How is rheumatoid arthritis (RA) of the cervical spine treated?

Answer

An approach to surgical and nonsurgical management for rheumatoid arthritis and for rheumatoid spondylitis can be developed based on the natural history of rheumatoid involvement of the cervical spine and radiographic predictors of paralysis.

As suggested by Boden, 3 goals should be kept in mind.^[47]The first goal is to avoid the development of an irreversible neurologic deficit, as patients with more severe deficits have less recovery and higher morbidity. A second goal is to prevent sudden death from unrecognized neural compression, as has been reported in up to 10% of deaths in rheumatoid arthritis.^[18]Finally, as one half of patients with rheumatoid arthritis with radiographic evidence of instability remain asymptomatic, it is best to avoid surgery if the patient can be identified as being one who will most likely not develop neurologic problems.

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Akhondi H, Varacallo M. Rheumatoid Spondylitis. 2019 Jan. [Medline]. [Full Text].
Menezes AH, VanGilder JC, Clark CR, el-Khoury G. Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with "cranial settling". J Neurosurg. 1985 Oct. 63(4):500-9. [Medline].
Tam LS, Gu J, Yu D. Pathogenesis of ankylosing spondylitis. Nat Rev Rheumatol. 2010 Jul. 6(7):399-405. [Medline].
Machado P, Landewe R, Braun J, Hermann KG, Baker D, van der Heijde D. Both structural damage and inflammation of the spine contribute to impairment of spinal mobility in patients with ankylosing spondylitis. Ann Rheum Dis. 2010 Aug. 69(8):1465-70. [Medline].
da Corte FC, Neves N. Cervical spine instability in rheumatoid arthritis. Eur J Orthop Surg Traumatol. 2014 Jul. 24 Suppl 1:S83-91. [Medline].
Meyer C, Bredow J, Heising E, Eysel P, Müller LP, Stein G. Rheumatoid Arthritis Affecting the Upper Cervical Spine: Biomechanical Assessment of the Stabilizing Ligaments. Biomed Res Int. 2017. 2017:6131703. [Medline]. [Full Text].
Fujiwara K, Yonenobu K, Ochi T. Natural history of upper cervical lesions in rheumatoid arthritis. J Spinal Disord. 1997 Aug. 10(4):275-81. [Medline].
Oda T, Fujiwara K, Yonenobu K, et al. Natural course of cervical spine lesions in rheumatoid arthritis. Spine. 1995 May 15. 20(10):1128-35. [Medline].
Paimela L, Laasonen L, Kankaanpaa E. Progression of cervical spine changes in patients with early rheumatoid arthritis. J Rheumatol. 1997 Jul. 24(7):1280-4. [Medline].
Pellicci PM, Ranawat CS, Tsairis P, Bryan J. A prospective study of the progression of rheumatoid arthritis of the cervical spine. J Bone Joint Surg Am. 1981 Mar. 63(3):342-50. [Medline].
Rana NA. Natural history of atlanto-axial subluxation in rheumatoid arthritis. Spine. 1989 Oct. 14(10):1054-6. [Medline].
Rajangam K, Thomas IM. Frequency of cervical spine involvement in rheumatoid arthritis. J Indian Med Assoc. 1995 Apr. 93(4):138-9, 137. [Medline].
Taniguchi D, Tokunaga D, Hase H, et al. Evaluation of lateral instability of the atlanto-axial joint in rheumatoid arthritis using dynamic open-mouth view radiographs. Clin Rheumatol. 2008 Jul. 27(7):851-7. [Medline].
Morizono Y, Sakou T, Kawaida H. Upper cervical involvement in rheumatoid arthritis. Spine. 1987 Oct. 12(8):721-5. [Medline].
Zhu S, Xu W, Luo Y, Zhao Y, Liu Y. Cervical spine involvement risk factors in rheumatoid arthritis: a meta-analysis. Int J Rheum Dis. 2017 May. 20 (5):541-549. [Medline].
Clarke MJ, Cohen-Gadol AA, Ebersold MJ, Cabanela ME. Long-term incidence of subaxial cervical spine instability following cervical arthrodesis surgery in patients with rheumatoid arthritis. Surg Neurol. 2006 Aug. 66(2):136-40; discussion 140. [Medline].
Iizuka H, Iizuka Y, Mieda T, Kobayashi R, Nishinome M, Ara T, et al. A Retrospective Analysis of Subaxial Subluxation After Atlanto-axial Arthrodesis in Patients With Rheumatoid Arthritis Based on Annual Radiographs Obtained for 5 Years. Clin Spine Surg. 2017 Jun. 30 (5):E598-E602. [Medline].
Mikulowski P, Wollheim FA, Rotmil P. Sudden death in rheumatoid arthritis with atlanto-axial dislocation. Acta Med Scand. 1975 Dec. 198(6):445-51. [Medline].
Heyde CE, Fakler JK, Hasenboehler E, et al. Pitfalls and complications in the treatment of cervical spine fractures in patients with ankylosing spondylitis. Patient Saf Surg. 2008 Jun 6. 2:15. [Medline].
