CERVICAL-SPINE SURGERY IN PATIENTS WITH RHEUMATOID-ARTHRITIS - AN APPRAISAL

Objectives-To review the outcome of surgery undertaken to stabilise th e neck in patients with rheumatoid arthritis performed over a five yea r period, to compare the results with those of previous reports, and t o identify factors that may predict surgical outcome. Methods-Outcome was assessed at time of discharge from hospital after surgery by revie w of patients' notes, and at follow up by patient interview, clinical examination, anonymous questionnaire, and cervical spine radiograph. T he Ranawat classification of neurological impairment and Steinbrocker functional classification were used. Results-Thirty nine patients unde rwent 44 procedures; 28 patients were available for review after a mea n period of 29.8 months (range 12-65 months). Fourteen patients had pr eoperative neurological impairment and were available for follow up; 1 3 returned the questionnaire. Four (29%) had improved Ranawat class, n ine were unchanged, and one had deteriorated. Nine (69%) reported a su bjective improvement in neurological symptoms by questionnaire, even t hough the Ranawat class was unchanged in five. Twenty five of the pati ents reviewed had pain before operation; 21 returned the questionnaire . Pain relief was reported by direct questioning and questionnaire in 76% and 67% of patients, respectively. Overall, 67% felt that surgery had been successful. Surgery was more successful in producing symptoma tic relief in patients with neck or radicular pain than in those with neurological deficit, but did prevent progression of neurological symp toms. Conclusions-Our results are similar to those from other centres. Overall patient satisfaction with surgery was good. Surgery was more Likely to produce symptomatic relief in patients with neck or radicula r pain before operation than in those with neurological deficit. The g reater subjective improvement in neurological symptoms as judged by qu estionnaire probably reflects the relative insensitivity of the Ranawa t classification in detecting change in neurological status; previous reports of poor outcome for patients with neurological symptoms who un dergo surgery may in part be a reflection of the insensitivity of this method of assessment. No clear factors emerged which allowed predicti on of those patients at greatest risk of operative mortality. In parti cular, an increased risk of neurological compromise appeared to confer no additional risk of immediate perioperative death. Our data support the suggestion that early surgery to correct symptomatic atlantoaxial subluxation may prevent progression of instability.