RESEARCH - High mortality rate in RA with subluxation of the cervical spine

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Spine. 2008 Sep 9. [Epub ahead of print]

High Mortality Rate in Rheumatoid Arthritis With Subluxation of the

Cervical Spine: A Cohort Study of Operated and Nonoperated Patients.

Paus AC, Steen H, Røislien J, Mowinckel P, Teigland J.

From the *Orthopaedic Department, Rikshospitalet University Hospital,

Oslo, Norway; daggerDepartment of Biostatistics, Institute of Basic

Medical Sciences, University of Oslo, Norway; and double

daggerDivision Woman and Child, Department of Paediatrics, Ullevål

University Hospital, Oslo, Norway.

STUDY DESIGN.: In a prospective cohort study 532 patients with

rheumatoid arthritis (RA) and subluxations of the cervical spine were

consecutively collected during 1974-1999.

OBJECTIVE.: The aims of the study were to assess important factors

affecting the mortality rate and the timing of surgical intervention.

SUMMARY OF BACKGROUND DATA.: The average follow-up time from the first

visit to death or to the end of the study was 8.5 (SD, 5.7) years. Of

the 217 operated patients 144 (66%) died, and of the 315 nonoperated

patients 137 (43%) died.

METHODS.: Patients were selected for operative intervention based on

anterior, vertical and subaxial subluxations, pain, and/or cervical

neurology. Survival analyses were used for comparisons between

patients with RA and the normal population, and between the operated

and those treated conservatively.

RESULTS.: The survival rate for all RA patients was significantly

reduced when compared with average survival in Norway (P < 0.001). The

operated group had a significantly lower survival rate than the

nonoperated group. In patients with severe instability of the cervical

spine, the defined selection criteria for surgical intervention were

specific. By comparison of calculated propensity scores, the operated

and nonoperated groups were too different to be directly comparable.

After surgery only 11 patients (5%) experienced residual pain in the

neck or neurologic symptoms. None of these patients were alive at the

end of the study, signifying that residual pain or neurologic symptoms

are poor prognostic signs (P = 0.015). In the operated group, anterior

subluxation and vertical settling greater than the lower indication

limits did not have a significant influence on the survival rate, but

there was a reduced survival for patients with subaxial subluxations.

A clear association was found between increased vertical settling and

sudden death.

CONCLUSION.: RA with neck involvement is a progressive and serious

condition with reduced lifetime expectancy. Hence, our interpretation

is that operative intervention improves local symptoms and most likely

changes the condition from worse to better by increasing lifetime

expectancy in high risk patients. Since the per- and postoperative

complications are few, a changed attitude toward more liberal

indications for earlier surgery may reduce the symptoms and the

mortality rate even more.

PMID: 18784629

http://www.ncbi.nlm.nih.gov/pubmed/18784629

Not an MD