Pahys JM, Pahys JR, Cho SK, et al. Methods to decrease postoperative infections following posterior cervical spine surgery. J Bone Joint Surg Am. 2013 Mar 20. 95(6):549-54. [Medline].
Casey AT, Crockard HA, Bland JM, et al. Surgery on the rheumatoid cervical spine for the non-ambulant myelopathic patient-too much, too late?. Lancet. 1996 Apr 13. 347(9007):1004-7. [Medline].
Boden SD, Dodge LD, Bohlman HH, Rechtine GR. Rheumatoid arthritis of the cervical spine. A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am. 1993 Sep. 75(9):1282-97. [Medline].
Clark CR, Goetz DD, Menezes AH. Arthrodesis of the cervical spine in rheumatoid arthritis. J Bone Joint Surg Am. 1989 Mar. 71(3):381-92. [Medline].
Fielding JW, Hawkins RJ, Ratzan SA. Spine fusion for atlanto-axial instability. J Bone Joint Surg Am. 1976 Apr. 58(3):400-7. [Medline].
Larsson SE, Toolanen G. Posterior fusion for atlanto-axial subluxation in rheumatoid arthritis. Spine. 1986 Jul-Aug. 11(6):525-30. [Medline].
Santavirta S, Konttinen YT, Laasonen E, et al. Ten-year results of operations for rheumatoid cervical spine disorders. J Bone Joint Surg Br. 1991 Jan. 73(1):116-20. [Medline].
Wertheim SB, Bohlman HH. Occipitocervical fusion. Indications, technique, and long-term results in thirteen patients. J Bone Joint Surg Am. 1987 Jul. 69(6):833-6. [Medline].
Zoma A, Sturrock RD, Fisher WD, et al. Surgical stabilisation of the rheumatoid cervical spine. A review of indications and results. J Bone Joint Surg Br. 1987 Jan. 69(1):8-12. [Medline].
El Miedany Y, El Gaafary M, Youssef S, Palmer D. Towards a multidimensional patient reported outcome measures assessment: development and validation of a questionnaire for patients with ankylosing spondylitis/spondyloarthritis. Joint Bone Spine. 2010 Dec. 77 (6):575-81. [Medline].
McRorie ER, McLoughlin P, Russell T, et al. Cervical spine surgery in patients with rheumatoid arthritis: an appraisal. Ann Rheum Dis. 1996 Feb. 55(2):99-104. [Medline].
Casey AT, Crockard HA, Stevens J. Vertical translocation. Part II. Outcomes after surgical treatment of rheumatoid cervical myelopathy. J Neurosurg. 1997 Dec. 87(6):863-9. [Medline].
Ronkainen A, Niskanen M, Auvinen A, Aalto J, Luosujarvi R. Cervical spine surgery in patients with rheumatoid arthritis: longterm mortality and its determinants. J Rheumatol. 2006 Mar. 33(3):517-22. [Medline].
Peppelman WC, Kraus DR, Donaldson WF 3rd, Agarwal A. Cervical spine surgery in rheumatoid arthritis: improvement of neurologic deficit after cervical spine fusion. Spine. 1993 Dec. 18(16):2375-9. [Medline].
Ryu JI, Bak KH, Kim JM, Chun HJ. Comparison of Transarticular Screw Fixation and C1 Lateral Mass-C2 Pedicle Screw Fixation in Patients with Rheumatoid Arthritis with Atlantoaxial Instability. World Neurosurg. 2017 Mar. 99:179-185. [Medline].
Wattenmaker I, Concepcion M, Hibberd P, Lipson S. Upper-airway obstruction and perioperative management of the airway in patients managed with posterior operations on the cervical spine for rheumatoid arthritis. J Bone Joint Surg Am. 1994 Mar. 76(3):360-5. [Medline].
van Asselt KM, Lems WF, Bongartz EB, Hamburger HL, Drossaers-Bakker KW, Dijkmans BA, et al. Outcome of cervical spine surgery in patients with rheumatoid arthritis. Ann Rheum Dis. 2001 May. 60 (5):448-52. [Medline]. [Full Text].
Gillick JL, Wainwright J, Das K. Rheumatoid Arthritis and the Cervical Spine: A Review on the Role of Surgery. Int J Rheumatol. 2015. 2015:252456. [Medline].
Ranawat CS, O'Leary P, Pellicci P, et al. Cervical spine fusion in rheumatoid arthritis. J Bone Joint Surg Am. 1979 Oct. 61(7):1003-10. [Medline].
Zochling J. Assessment and treatment of ankylosing spondylitis: current status and future directions. Curr Opin Rheumatol. 2008 Jul. 20(4):398-403. [Medline].
Younes M, Belghali S, Kriaa S, et al. Compared imaging of the rheumatoid cervical spine: prevalence study and associated factors. Joint Bone Spine. 2009 Jul. 76(4):361-8. [Medline].
Tateishi Y, Tagami A, Baba H, Osaki M, Kawakami A, Akira T. Duplex Ultrasonography-Detected Positional Vertebral Artery Occlusion in Upper Cervical Rheumatoid Arthritis. Spine (Phila Pa 1976). 2016 Jan. 41 (1):26-31. [Medline].
Casey AT, Crockard HA, Geddes JF, Stevens J. Vertical translocation: the enigma of the disappearing atlantodens interval in patients with myelopathy and rheumatoid arthritis. Part I. Clinical, radiological, and neuropathological features. J Neurosurg. 1997 Dec. 87(6):856-62. [Medline].
