Risk factor analysis of perioperative complications in patients with rheumatoid arthritis undergoing primary cervical spine surgery.

BACKGROUND: Rheumatoid arthritis (RA) often causes cervical spine lesions as the disease condition progresses, which induce occipital neuralgia or cervical myelopathy requiring surgical interventions. Meanwhile, patients with RA are susceptible to infection or other complications in the perioperative period because they frequently have comorbidities and use immunosuppressive medications. However, the risk factors or characteristics of patients with RA who experience perioperative complications after cervical spine surgery remain unknown. A risk factor analysis of perioperative complications in patients with RA who underwent primary cervical spine surgery was conducted in the present study. METHODS: A total of 139 patients with RA who underwent primary cervical spine surgery from January 2001 to March 2020 were retrospectively investigated. Age and height, weight, serum albumin, serum C-reactive protein, American Society of Anesthesiologists Physical Status (ASA-PS), Charlson comorbidity index, medications used, cervical spine lesion, surgery time, bleeding volume, and procedures were collected from medical records to compare the patients with complications to those without complications after surgery. The risk factors for perioperative complications were assessed by univariate and multivariate logistic regression analysis. RESULTS: Twenty-eight patients (20.1%) had perioperative complications. Perioperative complications were significantly associated with the following factors [data presented as odds ratio]: lower height [0.928, p=0.007], higher ASA-PS [2.296, p=0.048], longer operation time [1.013, p=0.003], more bleeding volume [1.004, p=0.04], higher rates of vertical subluxation [2.914, p=0.015] and subaxial subluxation (SAS) [2.507, p=0.036], occipito-cervical (OC) fusion [3.438, p=0.023], and occipito-cervical/thoracic (long) fusion [8.021, p=0.002] in univariate analyses. In multivariate analyses, lower height [0.915, p=0.005], higher ASA-PS [2.622, p=0.045] and long fusion [7.289, p=0.008] remained risk factors. High-dose prednisolone use [1.247, p=0.028], SAS [6.413, p=0.018], OC fusion [17.93, p=0.034], and long fusion [108.1, p<0.001] were associated with severe complications. CONCLUSIONS: ASA-PS and long fusion could be indicators predicting perioperative complications in patients with RA after cervical spine surgery. In addition, cervical spine lesions requiring OC fusion or long fusion and high-dose prednisolone use were suggested to be risk factors for increasing severe complications.

A not-to-miss Cause of Severe Cervical Spine Pain in a Patient with Rheumatoid Arthritis: A Case-Based Review.

BACKGROUND: Rheumatoid arthritis (RA) may affect any diarthrodial joint with a predilection on the peripheral skeleton in a symmetrical manner. When the axial skeleton is affected, it is the cervical spine (CS) that gets involved with potentially detrimental effects, if not treated promptly. CASE: A 60-year-old female suffering from RA presented with severe neck pain and stiffness, difficulty of standing and walking with brisk tendon reflexes, Babinski sign positive, and clonus. Despite the high inflammatory markers and high titres of autoantibodies (rheumatoid factor and anticitrullinated protein antibodies), she never received proper treatment. She was using only paracetamol and non-steroidal anti-inflammatory drugs. Conventional radiography (CR) of CS showed extensive degenerative changes affecting the C3-C5 vertebral level. Magnetic Resonance Imaging of the neck showed sub-axial subluxation (SAS) and spinal cord compression at C3 level, and to a lesser extent, in other levels. A multi-level cervical laminectomy and spinal cord decompression were deployed with good results. To this end, literature review was performed until September 2020 and showed that the frequency of radiological findings varies substantially, ranging between 0,7-95% in different studies. The most common radiological feature is the atlanto-axial subluxation (AAS) followed by SAS. Because CS involvement can often be clinically asymptomatic, its assessment should not be forgotten by physicians and should be assessed using CR, which is an easy-to-perform technique and gives important information as a screening tool. On the other hand, RA patients need to be treated in a prompt and efficient manner in order to avoid any potentially fatal complications.

