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66. Cervical spine surgery for rheumatoid arthritis
Proceedings of the NASS 18th Annual Meeting / The Spine Journal 3 (2003) 67S–171S
99S
RESULTS: The C2/7 angle decreased in all three groups: group S (split); 8.3 degrees, group D (dome); ⫺5.2 degrees, group I (intact); ⫺1.5 degrees. group S significantly lost the cervical kyphosis in comparison to group I. DISCUSSION: The original concept of laminoplasty was to reconstruct the bony structure of the posterior cervical spine. The theoretical and empirical consideration led the surgeons to the modification of the procedure by suturing the posterior muscles and keeping the nuchal ligament intact. Several studies as well as this study demonstrated the subaxial laminoplasty had little loss of the cervical alignment. In the previous studies on laminectomy, both C2 and subaxial laminectomies are reported to cause the progression of kyphosis. No previous study showed the alignment change after C2 and subaxial laminoplasty. This study elucidated the laminoplasty could not prevent the loss of the cervical alignment when C2 lamina is contained. As Nolan showed biomechanically, the semispinalis cervicis and C2 lamina is the main dynamic stabilizers. Laminoplasty need to be modified to minimize the dysfunction of the extensor muscles when the C2 lamina is contained. CONCLUSIONS: “Subaxial” laminoplasty maintained the cervical alignment. But if laminoplasty includes the C2 lamina, the alignment got worse to kyphosis. DISCLOSURES: No disclosures. CONFLICT OF INTEREST: No conflicts.
vs. 52% at least grade 3a; p⫽0.002) required more extensive surgery (mean OR time 279 vs. 164 minutes; p⫽0.008; level of fusion to C6/7 in 50% vs. 12%; p⫽0.05); and had worse post-operative RG (37% RG⫽0 vs. 92% RG⫽0). Immunosuppressive and corticosteroid use were not associated with complications or death. DISCUSSION: This study supports previous findings that PIF is a safe and effective procedure for rheumatoid arthritis patients with cervical or craniocervical involvement, but that the long-term outcome is less favorable in patients with high preoperative RG. CONCLUSIONS: Even in rheumatoid arthritis patients with very severe disease undergoing PIF markedly improved RG and VAS. Although there were no perioperative deaths, patients who were older, with worse underlying rheumatoid arthritis, and worse radiographic and neurologic parameters had a higher long-term risk of death. DISCLOSURES: Device or drug: Sofamor Danek lateral mass plates. Status: approved. Device or drug: Synthes Star Lock. Status: approved. CONFLICT OF INTEREST: No conflicts.
doi: 10.1016/S1529-9430(03)00248-1
5:20 67. Non-operative treatment of patients with cervical stenosis and radiculopathy: a two year follow-up study Jeffrey Saal, MD1, Joel Saal, MD1, Robert Gamburd, MD1; 1SOAR, Physiatry Medical Group, Redwood City, CA, USA
5:13 66. Cervical spine surgery for rheumatoid arthritis Michael Goytan, BSc, MD, FRCSC1, Christine Peschken, MSc, MD, FRCPC1; 1University of Manitoba, Winnipeg, MB, Canada HYPOTHESIS: Patients with severe long-standing rheumatoid arthritis and neurologic involvement benefit from a posterior instrumented fusion (PIF) of the cervical spine. METHODS: Thirty-three consecutive patients with rheumatoid arthritis undergoing PIF were evaluated. Patient demographics and joint counts, Ranawat grades (RG), and neck pain visual analogue scores (VAS), were collected prospectively during clinic visits before and after surgery. All patients had PIF with autograft, 5 patients had a preceding transoral odontoidectomy during the same anaesthetic. All patients were seen and assessed at 6 weeks, 3 months, 6 months and at one year and annually. RESULTS: There were 3 males and 30 females, 20 were Caucasian, 12 were Aboriginal, and 1 was Asian. Mean age was 58 years (range 35–85), mean disease duration 20 years (6–41), and mean number of joints affected 37 (range 8–69). Sixty-one percent were taking corticosteroids, and 85% were taking immunosuppressives. RG before surgery was 2 in 36%, 3a in 43%, and 3b in 21%. Mean VAS score before surgery was 8.5/10. All