Rheumatoid arthritis of the cervical spine. Surgical decision making based on predictors of paralysis and recovery

Abstract

Objective: This article reviews the current knowledge of predictors of paralysis and the potential for neurologic recovery in patients with rheumatoid arthritis involving the cervical spine. The primary goal is to prevent the onset of an irreversible neurologic deficit.

Summary of background data: Use of the posterior atlantodental interval of less than 14 mm as measured from lateral cervical radiographs is a reliable screening tool for identifying high risk patients who require further evaluation with magnetic resonance or computed tomography/myelography. The primary technical objective of surgery in patients with impending neurologic deficit is stabilization of the diseased spine segments and relief of spinal cord compression via reduction of subluxation or direct decompression. Complications are not uncommon, but tend to occur less frequently in patients who have surgical intervention before the onset of severe myelopathy. Pain relief is good when a solid arthrodesis is achieved, and neurologic recovery is most favorable when severe cord compression is not present preoperatively.

Conclusion: An improved understanding of the natural history, physical findings, and radiographic parameters will allow the construction of a management strategy for timely intervention in rheumatoid patients with progressive cervical disease.