Cervical spine manifestations of rheumatoid arthritis: a review.

Rheumatoid arthritis (RA) is a progressive autoimmune inflammatory disease affecting 1% of the population with three times as many women as men. As many as 86% of patients suffering from RA have cervical spine involvement. Synovial inflammation in the cervical spine causes instability and injuries including atlantoaxial subluxation, retroodontoid pannus formation, cranial settling, and subaxial subluxation. While many patients with cervical spine involvement are asymptomatic, symptomatic patients often present with nonspecific symptoms resulting from inflammation and additional secondary symptoms that are due to compression of the brainstem, cranial nerves, vertebral artery, and spinal cord. Radiographs are the imaging modality used most often, while MRI and CT are used for assessment of neural element involvement and surgical planning. Multiple classification systems exist. Early diagnosis and treatment of cervical spine involvement is critical. Surgical management is indicated when patients experience symptoms from cervical involvement that result in biomechanical instability and, or a neurological deficit. Atlantoaxial instability managed with atlantoaxial fusion, retroodontoid pannus with neural element compression is managed with posterior decompression and atlantoaxial fusion or occipitocervical fusion. Cranial settling is managed can be managed with anterior decompression and posterior fusion or with dorsal only approaches. Subaxial subluxation is managed with circumferential fusion or posterior only decompression and fusion. Patients with atlantoaxial instability have better functional and neurologic outcomes. RA patients have higher complication rates and more frequent need for revision surgery than the general population of spine surgery patients.

Changes in the incidence of cervical lesions owing to the development of rheumatoid arthritis treatment and the impact of cervical lesions on patients' quality of life.

Objectives: To clarify changes in the incidence of cervical lesions in rheumatoid arthritis (RA) patients with advanced treatment and the impact of cervical lesions on the patients' quality of life (QOL).Methods: Incidence of radiographic cervical lesions in 1333 RA patients in 2015 was compared with that in our 1999 survey. The association between cervical lesions and QOL evaluated using three different patient-based questionnaires was also analyzed.Results: The incidence of atlantoaxial subluxation (AAS), vertical subluxation (VS), and subaxial subluxation (SAS) in 2015 decreased by 50%, 75%, and 5%, respectively, compared to the 1999 survey. Although QOL, evaluated using the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ; specific to myelopathy), deteriorated as the cervical lesion progressed, there was no association between cervical lesion progression and QOL evaluated using the Short Form-8™ (SF-8™; comprehensive health-related QOL). Cervical lesion progression was also associated with QOL deterioration evaluated using the Health Assessment Questionnaire Disability Index (HAQ-DI; specific to RA), but age and disease duration had stronger influences.Conclusion: The incidence of cervical lesions decreased in 2015 compared to 1999. Cervical lesion progression may be associated with QOL deterioration due to myelopathy. Age and disease duration have more impact on disease-specific QOL.

Ten-Year Results of Reconstruction for Rheumatoid Cervical Spine Lesions and Occurrence Factor of Subaxial Subluxation.

