What is the role of surgery in the treatment 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 identification of a subset of patients with impending neurologic deficit has been elusive due to the poor correlation of neurologic symptoms with radiographic indicators of instability. Therefore, universally accepted surgical indications have been slow to develop. However, patients with rheumatoid arthritis or, particularly, rheumatoid spondylitis, who have refractory pain, clearly evident neurologic compromise, or intrinsic spinal cord signal changes on magnetic resonance imaging (MRI) are generally candidates for surgical intervention.

Controversy surrounds treatment for patients with little or no pain, no neural deficit, and radiographs suggestive of instability. To facilitate understanding of the operative indications and perioperative details, categorization of these patients by their pathologic lesion is helpful. [50, 51, 52, 53, 54, 37]

Contraindications to surgery for rheumatoid spondylitis include medical conditions that suggest the patient would not tolerate the stress of surgery, such as unstable angina or a recent myocardial infarction or stroke. [55] Active infection with likely bacteremia would also be a relative contraindication to surgery, especially in the setting of planned instrumentation. The patient's medical condition should be optimized before proceeding with any planned surgical intervention.


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