Sd. Boden et al., RHEUMATOID-ARTHRITIS OF THE CERVICAL-SPINE - A LONG-TERM ANALYSIS WITH PREDICTORS OF PARALYSIS AND RECOVERY, Journal of bone and joint surgery. American volume, 75A(9), 1993, pp. 1282-1297
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-u
p of seven years. A neurological deficit did not develop in thirty-one
patients (Ranawat et al. Class I) and paralysis developed in the rema
ining forty-two patients: Class II in eleven and Class III in thirty-o
ne. Of the forty-two patients in whom paralysis developed, thirty-rive
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 them had an increase in the severity of the para
lysis. The posterior atlanto-odontoid interval and the diameter of the
subaxial sagittal canal measured on the cervical radiographs demonstr
ated statistically significant correlations with the presence and seve
rity of paralysis. All of the patients who had a Class-III neurologica
l 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 r
eported, did not correlate with paralysis. The prognosis for neurologi
cal recovery following the operation was not affected by the duration
of the paralysis but was influenced by the severity of the paralysis a
t the time of the operation. The most important predictor of the poten
tial for neurological recovery after the operation was the preoperativ
e posterior atlanto-odontoid interval. In patients who had paralysis d
ue to atlantoaxial subluxation, no recovery occurred if the posterior
atlanto-odontoid interval was less than ten millimeters, whereas recov
ery of at least one neurological class always occurred when the poster
ior atlanto-odontoid interval was at least ten millimeters. If basilar
invagination was superimposed, clinically important neurological reco
very occurred only when the posterior atlanto-odontoid interval was at
least thirteen millimeters. All patients who had paralysis and a post
erior atlanto-odontoid interval or diameter of the subaxial canal of f
ourteen millimeters had complete motor recovery after the operation. I
n this series, although only patients who had a neurological deficit w
ere operated on, we observed the range of the posterior atlanto-odonto
id interval that was associated with poor or no recovery after the ope
ration, and we identified the safe range on the basis of the patients
in whom paralysis did not develop. Therefore, to minimize the potentia
l risk of the development of irreversible paralysis, we recommend oper
ative stabilization of the rheumatoid cervical spine, in the presence
or absence of a neurological deficit, for patients who have atlanto-ax
ial subluxation and a posterior atlanto-odontoid interval of fourteen
millimeters or less, patients who have atlanto-axial subluxation and a
t least rive millimeters of basilar invagination, and patients who hav
e subaxial subluxation and a sagittal diameter of the spinal canal of
fourteen millimeters or less.