RESEARCH - RA in the cervical spine

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J Am Acad Orthop Surg, Vol 13, No 7, November 2005, 463-474.

Rheumatoid Arthritis in the Cervical Spine

H. Kim, MD and Alan S. Hilibrand, MD

Dr. Kim is Assistant Clinical Professor of Orthopaedic Surgery,

Department of Orthopaedic Surgery, Tufts University School of

Medicine, Boston, MA, and The Boston Spine Group, New England Baptist

Hospital, Boston. Dr. Hilibrand is Associate Professor, Departments of

Orthopaedic Surgery and Neurosurgery, and Director of Medical

Education for the Department of Orthopaedic Surgery, Jefferson Medical

College, Jefferson University, Philadelphia, PA, and The

Rothman Institute, Philadelphia.

The cervical spine often becomes involved early in the course of

rheumatoid arthritis, leading to three different patterns of

instability: atlantoaxial subluxation, atlantoaxial impaction, and

subaxial subluxation. Although radiographic changes are common, the

prevalence of neurologic injury is relatively low. The primary goal of

treatment is to prevent permanent neurologic injury while avoiding

potentially dangerous and unnecessary surgery. Strategies include

patient education, lifestyle modification, regular radiographic

follow-up, and early surgical intervention, when indicated. Magnetic

resonance imaging is indicated when neurologic deficit (myelopathy)

occurs or when plain radiographs show atlantoaxial subluxation with a

posterior atlantodental interval 14 mm, any degree of atlantoaxial

impaction, or subaxial stenosis with a canal diameter 14 mm. Surgery

should be considered promptly for any of the following: progressive

neurologic deficit, chronic neck pain in the setting of radiographic

instability that does not respond to nonnarcotic pain medication, any

degree of atlantoaxial impaction or cord stenosis, a posterior

atlantodental interval 14 mm, atlantoaxial impaction represented by

odontoid migration 5 mm rostral to McGregor's line, sagittal canal

diameter <14 mm, or a cervicomedullary angle <135°.

http://www.jaaos.org/cgi/content/abstract/13/7/463

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