in either group in which a patient's condition improved to Class I. Patients with a Ranawat Class IIIB score have the worst prognosis and outcome.

As far as neurological improvement is concerned, overall, statistics demonstrated the superiority of the posterior approach in patients whose subluxation is reducible. Hence, it would be best to avoid an anterior approach unless it is indicated, as in those cases in which a subluxation is not reducible, even with traction. We recommend that surgical decision making in managing CVJ complications of RA should be based on the correlation between the clinical picture and radiological findings in individual patients, and we hope that our results will be helpful in that process.

Author Contributions

Conception and design: Madhavan. Acquisition of data: Chieng. Analysis and interpretation of data: Madhavan, Chieng. Drafting the article: Chieng. Critically revising the article: Madhavan. Reviewed submitted version of manuscript: Vanni. Statistical analysis: Madhavan. Administrative/technical/material support: Vanni. Study supervision: Madhavan, Vanni.

References

  • 1

    Aggarwal AKulshreshtha AChaturvedi VMisra R: Cervical spine involvement in rheumatoid arthritis: prevalence and relationship with overall disease severity. J Assoc Physicians India 44:4684711996

    • Search Google Scholar
    • Export Citation
  • 2

    Bland JHDavis PHLondon MGVanbuskirk FWDuarte CG: Rheumatoid arthritis of cervical spine. Arch Intern Med 112:8928981963

  • 3

    Boden SDDodge LDBohlman HHRechtine GR: Rheumatoid arthritis of the cervical spine. A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 75:128212971993

    • Search Google Scholar
    • Export Citation
  • 4

    Cabot ABecker A: The cervical spine in rheumatoid arthritis. Clin Orthop Relat Res 131:1301401978

  • 5

    Casey ATCrockard HABland JMStevens JMoskovich RRansford A: Predictors of outcome in the quadriparetic non-ambulatory myelopathic patient with rheumatoid arthritis: a prospective study of 55 surgically treated Ranawat class IIIb patients. J Neurosurg 85:5745811996

    • Search Google Scholar
    • Export Citation
  • 6

    Casey ATCrockard HABland JMStevens JMoskovich RRansford AO: Surgery on the rheumatoid cervical spine for the non-ambulant myelopathic patient-too much, too late?. Lancet 347:100410071996

    • Search Google Scholar
    • Export Citation
  • 7

    Casey ATCrockard HAStevens J: Vertical translocation. Part II. Outcomes after surgical treatment of rheumatoid cervical myelopathy. J Neurosurg 87:8638691997

    • Search Google Scholar
    • Export Citation
  • 8

    Chan DPNgian KSCohen L: Posterior upper cervical fusion in rheumatoid arthritis. Spine (Phila Pa 1976) 17:2682721992

  • 9

    Choi DCrockard HA: Evolution of transoral surgery: three decades of change in patients, pathologies, and indications. Neurosurgery 73:2963042013

    • Search Google Scholar
    • Export Citation
  • 10

    Christensson DSäveland HRydholm U: Cervical spine surgery in rheumatoid arthritis. A Swedish nation-wide registration of 83 patients. Scand J Rheumatol 29:3143192000

    • Search Google Scholar
    • Export Citation
  • 11

    Clark CRGoetz DDMenezes AH: Arthrodesis of the cervical spine in rheumatoid arthritis. J Bone Joint Surg Am 71:3813921989

  • 12

    Clarke MJCohen-Gadol AAEbersold MJCabanela ME: Long-term incidence of subaxial cervical spine instability following cervical arthrodesis surgery in patients with rheumatoid arthritis. Surg Neurol 66:1361402006

    • Search Google Scholar
    • Export Citation
  • 13

    Conlon PWIsdale ICRose BS: Rheumatoid arthritis of the cervical spine. An analysis of 333 cases. Ann Rheum Dis 25:1201261966

  • 14

    Crockard HACalder IRansford AO: One-stage transoral decompression and posterior fixation in rheumatoid atlantoaxial subluxation. J Bone Joint Surg Br 72:6826851990

    • Search Google Scholar
    • Export Citation
  • 15

    Crockard HAPozo JLRansford AOStevens JMKendall BEEssigman WK: Transoral decompression and posterior fusion for rheumatoid atlanto-axial subluxation. J Bone Joint Surg Br 68:3503561986