patients had an atlantodens interval (ADI) of > 5mm; 25 patients had vertical migration of the odontoid (VMO); and 5 patients had a posterior atlantodens interval (PADI)⬍13mm. Five patients had a transoral odontoidectomy for an irreducible C1-2 subluxation and VMO, all patients had a PIF. Twenty-five patients had an occipitocervical fusion, 4 patients had a C1-2 fusion, and 4 patients had a C1-subaxial spine fusion. Mean OR time was 192 minutes (range 92–600), mean blood loss was 312 ml (range 100– 1000). Mean follow-up was 33 months (range 3–67), (there was one death at 3 months). Twenty-six patients (79%) had a postoperative RG of zero (no parasthesia or weakness), and 88% had an improvement of at least 2 grades on the RG. The postoperative VAS declined by a mean of 7.9 (range 2–10). There were 8 deaths at 3, 8, 10, 13, 16, 17, 17, and 21 months respectively. Causes of death were pneumonia with respiratory failure, cardiopulmonary failure, cancer, and bowel perforation. Two patients (11%) had a major complication (hardware failure in one, and a soft palate dehiscence and hydrocephalous in the other), and 4 patients (22%) had minor complications. Those patients who died were older at the time of surgery (67 vs. 55 years; p⫽0.024) had significantly worse underlying arthritis (disease duration 27 vs. 19 years; p⫽0.037; mean affected joint count 48 vs. 34; p⫽0.025), had worse pre-op RG (100% at least grade 3a
doi: 10.1016/S1529-9430(03)00249-3
HYPOTHESIS: Patients who present with cervical radiculopathy due to stenosis are often treated surgically. There is no compelling scientific evidence validating that approach. It is often assumed that patients with cervical radiculopathy due to stenosis will remain symptomatic and have progressive symptoms unless the structural pathology is surgically corrected. These assumptions have not been validated, but despite this many patients are advised to undergo surgery for this condition. The purpose of this study is to determine if a group of patients with cervical radiculopathy due to stenosis can be treated non-operatively. METHODS: Consecutively identified group of patients who presented with cervical radiculopathy due to stenosis were treated non-operatively and followed for 2 years. The diagnosis was based upon an MRI documenting stenosis at the index level, concomitant clinical pattern of radicular pain with or without neurologic loss consistent with the index level, and EMG findings corroborating the radiculopathy. Non-operative treatment consisted of physical rehabilitation, corticosteroid treatment either orally or via fluoroscopically guided transforaminal selective injection Followup outcome tools included: pre and post VAS scores; pre and post pain diagrams; and post treatment surgical intervention. RESULTS: The study group was comprised of 53 consecutively identified patients. Three of 53 underwent surgical treatment within the first 6 months of non-operative care, and 2 additional patients underwent subsequent surgical treatment during the follow-up period. Forty-one of 53 (77%) had a neurologic loss on gross neurologic exam. 36 of 41(88%) had resolution of their neurologic loss at follow-up. Forty of 48 (83%) of the non-operatively treated patients had reduction of VAS by at least 50%. Forty-five of 48 (94%) had resolution of their arm symptoms. DISCUSSION: A randomized clinical trial comparing surgical and nonsurgical care for patients with cervical radiculopathy due to stenosis should be undertaken to determine the optimal treatment course for this group of patients. Until that is undertaken, non-operative care represents a viable and important option for these patients. The decision to operate purely based upon the MRI findings and the clinical syndrome remains invalidated and may be unwarranted. CONCLUSIONS: Patients with cervical radiculopathy due to stenosis can be treated non-operatively with a high degree of success. In this study group 48 of 53 patients were treated without surgery, 45 of 48 had resolution of their arm symptoms, and 40 of 53 had a reduction of their pre-treatment VAS scores by 50% or more with non-operative care alone.
