Occipito-cervical fixation in rheumatoid arthritis--an analysis of surgical risk factors in 163 patients

163 patients with rheumatoid arthritis (RA) and atlanto-axial subluxation treated by posterior occipito-cervical fixation (OCF) over a period of twenty-one years (November 1970-January 1991) were followed. Common complaints prior to surgery were occipital headache, neck pain, radicular pain and myelopathy. The mean age at time of surgery was 61 years. The mean follow-up time was 54 months. Clinical improvement was obtained in 88% of the patients, whereas 7% were unchanged and 5% had progressive symptoms in spite of surgery. There was no pre-operative or immediate postoperative mortality. In 79 patients, one or more potential surgical risk factors were identified. Twenty-four reoperations were performed in the neck. The most common cause for reoperation was mechanical failure due to wire-break or spinous process fracture. Wound infection in the neck was recorded in 16 patients. Five were deep and required removal of the fixation material. Following OCF, new or progressive subaxial subluxation (SAS) led to further surgery in 4%. The study offers support for the beneficial effect of OCF in rheumatoid AAS. We conclude that, in spite of a number of identified risk factors, OCF with the Brattström-Granholm technique remains a safe and effective method for stabilization of upper cervical subluxations in RA.