    • Search Google Scholar
    • Export Citation
  • 16

    Eyres KSGray DHRobertson P: Posterior surgical treatment for the rheumatoid cervical spine. Br J Rheumatol 37:7567591998

  • 17

    Fang HSYOng GB: Direct anterior approach to the upper cervical spine. J Bone Joint Surg Am 44:158816041962

  • 18

    Hadley MNSpetzler RFSonntag VKH: The transoral approach to the superior cervical spine. A review of 53 cases of extradural cervicomedullary compression. J Neurosurg 71:16231989

    • Search Google Scholar
    • Export Citation
  • 19

    Kerschbaumer FKandziora FKlein CMittlmeier TStarker M: Transoral decompression, anterior plate fixation, and posterior wire fusion for irreducible atlantoaxial kyphosis in rheumatoid arthritis. Spine (Phila Pa 1976) 25:270827152000

    • Search Google Scholar
    • Export Citation
  • 20

    Kolen ERSchmidt MH: Rheumatoid arthritis of the cervical spine. Semin Neurol 22:1791862002

  • 21

    Kotil K: The long time follow-up of craniovertebral junction fixation in patients with rheumatoid arthritis. J Craniovertebr Junction Spine 3:42462012

    • Search Google Scholar
    • Export Citation
  • 22

    Laiho KBelt EKauppi M: The cervical spine in mutilant rheumatoid arthritis. Rheumatol Int 20:2252282001

  • 23

    Landi AMarotta NMorselli CMarongiu ADelfini R: Pannus regression after posterior decompression and occipitocervical fixation in occipito-atlanto-axial instability due to rheumatoid arthritis: case report and literature review. Clin Neurol Neurosurg 115:1111162013

    • Search Google Scholar
    • Export Citation
  • 24

    Larsson EMHoltås SZygmunt S: Pre- and postoperative MR imaging of the craniocervical junction in rheumatoid arthritis. AJR Am J Roentgenol 152:5615661989

    • Search Google Scholar
    • Export Citation
  • 25

    Larsson SEToolanen G: Posterior fusion for atlanto-axial subluxation in rheumatoid arthritis. Spine (Phila Pa 1976) 11:5255301986

    • Search Google Scholar
    • Export Citation
  • 26

    Menezes AHVanGilder JC: Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg 69:8959031988

    • Search Google Scholar
    • Export Citation
  • 27

    Menezes AHVanGilder JCClark CRel-Khoury G: Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with “cranial settling.”. J Neurosurg 63:5005091985

    • Search Google Scholar
    • Export Citation
  • 28

    Menezes AHVanGilder JCGraf CJMcDonnell DE: Craniocervical abnormalities. A comprehensive surgical approach. J Neurosurg 53:4444551980

    • Search Google Scholar
    • Export Citation
  • 29

    Miyamoto HSumi MUno K: Outcome of surgery for rheumatoid cervical spine at one institute over three decades. Spine J 13:147714842013

    • Search Google Scholar
    • Export Citation
  • 30

    Nannapaneni RBehari STodd NV: Surgical outcome in rheumatoid Ranawat Class IIIb myelopathy. Neurosurgery 56:7067152005

  • 31

    Omura KHukuda SKatsuura ASaruhashi YImanaka TImai S: Evaluation of posterior long fusion versus conservative treatment for the progressive rheumatoid cervical spine. Spine (Phila Pa 1976) 27:133613452002

    • Search Google Scholar
    • Export Citation
  • 32

    Pellicci PMRanawat CSTsairis PBryan WJ: A prospective study of the progression of rheumatoid arthritis of the cervical spine. J Bone Joint Surg Am 63:3423501981

    • Search Google Scholar
    • Export Citation
  • 33

    Ranawat CSO’Leary PPellicci PTsairis PMarchisello PDorr L: Cervical spine fusion in rheumatoid arthritis. J Bone Joint Surg Am 61:100310101979

    • Search Google Scholar
    • Export Citation
  • 34

    Ronkainen ANiskanen MAuvinen AAalto JLuosujärvi R: Cervical spine surgery in patients with rheumatoid arthritis: longterm mortality and its determinants. J Rheumatol 33:5175222006

    • Search Google Scholar
    • Export Citation
  • 35

    Santavirta SKonttinen YTLaasonen EHonkanen VAntti-Poika IKauppi M: Ten-year results of operations for rheumatoid cervical spine disorders. J Bone Joint Surg Br 73:1161201991