Redlund-Johnell I, Pettersson H. Radiographic measurements of the cranio-vertebral region. Designed for evaluation of abnormalities in rheumatoid arthritis. Acta Radiol Diagn (Stockh). 1984. 25(1):23-8. [Medline].
Castro S, Verstraete K, Mielants H. Cervical spine involvement in rheumatoid arthritis: a clinical, neurological and radiological evaluation. Clin Exp Rheumatol. 1994 Jul-Aug. 12(4):369-74. [Medline].
Dvorak J, Grob D, Baumgartner H, et al. Functional evaluation of the spinal cord by magnetic resonance imaging in patients with rheumatoid arthritis and instability of upper cervical spine. Spine. 1989 Oct. 14(10):1057-64. [Medline].
Kawaida H, Sakou T, Morizono Y, Yoshkuni N. Magnetic resonance imaging of upper cervical disorders in rheumatoid arthritis. Spine. 1989 Nov. 14(11):1144-8. [Medline].
Boden SD. Rheumatoid arthritis of the cervical spine. Surgical decision making based on predictors of paralysis and recovery. Spine (Phila Pa 1976). 1994 Oct 15. 19(20):2275-80. [Medline].
Kauppi M, Anttila P. A stiff collar can restrict atlantoaxial instability in rheumatoid cervical spine in selected cases. Ann Rheum Dis. 1995 Apr. 54(4):305-7. [Medline].
Kauppi M, Anttila P. A stiff collar for the treatment of rheumatoid atlantoaxial subluxation. Br J Rheumatol. 1996 Aug. 35(8):771-4. [Medline].
Ito H, Neo M, Yoshida M, Fujibayashi S, Yoshitomi H, Nakamura T. Efficacy of computer-assisted pedicle screw insertion for cervical instability in RA patients. Rheumatol Int. 2007 Apr. 27(6):567-74. [Medline].
Schmitt-Sody M, Kirchhoff C, Buhmann S, et al. Timing of cervical spine stabilisation and outcome in patients with rheumatoid arthritis. Int Orthop. 2008 Aug. 32(4):511-6. [Medline].
Etame AB, Than KD, Wang AC, Marca FL, Park P. Surgical management of symptomatic cervical or cervicothoracic kyphosis due to ankylosing spondylitis. Spine. 2008 Jul 15. 33(16):E559-64. [Medline].
Ishii K, Matsumoto M, Takahashi Y, et al. Risk factors for development of subaxial subluxations following atlantoaxial arthrodesis for atlantoaxial subluxations in rheumatoid arthritis. Spine (Phila Pa 1976). 2010 Jul 15. 35(16):1551-5. [Medline].
Miyamoto H, Sumi M, Uno K. Outcome of surgery for rheumatoid cervical spine at one institute over three decades. Spine J. 2013 Nov. 13(11):1477-84. [Medline].
Zha AM, Di Napoli M, Behrouz R. Prevention of Stroke in Rheumatoid Arthritis. Curr Neurol Neurosci Rep. 2015 Dec. 15 (12):77. [Medline].
Grob D, Crisco JJ 3rd, Panjabi MM. Biomechanical evaluation of four different posterior atlantoaxial fixation techniques. Spine. 1992 May. 17(5):480-90. [Medline].
Gallie WE. Fractures and dislocations of the cervical spine. J Bone Joint Surg. 1939. 46A:495.
Grob D, Magerl F. [Surgical stabilization of C1 and C2 fractures]. Orthopade. 1987 Feb. 16(1):46-54. [Medline].
Jun BY. Anatomic study for ideal and safe posterior C1-C2 transarticular screw fixation. Spine. 1998 Aug 1. 23(15):1703-7. [Medline].
Crockard HA, Calder I, Ransford AO. One-stage transoral decompression and posterior fixation in rheumatoid atlanto-axial subluxation. J Bone Joint Surg Br. 1990 Jul. 72(4):682-5. [Medline].
Menezes AH, VanGilder JC. Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg. 1988 Dec. 69(6):895-903. [Medline].
Iacoangeli M, Nasi D, Colasanti R, Pan B, Re M, Di Rienzo A, et al. Endoscopic Endonasal Odontoidectomy with Anterior C1 Arch Preservation in Rheumatoid Arthritis: Long-Term Follow-Up and Further Technical Improvement by Anterior Endoscopic C1-C2 Screw Fixation and Fusion. World Neurosurg. 2017 Nov. 107:820-829. [Medline].
Grob D, Wursch R, Grauer W. Atlantoaxial fusion and retrodental pannus in rheumatoid arthritis. Spine. 1997 Jul 15. 22(14):1580-3; discussion 1584. [Medline].
Heywood AW, Learmonth ID, Thomas M. Internal fixation for occipito-cervical fusion. J Bone Joint Surg Br. 1988 Nov. 70(5):708-11. [Medline].
Smith MD, Anderson P, Grady MS. Occipitocervical arthrodesis using contoured plate fixation. An early report on a versatile fixation technique. Spine. 1993 Oct 15. 18(14):1984-90. [Medline].
Grob D, Dvorak J, Panjabi MM, Antinnes JA. The role of plate and screw fixation in occipitocervical fusion in rheumatoid arthritis. Spine. 1994 Nov 15. 19(22):2545-51. [Medline].
An HS. Internal fixation of the cervical spine: current indications and techniques. J Am Acad Orthop Surg. 1995 Jul. 3(4):194-206. [Medline].

