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The Journal of Bone and Joint Surgery, Vol 75, Issue 9 1282-1297, Copyright © 1993 by Journal of Bone and Joint Surgery, Inc
Rheumatoid arthritis of the cervical spine. A long-term analysis with predictors of paralysis and recovery
SD Boden, LD Dodge, HH Bohlman and GR Rechtine
Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland 44106.
We analyzed the cases of seventy-three patients who were managed over a
twenty-year period for rheumatoid involvement of the cervical spine and
were followed for a minimum of two years, with an average follow-up of
seven years. A neurological deficit did not develop in thirty-one patients
(Ranawat et al. Class I) and paralysis developed in the remaining forty-two
patients: Class II in eleven and Class III in thirty-one. Of the forty-two
patients in whom paralysis developed, thirty-five had operative
stabilization. Seven patients were managed with a soft cervical collar
because they refused or were medically unable to have the operation; all of
the had an increase in the severity of the paralysis. The posterior
atlanto-odontoid interval and the diameter of the subaxial sagittal canal
measured on the cervical radiographs demonstrated statistically significant
correlations with the presence and severity of paralysis. All of the
patients who had a Class-III neurological deficit had a posterior
atlanto-odontoid interval or diameter of the subaxial canal that was less
than fourteen millimeters. In contrast, the anterior atlanto-odontoid
interval, which has traditionally been reported, did not correlate with
paralysis. The prognosis for neurological recovery following the operation
was not affected by the duration of the paralysis but was influenced by the
severity of the paralysis at the time of the operation. The most important
predictor of the potential for neurological recovery after the operation
was the preoperative posterior atlanto-odontoid interval. In patients who
had paralysis due to atlanto-axial subluxation, no recovery occurred if the
posterior atlanto-odontoid interval was less than ten millimeters, whereas
recovery of at least one neurological class always occurred when the
posterior atlanto-odontoid interval was at least ten millimeters. If
basilar invagination was superimposed, clinically important neurological
recovery occurred only when the posterior atlanto-odontoid interval was at
least thirteen millimeters. All patients who had paralysis and a posterior
atlanto-odontoid interval or diameter of the subaxial canal of fourteen
millimeters had complete motor recovery after the operation. In this
series, although only patients who had a neurological deficit were operated
on, we observed the range of the posterior atlanto-odontoid interval that
was associated with poor or no recovery after the operation, and we
identified the safe range on the basis of the patients in whom paralysis
did not develop.(ABSTRACT TRUNCATED AT 400 WORDS)
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