    • Search Google Scholar
    • Export Citation
  • 36

    Spetzler RFHadley MNSonntag VK: The transoral approach to the anterior superior cervical spine. A review of 29 cases. Acta Neurochir Suppl (Wien) 43:69741988

    • Search Google Scholar
    • Export Citation
  • 37

    Stiskal MANeuhold ASzolar DHSaeed MCzerny CLeeb B: Rheumatoid arthritis of the craniocervical region by MR imaging: detection and characterization. AJR Am J Roentgenol 165:5855921995

    • Search Google Scholar
    • Export Citation
  • 38

    Tanaka NSakahashi HHirose KIshima TTakahashi HIshii S: Results after 24 years of prophylactic surgery for rheumatoid atlantoaxial subluxation. J Bone Joint Surg Br 87:9559582005

    • Search Google Scholar
    • Export Citation
  • 39

    Thompson RC JrMeyer TJ: Posterior surgical stabilization for atlantoaxial subluxation in rheumatoid arthritis. Spine (Phila Pa 1976) 10:5976011985

    • Search Google Scholar
    • Export Citation
  • 40

    Zikou AKAlamanos YArgyropoulou MITsifetaki NTsampoulas CVoulgari PV: Radiological cervical spine involvement in patients with rheumatoid arthritis: a cross sectional study. J Rheumatol 32:8018062005

    • Search Google Scholar
    • Export Citation
  • 41

    Zoma ASturrock RDFisher WDFreeman PAHamblen DL: Surgical stabilisation of the rheumatoid cervical spine. A review of indications and results. J Bone Joint Surg Br 69:8121987

    • Search Google Scholar
    • Export Citation
  • 42

    Zygmunt SSäveland HBrattström HLjunggren BLarsson EMWollheim F: Reduction of rheumatoid periodontoid pannus following posterior occipitocervical fusion visualised by magnetic resonance imaging. Br J Neurosurg 2:3153201988

    • Search Google Scholar
    • Export Citation

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Article Information

Contributor Notes

Correspondence Karthik Madhavan, Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, 2nd Fl., 1095 N.W. 14th Terrace (D4-6), Miami, FL 33136. email:drkarthik19@gmail.com.INCLUDE WHEN CITING DOI: 10.3171/2015.1.FOCUS14838.DISCLOSURE The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© Copyright 1944-2019 American Association of Neurological Surgeons

Headings
Figures
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    Flow diagram representing the search criteria for selecting the articles. Out of 489 articles identified in the PubMed database and evaluated for this study, only 17 met the criteria for inclusion in the pooled data analysis.

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    Bar diagram summarizing the comparative neurological improvement in patients treated with anterior versus posterior approaches. About 68% of patients who underwent an anterior approach demonstrated neurological improvement in comparison with 98% of patients who underwent a posterior approach. Neuro = neurological.

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    Analysis of the pooled data demonstrating the neurological outcome based on the Ranawat criteria for the anterior approach. It is easily appreciated that the more severe the disease is, the less is the possibility of improvement.

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    Analysis of the pooled data demonstrating the neurological outcome based on the Ranawat criteria for the posterior approach. Ranawat scores have shown better improvement in the posterior approach.

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    Treatment algorithm of Menezes et al., which assists the surgeon in decision making depending on the physical examination and radiological findings and the reducibility of the deformity. Decompr. = decompression; 1° = primary. From Menezes et al.28 Published with permission.

References
  • 1

    Aggarwal AKulshreshtha AChaturvedi VMisra R: Cervical spine involvement in rheumatoid arthritis: prevalence and relationship with overall disease severity. J Assoc Physicians India 44:4684711996

    • Search Google Scholar
    • Export Citation
  • 2

    Bland JHDavis PHLondon MGVanbuskirk FWDuarte CG: Rheumatoid arthritis of cervical spine. Arch Intern Med 112:8928981963

  • 3

    Boden SDDodge LDBohlman HHRechtine GR: Rheumatoid arthritis of the cervical spine. A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 75:128212971993

    • Search Google Scholar
    • Export Citation
  • 4

    Cabot ABecker A: The cervical spine in rheumatoid arthritis. Clin Orthop Relat Res 131:1301401978

  • 5

    Casey ATCrockard HABland JMStevens JMoskovich RRansford A: Predictors of outcome in the quadriparetic non-ambulatory myelopathic patient with rheumatoid arthritis: a prospective study of 55 surgically treated Ranawat class IIIb patients. J Neurosurg 85:5745811996