99S
RESULTS: The C2/7 angle decreased in all three groups: group S (split); 8.3 degrees, group D (dome); ⫺5.2 degrees, group I (intact); ⫺1.5 degrees. group S significantly lost the cervical kyphosis in comparison to group I. DISCUSSION: The original concept of laminoplasty was to reconstruct the bony structure of the posterior cervical spine. The theoretical and empirical consideration led the surgeons to the modification of the procedure by suturing the posterior muscles and keeping the nuchal ligament intact. Several studies as well as this study demonstrated the subaxial laminoplasty had little loss of the cervical alignment. In the previous studies on laminectomy, both C2 and subaxial laminectomies are reported to cause the progression of kyphosis. No previous study showed the alignment change after C2 and subaxial laminoplasty. This study elucidated the laminoplasty could not prevent the loss of the cervical alignment when C2 lamina is contained. As Nolan showed biomechanically, the semispinalis cervicis and C2 lamina is the main dynamic stabilizers. Laminoplasty need to be modified to minimize the dysfunction of the extensor muscles when the C2 lamina is contained. CONCLUSIONS: “Subaxial” laminoplasty maintained the cervical alignment. But if laminoplasty includes the C2 lamina, the alignment got worse to kyphosis. DISCLOSURES: No disclosures. CONFLICT OF INTEREST: No conflicts.
vs. 52% at least grade 3a; p⫽0.002) required more extensive surgery (mean OR time 279 vs. 164 minutes; p⫽0.008; level of fusion to C6/7 in 50% vs. 12%; p⫽0.05); and had worse post-operative RG (37% RG⫽0 vs. 92% RG⫽0). Immunosuppressive and corticosteroid use were not associated with complications or death. DISCUSSION: This study supports previous findings that PIF is a safe and effective procedure for rheumatoid arthritis patients with cervical or craniocervical involvement, but that the long-term outcome is less favorable in patients with high preoperative RG. CONCLUSIONS: Even in rheumatoid arthritis patients with very severe disease undergoing PIF markedly improved RG and VAS. Although there were no perioperative deaths, patients who were older, with worse underlying rheumatoid arthritis, and worse radiographic and neurologic parameters had a higher long-term risk of death. DISCLOSURES: Device or drug: Sofamor Danek lateral mass plates. Status: approved. Device or drug: Synthes Star Lock. Status: approved. CONFLICT OF INTEREST: No conflicts.
doi: 10.1016/S1529-9430(03)00248-1
5:20 67. Non-operative treatment of patients with cervical stenosis and radiculopathy: a two year follow-up study Jeffrey Saal, MD1, Joel Saal, MD1, Robert Gamburd, MD1; 1SOAR, Physiatry Medical Group, Redwood City, CA, USA
5:13 66. Cervical spine surgery for rheumatoid arthritis Michael Goytan, BSc, MD, FRCSC1, Christine Peschken, MSc, MD, FRCPC1; 1University of Manitoba, Winnipeg, MB, Canada HYPOTHESIS: Patients with severe long-standing rheumatoid arthritis and neurologic involvement benefit from a posterior instrumented fusion (PIF) of the cervical spine. METHODS: Thirty-three consecutive patients with rheumatoid arthritis undergoing PIF were evaluated. Patient demographics and joint counts, Ranawat grades (RG), and neck pain visual analogue scores (VAS), were collected prospectively during clinic visits before and after surgery. All patients had PIF with autograft, 5 patients had a preceding transoral odontoidectomy during the same anaesthetic. All patients were seen and assessed at 6 weeks, 3 months, 6 months and at one year and annually. RESULTS: There were 3 males and 30 females, 20 were Caucasian, 12 were Aboriginal, and 1 was Asian. Mean age was 58 years (range 35–85), mean disease duration 20 years (6–41), and mean number of joints affected 37 (range 8–69). Sixty-one percent were taking corticosteroids, and 85% were taking immunosuppressives. RG before surgery was 2 in 36%, 3a in 43%, and 3b in 21%. Mean VAS score before surgery was 8.5/10. All patients had an atlantodens interval (ADI) of > 5mm; 25 patients had vertical migration of