Media Gallery

Rheumatoid spondylitis. Depiction of anterior subluxation of C1 on C2, retrodental pannus, and osseous erosions; the spinal cord is compressed between the pannus anteriorly and the posterior arch of the atlas.
Rheumatoid spondylitis. Depiction of superior migration of the odontoid into the foramen magnum with compression of the spinal cord.
Rheumatoid spondylitis. Pertinent measurements of superior migration of the odontoid; cranial migration distance (CMD).
Rheumatoid spondylitis. MRI of a patient with superior migration of the odontoid and subaxial subluxation. Courtesy of Steven R. Garfin.
Rheumatoid spondylitis. Modified Gallie fusion. Note the H-shaped bone block wired over the spinous process of C2.
Rheumatoid spondylitis. Brooks-type fusion. Rectangular structural grafts are beveled to fit between the arches of C1 and C2; then they are secured by bilateral doubled-twisted wires.
Rheumatoid spondylitis. C1-C2 transarticular screw fixation. Courtesy of Steven R. Garfin.
Rheumatoid spondylitis. Occipitocervical fusion combined with lateral mass plating for a patient with combined superior migration of the odontoid and subaxial subluxation. Courtesy of Steven R. Garfin.

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Author

Steven R Garfin, MD Professor and Chair, Department of Orthopedics, UC San Diego Medical Center

Steven R Garfin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, North American Spine Society, Orthopaedic Research Society, Western Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William O Shaffer, MD Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Kentucky Medical Association, North American Spine Society, Kentucky Orthopaedic Society, International Society for the Study of the Lumbar Spine, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Received royalty from DePuySpine 1997-2007 (not presently) for consulting; Received grant/research funds from DePuySpine 2002-2007 (closed) for sacropelvic instrumentation biomechanical study; Received grant/research funds from DePuyBiologics 2005-2008 (closed) for healos study just closed; Received consulting fee from DePuySpine 2009 for design of offset modification of expedium.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Nuvasive, NLT Spine, RTI, Magellan Health<br/>Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.

Additional Contributors

Lee H Riley III, MD Chief, Division of Orthopedic Spine Surgery, Associate Professor, Departments of Orthopedic Surgery and Neurosurgery, Johns Hopkins University School of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Michael J Vives, MD Associate Professor, Department of Orthopedics, Division of Spine Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey

Michael J Vives, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and North American Spine Society

Disclosure: Nothing to disclose.

How is rheumatoid arthritis (RA) of the cervical spine treated?

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