    • Search Google Scholar
    • Export Citation
  • 6

    Casey ATCrockard HABland JMStevens JMoskovich RRansford AO: Surgery on the rheumatoid cervical spine for the non-ambulant myelopathic patient-too much, too late?. Lancet 347:100410071996

    • Search Google Scholar
    • Export Citation
  • 7

    Casey ATCrockard HAStevens J: Vertical translocation. Part II. Outcomes after surgical treatment of rheumatoid cervical myelopathy. J Neurosurg 87:8638691997

    • Search Google Scholar
    • Export Citation
  • 8

    Chan DPNgian KSCohen L: Posterior upper cervical fusion in rheumatoid arthritis. Spine (Phila Pa 1976) 17:2682721992

  • 9

    Choi DCrockard HA: Evolution of transoral surgery: three decades of change in patients, pathologies, and indications. Neurosurgery 73:2963042013

    • Search Google Scholar
    • Export Citation
  • 10

    Christensson DSäveland HRydholm U: Cervical spine surgery in rheumatoid arthritis. A Swedish nation-wide registration of 83 patients. Scand J Rheumatol 29:3143192000

    • Search Google Scholar
    • Export Citation
  • 11

    Clark CRGoetz DDMenezes AH: Arthrodesis of the cervical spine in rheumatoid arthritis. J Bone Joint Surg Am 71:3813921989

  • 12

    Clarke MJCohen-Gadol AAEbersold MJCabanela ME: Long-term incidence of subaxial cervical spine instability following cervical arthrodesis surgery in patients with rheumatoid arthritis. Surg Neurol 66:1361402006

    • Search Google Scholar
    • Export Citation
  • 13

    Conlon PWIsdale ICRose BS: Rheumatoid arthritis of the cervical spine. An analysis of 333 cases. Ann Rheum Dis 25:1201261966

  • 14

    Crockard HACalder IRansford AO: One-stage transoral decompression and posterior fixation in rheumatoid atlantoaxial subluxation. J Bone Joint Surg Br 72:6826851990

    • Search Google Scholar
    • Export Citation
  • 15

    Crockard HAPozo JLRansford AOStevens JMKendall BEEssigman WK: Transoral decompression and posterior fusion for rheumatoid atlanto-axial subluxation. J Bone Joint Surg Br 68:3503561986

    • Search Google Scholar
    • Export Citation
  • 16

    Eyres KSGray DHRobertson P: Posterior surgical treatment for the rheumatoid cervical spine. Br J Rheumatol 37:7567591998

  • 17

    Fang HSYOng GB: Direct anterior approach to the upper cervical spine. J Bone Joint Surg Am 44:158816041962

  • 18

    Hadley MNSpetzler RFSonntag VKH: The transoral approach to the superior cervical spine. A review of 53 cases of extradural cervicomedullary compression. J Neurosurg 71:16231989

    • Search Google Scholar
    • Export Citation
  • 19

    Kerschbaumer FKandziora FKlein CMittlmeier TStarker M: Transoral decompression, anterior plate fixation, and posterior wire fusion for irreducible atlantoaxial kyphosis in rheumatoid arthritis. Spine (Phila Pa 1976) 25:270827152000

    • Search Google Scholar
    • Export Citation
  • 20

    Kolen ERSchmidt MH: Rheumatoid arthritis of the cervical spine. Semin Neurol 22:1791862002

  • 21

    Kotil K: The long time follow-up of craniovertebral junction fixation in patients with rheumatoid arthritis. J Craniovertebr Junction Spine 3:42462012

    • Search Google Scholar
    • Export Citation
  • 22

    Laiho KBelt EKauppi M: The cervical spine in mutilant rheumatoid arthritis. Rheumatol Int 20:2252282001

  • 23

    Landi AMarotta NMorselli CMarongiu ADelfini R: Pannus regression after posterior decompression and occipitocervical fixation in occipito-atlanto-axial instability due to rheumatoid arthritis: case report and literature review. Clin Neurol Neurosurg 115:1111162013

    • Search Google Scholar
    • Export Citation
  • 24

    Larsson EMHoltås SZygmunt S: Pre- and postoperative MR imaging of the craniocervical junction in rheumatoid arthritis. AJR Am J Roentgenol 152:5615661989