the odontoid (VMO); and 5 patients had a posterior atlantodens interval (PADI)⬍13mm. Five patients had a transoral odontoidectomy for an irreducible C1-2 subluxation and VMO, all patients had a PIF. Twenty-five patients had an occipitocervical fusion, 4 patients had a C1-2 fusion, and 4 patients had a C1-subaxial spine fusion. Mean OR time was 192 minutes (range 92–600), mean blood loss was 312 ml (range 100– 1000). Mean follow-up was 33 months (range 3–67), (there was one death at 3 months). Twenty-six patients (79%) had a postoperative RG of zero (no parasthesia or weakness), and 88% had an improvement of at least 2 grades on the RG. The postoperative VAS declined by a mean of 7.9 (range 2–10). There were 8 deaths at 3, 8, 10, 13, 16, 17, 17, and 21 months respectively. Causes of death were pneumonia with respiratory failure, cardiopulmonary failure, cancer, and bowel perforation. Two patients (11%) had a major complication (hardware failure in one, and a soft palate dehiscence and hydrocephalous in the other), and 4 patients (22%) had minor complications. Those patients who died were older at the time of surgery (67 vs. 55 years; p⫽0.024) had significantly worse underlying arthritis (disease duration 27 vs. 19 years; p⫽0.037; mean affected joint count 48 vs. 34; p⫽0.025), had worse pre-op RG (100% at least grade 3a
doi: 10.1016/S1529-9430(03)00249-3
HYPOTHESIS: Patients who present with cervical radiculopathy due to stenosis are often treated surgically. There is no compelling scientific evidence validating that approach. It is often assumed that patients with cervical radiculopathy due to stenosis will remain symptomatic and have progressive symptoms unless the structural pathology is surgically corrected. These assumptions have not been validated, but despite this many patients are advised to undergo surgery for this condition. The purpose of this study is to determine if a group of patients with cervical radiculopathy due to stenosis can be treated non-operatively. METHODS: Consecutively identified group of patients who presented with cervical radiculopathy due to stenosis were treated non-operatively and followed for 2 years. The diagnosis was based upon an MRI documenting stenosis at the index level, concomitant clinical pattern of radicular pain with or without neurologic loss consistent with the index level, and EMG findings corroborating the radiculopathy. Non-operative treatment consisted of physical rehabilitation, corticosteroid treatment either orally or via fluoroscopically guided transforaminal selective injection Followup outcome tools included: pre and post VAS scores; pre and post pain diagrams; and post treatment surgical intervention. RESULTS: The study group was comprised of 53 consecutively identified patients. Three of 53 underwent surgical treatment within the first 6 months of non-operative care, and 2 additional patients underwent subsequent surgical treatment during the follow-up period. Forty-one of 53 (77%) had a neurologic loss on gross neurologic exam. 36 of 41(88%) had resolution of their neurologic loss at follow-up. Forty of 48 (83%) of the non-operatively treated patients had reduction of VAS by at least 50%. Forty-five of 48 (94%) had resolution of their arm symptoms. DISCUSSION: A randomized clinical trial comparing surgical and nonsurgical care for patients with cervical radiculopathy due to stenosis should be undertaken to determine the optimal treatment course for this group of patients. Until that is undertaken, non-operative care represents a viable and important option for these patients. The decision to operate purely based upon the MRI findings and the clinical syndrome remains invalidated and may be unwarranted. CONCLUSIONS: Patients with cervical radiculopathy due to stenosis can be treated non-operatively with a high degree of success. In this study group 48 of 53 patients were treated without surgery, 45 of 48 had resolution of their arm symptoms, and 40 of 53 had a reduction of their pre-treatment VAS scores by 50% or more with non-operative care alone.