cervical spine surgery - pronto marketing · sudden death in ra post mortem study- 11 consecutive...
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Cervical Spine Surgery –For Patients with Rheumatoid Arthritis
Wayne Cheng, MD.
Bones and Spine
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Outline
The most common abnormalities.
Clinical Presentation.
Radiological Evaluation.
Natural History.
Predictor of progression and recovery.
Indication for surgery
Surgical Considerations
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Incidence
RA affects 1% of adult population in US.
C-spine is the secondmost common skeletal manifestation (15-86%).
Up to 26% of in-patients with RA may need surgical intervention.
Three most common abnormalities:– 1. AAS
– 2. AAI
– 3. SAS
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Atlantoaxial Subluxation (AAS)
Most common
– (43 -86%)
Transverse ligament.
Ant, lateral, posterior.
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Atlantoaxial Impaction
Second most frequent
– (5-34%)
Other names
– Basilar invagination
– Cranial settling
– Vertical subluxation
– Superior migration.
Joint incompetent: Result
from bone and cartilage
loss.
Impinge on the brain stem.
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Subaxial Subluxation
10-25%.
Most frequent:
– C23, C34.
Incompetent
ligaments,facets.
“Staircase”
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Clinical Presentation
#1: Pain(40-88%)
#2: Neuro(7-34%)
#3: Sudden death (10%)
Earliest signs
– Pain & neck stiffness
High index of suspicion
– Change in ambulation.
– Long tract sign.
– Vertebrobasilar SX.
• Loss of equilibrium
• Tennitus,vertigo,diplopia
• Visual distrubances
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Sudden Death in RA
Post mortem study- 11 consecutive cases of atlanto-axial dislocation (104 patients total).
Sudden death
– 7 out 11
Correct diagnosis
– 2 out 11
Spastic SX
– only in 4/11 patients.
Conclusion:
– 1. 10% incidence of fatal medulla compression.
– 2. Neurological signs are not helpful to point out the risk of fatal cord compression.
Miculowski et al., Acta Med. Scand, 1975
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Ranawat Classification
I No neural deficit.
II Subjective weakness/dysesthesia
III Objective weakness/long-tract signs.• IIIA ambulatory
• IIIB not ambulatory
Ranawat et al, JBJS 1979 Vol 61A-7
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Radiological Eval - AAS
Need flexion lateral.
Normal is 3mm.
>10 –12 mm =
complete disruption
Not reliable – May
decrease as odontoid
moves superiorly.
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Radiologic Eval - AAS
PADI
>14 mm = 94%
negative predictive
value.
Different than space
available for the cord.
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Radiologic Eval – AAS
MRI
neutral vs. flexion
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Radiologic Eval - AAI
Ranawat’s distance-
– distance between
transverse axis of C1
and middle of pedicle
of C2.
Abnormal if:
– Male < 15mm.
– Female < 13 mm.
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Radiologic Eval. - AAI
McGreggor’s line.
Line from hard palate
to occipt.
Abnormal if dens >
4.5mm above the line.
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Radiologic Eval - AAI
Redlund-Johnell
Distance between
McGregor’s line and
inferior end plate of
C2.
Abnormal if male < 34
mm and female <
29mm.
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Radiologic Eval - AAI
Clark Station
Divide C2 into thirds
on sagittal plan.
Abnormal if the
middle or lower third
of C2 is at the level of
arch of C1.
I
II
III
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Radiologic Eval - AAI The most specific:
Redlund-Johnell (76%)
The most sensitive:
Clark Station (83%)
To achieve > 90%
sensitivity+specificity
– Use combination of
Clark station +
Redlund-Johnell +
Ranawat
When in doubt
– get a MRI.Riew et al. JBJS 83A(2). 2001
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Natural History
Without cervical
myelopathy
With Cervical
myelopathy.
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Natural History –
without myelopathyProspective Study of 106 patients over 5
years.
80% had radiographic progression.
36% had neurologic deterioration.
Only 10% required surgery.
Pellicci et al. JBJS 63A(3) 1981
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Natural History –
with myelopathy Sunahara, Spine
22(22), 1997
21 pt with AAS,
refused surgery.
All patients bedridden
within 3 years.
7 patients had sudden
death.
Meijers, Clinical and
Exp Rheu, 1984
9 patients.
All 9 patients died
within a year.
4 due to consequences
of cord compression.
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Natural History
Without cervical
myelopathy With Cervical
myelopathy.
Good Bad
Predictor
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Predictor of Paralysis
PADI < 14mm.
Cervicomedullary angle less than 135
degree.
SAC < 13 mm on MRI
Cord diameter < 6 mm.
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Predictor of Recovery
Boden:
– No recovery if PADI < 10mm.
– At least one neuro. Class improvement if PADI > 10 mm.
Klein:
– Duration of SX.
Casey:
– Pre-op neuro. Function, cord area, degree of AAI.
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Indications for Surgery
Accepted:
– Intractable pain.
– Progressive neurologic impairment.
– Presence of myelopathy
Controversial:
– impending neurologic deficit.
• Arguments for and against.
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Surgical Consideration
Frail.
Malnourished.
Osteoporotic.
Immunosuppressed.
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Preoperative Cervical Traction
Used for AAI and
severe subluxation.
Goal: reduce
subluxation and
relieve compression.
Advantages.
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Airway Management
Awake fiberoptic-assisted intubation Vs.
traditional.
128 patients with RA.
Upper-airway obstruction after extubation
decrease from 14% to 1%.
Wattenmaker et al. JBJS 76-A(3), 1994
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DecompressionPersistent neurologic deficit despite
traction.
Level depend on location
– of cord impingement.
Controversial.
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StabilizationInclude all unstable levels.
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Complication
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Complication
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Complication
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Surgical Outcomes
Year Author #patients Pain
relief%Neuro.
Improv %
2001 Asselt 31 62% 67%
1999 Grob 39 96 77
1998 Eyres 26 92 89
1998 Mori 25 96 67
1989 Clark 41 91 27
1987 Sakou 16 100 100
1985 Menezes 45 100 100
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CONCLUSION
High index of suspicion
Majority of RA does not require surgery.
Surgical indication:
– Intractable pain
– Progressive neurologic deficit
– Myelopathy
– Impending neurologic deficit?
Careful surgical planning/team approach.
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