Surgical management of the subaxial cervical spine (C3-T1) in rheumatoid arthritis

In the process of skeletal changes in rheumatoid arthritis (RA) the lower cervical spine may characteristically be affected by subluxation, discoligamentous insufficiency and bone resorption. These may cause severe pain and important neurological deficit and necessitate surgical intervention. Out of a series of 122 RA patients who underwent surgery of the cervical spine, in 23 the subaxial cervical spine was operated on. Pain was the leading symptom in all patients. In only six were there no pathological neurological findings, and all showed marked kyphotic deformity of the cervical spine. Fourteen patients were operated by a posterior approach, one by a ventral approach, and in eight patients the surgical procedure consisted of anterior decompression and dorsal stabilization. A mean of 21.3 months after surgery, clinical and radiological evaluation was performed. In two patients the sensomotor deficit improved, and out of 16 patients with cervical myelopathy, nine improved. No pseudoarthrosis was noted, and moderate loss of correction was seen in only three patients. In a subjective evaluation, 14 patients rated their result as good, six as fair and none as poor. In conclusion, following decompression, we noted good recovery from myelopathic symptoms. Sufficient stability in patients with RA is achieved by a combined anterior and posterior approach, the main goal of the anterior approach being decompression by vertebrectomy and that of the posterior approach stabilization by plate and screw fixation.