Abstrakt
Cervical spine involvement in rheumatoid arthritis (RA) is common and can lead to severe pain, irreversible neurological deterioration and even death. It presents a challenge to the treating physician as the pain, neurological symptoms and instability cannot be equated with each other.
RA of the cervical spine follows the same pathophysiology as in the peripheral joints and leads to instability due to atlanto-axial subluxation, mid- and lower cervical spine instability and basilar invagination. The clinical presentation is variable and neurological assessment is difficult due to peripheral disease.
Patients with minimal symptoms can have major life-threatening instability. Treatment goals are to prevent irreversible neurological deficit, alleviate intractable pain and to avoid death due to cord compression.
Timing of surgical interventions is extremely important. It is generally recommended to address the instability (usually C1/C2) early in order to avoid more extensive fixation and fusion.
Surgical stabilization is challenging because of suboptimal bone quality, increased risks of infection and difficult post-operative rehabilitation but generally leads to favourable outcomes. Referral of patients to specialist rheumatology centres and screening of cervical spine with flexion-extension radiographs and MRI scans seems optimal to avoid patients presenting with major deformity, instability and advanced myelopathy.
Surgical treatment of the rheumatoid cervical spine is very demanding and should therefore be performed at centres where cervical spine surgery is performed on a regular basis. In our experience, even advanced neurological deficit can significantly improve following well-executed surgery.