What is the prognosis of rheumatoid arthritis (RA) of the cervical spine?

Updated: Aug 13, 2019
  • Author: Steven R Garfin, MD; Chief Editor: Jeffrey A Goldstein, MD  more...
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Answer

The likelihood of cervical involvement appears to increase with the duration of rheumatic disease. Many patients with pain and radiographic criteria for instability do not develop neurologic sequelae; neurologic deficit is seen only in 7-34% of cases. However, 10% of patients with atlantoaxial subluxation (AAS) from rheumatoid arthritis may die from brainstem compression that is unrecognized before their sudden death. [18]

Rheumatoid arthritis is a systemic disorder, and patients may have varying degrees of generalized debilitation. [19]  The postoperative course of such patients can be complicated by fragile skin and poor wound healing. Poor preoperative nutritional status and corticosteroid dependence may potentiate wound-healing problems and predispose toward infection. [20]

Age, sex, duration of paralysis, preoperative atlantodental interval (ADI), and percentage of slippage in subaxial subluxations all have been found to have no correlation with neurologic recovery. The degree of preoperative neurologic deficit has been shown to correlate with neurologic recovery. The results appear to be less favorable in patients with more advanced preoperative neurologic deficits. Casey and colleagues reported that in patients classified as Ranawat class III, 58% of ambulatory patients (grade IIIA) attained a grade I or grade II after surgery. Conversely, only 20% of nonambulatory patients (grade IIIB) improved to grade I or grade II postoperatively. [21]

Radiographic parameters also have been shown to predict postoperative neurologic recovery. Boden et al reported that patients with AAS whose posterior ADI (PADI) was less than 10 mm before surgery had poor return of motor function. [22] With superimposed SMO, clinically significant neurologic recovery was seen only when the PADI was at least 13 mm before surgery. For patients with subaxial subluxations, less recovery was seen in those with a residual postoperative subaxial canal diameter of less than 14 mm.

Cervical fusion in patients with rheumatoid spondylitis has a clinical success rate of 60-90%. [23, 24, 25, 26, 27, 28, 29] This wide range is partly due to the definition of clinical success and by variation in disease severity at the time of surgery. Rates of neurologic improvement also vary widely, ranging from 27-100%. [23, 24, 25, 26, 27, 30, 31, 32] Peppelman et al reported that 95% of 90 patients treated surgically for AAS improved by at least one Ranawat grade, 76% of patients with combined AAS and superior migration of the odontoid (SMO) had neurologic improvement, and 94% of those surgically treated for isolated subaxial subluxation also showed neurologic improvement. [33]

A study comparing surgical outcome between transarticular screw fixation (TAF) and C1 lateral mass-C2 pedicle screw fixation (C1LM-C2P) in 58 patients with atlantoaxial instability found no statistical significance in fusion rate, clinical outcomes, or complications. Bone fusion was achieved in 97% of patients who received TAF and 100% of patients who underwent C1LM-C2P. Complications (regardless of neurologic deterioration) were cable loosening and screw malposition in the TAF group and violation into the vertebral canal and spinal canal in the C1LM-C2P group. [34]

Nonunion rates in this population have been estimated at 5-20%. Many of these nonunions may be asymptomatic, so management should be individualized.

Some airways are difficult to intubate. Excessive trauma during intubation may be responsible for postoperative breathing problems. In a review of 128 consecutive posterior operations on the cervical spine for problems related to rheumatoid arthritis, Wattenmaker et al reported a 14% incidence of upper airway obstruction after extubation in patients intubated without fiberoptic assistance, compared with a 1% incidence in patients intubated fiberoptically. [35]  

The perioperative mortality rate has been reported to be as high as 5-10%. However, the mortality rate may relate to the severity of the underlying disease and not to the surgery itself. [36]


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