[Occipitocervical fusion in chronic polyarthritis]

Abstract

This report will relate our experience with the y-plate, which we used in the treatment of 39 patients (32 women and 7 men) with a mean age of 62.6 years (range 47 to 79 years) between 1987 and 1994. All patients had rheumatoid arthritis. Occipitocervical fusion was indicated by instabilities within the occipitocervical region and in cases with additional basilar invagination and/or after transoral dens resection for decompression of the spinal cord. The length of the fusion depended on the pathological changes of the subaxial cervical spine. Before surgery, 35 patients suffered from strong and 4 patients from moderate pain in the neck and/or the back of the head. On a linear scale from 0 to 10, the pain was rated as 8:1 on average (range 4 to 10). 31 patients had an instability of the atlantoaxial region and 19 patients a basilar invagination of the odontoid. A cervical myelopathy was found in 20 cases. One surgeon fused the occiput to C2 in 22 cases, to C3-C5 in 8 cases and to C7-T2 in 9 cases. An important factor in this operation is the integration of atlantoaxial screws in order to resist the translational dislocation of C1/C2. In 13 patients a resection of the odontoid had to be performed to adequately decompress the spinal cord. A reduction of C2 without dens resection was performed in cases with reducible instability C1/2. 32 of the patients could be controlled with a minimum follow-up of 12 months (average 32.2 months, range 12 to 66 months). Out of the other 7, 6 patients had died. At the time of follow-up, the pain was rated as 2.3 on average (range 0 to 10). A myelopathy was present in 2 cases. Six patients required further operations on the cervical spine; 4 patients developed an instability at the level(s) below the fusion and an enlargement of the fusion to these levels has been performed. The fusion rate was 96.9%, despite breakage of the implant in 3 and a screw loosening in 2 patients. According to the criteria of Conaty, the result was satisfying in 25 (75%) and not satisfying in 8 patients (25%). These results show the effectiveness of the occipitocervical fusion with the y-plate in rheumatoid arthritis. A transoral dens resection is only indicated in cases with basilar invagination causing a compression of the spinal cord or in such cases where a compression caused by the dens or the retrodental pannus formation cannot be treated by a reduction of the second cervical vertebra alone.