    • Search Google Scholar
    • Export Citation
  • 25

    Larsson SEToolanen G: Posterior fusion for atlanto-axial subluxation in rheumatoid arthritis. Spine (Phila Pa 1976) 11:5255301986

    • Search Google Scholar
    • Export Citation
  • 26

    Menezes AHVanGilder JC: Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg 69:8959031988

    • Search Google Scholar
    • Export Citation
  • 27

    Menezes AHVanGilder JCClark CRel-Khoury G: Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with “cranial settling.”. J Neurosurg 63:5005091985

    • Search Google Scholar
    • Export Citation
  • 28

    Menezes AHVanGilder JCGraf CJMcDonnell DE: Craniocervical abnormalities. A comprehensive surgical approach. J Neurosurg 53:4444551980

    • Search Google Scholar
    • Export Citation
  • 29

    Miyamoto HSumi MUno K: Outcome of surgery for rheumatoid cervical spine at one institute over three decades. Spine J 13:147714842013

    • Search Google Scholar
    • Export Citation
  • 30

    Nannapaneni RBehari STodd NV: Surgical outcome in rheumatoid Ranawat Class IIIb myelopathy. Neurosurgery 56:7067152005

  • 31

    Omura KHukuda SKatsuura ASaruhashi YImanaka TImai S: Evaluation of posterior long fusion versus conservative treatment for the progressive rheumatoid cervical spine. Spine (Phila Pa 1976) 27:133613452002

    • Search Google Scholar
    • Export Citation
  • 32

    Pellicci PMRanawat CSTsairis PBryan WJ: A prospective study of the progression of rheumatoid arthritis of the cervical spine. J Bone Joint Surg Am 63:3423501981

    • Search Google Scholar
    • Export Citation
  • 33

    Ranawat CSO’Leary PPellicci PTsairis PMarchisello PDorr L: Cervical spine fusion in rheumatoid arthritis. J Bone Joint Surg Am 61:100310101979

    • Search Google Scholar
    • Export Citation
  • 34

    Ronkainen ANiskanen MAuvinen AAalto JLuosujärvi R: Cervical spine surgery in patients with rheumatoid arthritis: longterm mortality and its determinants. J Rheumatol 33:5175222006

    • Search Google Scholar
    • Export Citation
  • 35

    Santavirta SKonttinen YTLaasonen EHonkanen VAntti-Poika IKauppi M: Ten-year results of operations for rheumatoid cervical spine disorders. J Bone Joint Surg Br 73:1161201991

    • Search Google Scholar
    • Export Citation
  • 36

    Spetzler RFHadley MNSonntag VK: The transoral approach to the anterior superior cervical spine. A review of 29 cases. Acta Neurochir Suppl (Wien) 43:69741988

    • Search Google Scholar
    • Export Citation
  • 37

    Stiskal MANeuhold ASzolar DHSaeed MCzerny CLeeb B: Rheumatoid arthritis of the craniocervical region by MR imaging: detection and characterization. AJR Am J Roentgenol 165:5855921995

    • Search Google Scholar
    • Export Citation
  • 38

    Tanaka NSakahashi HHirose KIshima TTakahashi HIshii S: Results after 24 years of prophylactic surgery for rheumatoid atlantoaxial subluxation. J Bone Joint Surg Br 87:9559582005

    • Search Google Scholar
    • Export Citation
  • 39

    Thompson RC JrMeyer TJ: Posterior surgical stabilization for atlantoaxial subluxation in rheumatoid arthritis. Spine (Phila Pa 1976) 10:5976011985

    • Search Google Scholar
    • Export Citation
  • 40

    Zikou AKAlamanos YArgyropoulou MITsifetaki NTsampoulas CVoulgari PV: Radiological cervical spine involvement in patients with rheumatoid arthritis: a cross sectional study. J Rheumatol 32:8018062005

    • Search Google Scholar
    • Export Citation
  • 41

    Zoma ASturrock RDFisher WDFreeman PAHamblen DL: Surgical stabilisation of the rheumatoid cervical spine. A review of indications and results. J Bone Joint Surg Br 69:8121987

    • Search Google Scholar
    • Export Citation
  • 42

    Zygmunt SSäveland HBrattström HLjunggren BLarsson EMWollheim F: Reduction of rheumatoid periodontoid pannus following posterior occipitocervical fusion visualised by magnetic resonance imaging. Br J Neurosurg 2:3153201988

    • Search Google Scholar
    • Export Citation
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