Study Design: Retrospective chart review. Purpose: This study evaluated long-term surgical outcomes of computer-assisted reconstruction using transarticular or cervical pedicle screws for cervical spine lesions caused by advanced rheumatoid arthritis (RA). Overview of Literature: We routinely employ C1-C2 transarticular and cervical pedicle screw instrumentation to reconstruct advanced and unstable RA cervical lesions. However, few reports are available on the long-term results of surgical reconstruction for rheumatoid cervical disorders, particularly regarding cervical pedicle screw fixation. Methods: Six subjects (all female) with RA cervical lesions who underwent atlantoaxial or occipitocervical fixation and were followed for at least 10 years were retrospectively studied. A frameless, stereotactic, optoelectronic, computed tomography-based image guidance system was used for correct screw placement. Variables including the Japanese Orthopaedic Association score, EuroQol, Ranawat value, and C2-C7 angle before and 2, 5, and 10 years after surgery were assessed along with the occurrence of subaxial subluxation (SAS). Results: Mean age at initial surgery was 58.2±7 years (range, 51-68 years), and mean follow-up period was 141±11 months (range, 122-153 months). Lesions included atlantoaxial subluxation (AAS, n=2) and AAS+vertical subluxation (n=4). Mean C2-C7 lordotic angle before and 2, 5, and 10 years after surgery was 20.1°±6.1°, 21.0°±4.0°, 18.8°±4.7°, and 17.8°±5.3°, respectively. SAS did not occur in cases maintaining the C2-C7 lordotic angle. In two cases where the C2-C7 lordotic angle declined from 5 years postoperatively, SAS occurred at the C2-C3 level in one and at the C4-C5 level in the other, both of which required reoperation. Conclusions: Patients with rheumatoid cervical lesions who undergo atlantoaxial or occipitocervical fixation using C1-C2 transarticular or pedicle screws carry a risk of SAS for up to 10 years postoperatively, which may require reoperation.

Radiological evaluation of cervical spine involvement in rheumatoid arthritis.

Cervical spine involvement commonly occurs in patients with rheumatoid arthritis (RA), especially those with inadequate treatment or severe disease forms. The most common site affected by RA is the atlantoaxial joint, potentially resulting in atlantoaxial instability, with cervical pain and neurological deficits. The second most common site of involvement is the subaxial cervical spine, often with subluxation, resulting in nerve root or spinal cord compression. In this paper, the authors review the most commonly used plain radiographic criteria to diagnose cervical instabilities seen with RA. Finally, we discuss the advantages and disadvantages of cervical CT and MRI in the setting of cervical involvement in RA.

Cervical spine involvement in rheumatoid arthritis--a systematic review.

Rheumatoid arthritis (RA) is a systemic chronic inflammatory disorder that can compromise the cervical spine in up to 80% of the cases. The most common radiological presentations of cervical involvement are atlantoaxial subluxation (AAS), cranial settling and subaxial subluxation (SAS). We performed a systematic review in the PubMed Database of articles published later 2005 to evaluate the prevalence, progression and risk factors for cervical spine involvement in RA patients. Articles were classified according to their level of evidence. Our literature review reported a wide range in the prevalence of cervical spine disease, probably explained by the different studied populations and disease characteristics. Uncontrolled RA is probably the main risk factor for developing a spinal instability. Adequate treatment with DMARD and BA can prevent development of cervical instabilities but did not avoid progression of a pre-existing injury. MRI is the best radiological method for diagnosis cervical spine involvement. AAS is the most common form of RA. Long term radiological follow-up is necessary to diagnosis patients with late instabilities and monitoring progression of diagnosed injuries.

Advances in the treatment of cervical rheumatoid: Less surgery and less morbidity.

Rheumatoid arthritis is a chronic systemic inflammatory disease that often affects the cervical spine. While it was initially thought that cervical involvement was innocuous, natural history studies have substantiated the progressive nature of untreated disease. Over the past 50 years, there has been further elucidation in the pathophysiology of the disease, as well as significant advancements in medical and surgical therapy. The introduction of disease modifying drugs and biologic agents has reduced the amount of patients with advanced stages of the disease needing surgery. Advancement in instrumentation techniques has improved patient outcomes and fusion rates. The introduction of endoscopic approaches for ventral decompression may further lower surgical morbidity. In this review, we give a brief overview of the pertinent positives of the disease. A discussion of historical techniques and the evolution of surgical therapy into the modern era is provided. With improved medical therapies and less invasive approaches, we will likely continue to see less advanced cases of disease and less surgical morbidity. Nonetheless, a thorough understanding of the disease is crucial, as its systemic involvement and need for continued medical therapy have tremendous impact on overall complications and outcomes even in patients being seen for standard degenerative disease with comorbid rheumatoid.