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Lookup NU author(s): Nicholas Todd
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OBJECTIVE: Rheumatoid arthritis frequently affects the craniovertebral junction (CVJ) and may lead to severe neck pain, quadriparesis, and respiratory dysfunction. Surgery in rheumatoid nonambulatory (Ranawat Class IIIb) patients carries a significant risk. This study presents the surgical outcome of Class Illb patients with CVJ rheumatoid myelopathy and reviews the literature. METHODS: One hundred twelve consecutive patients with rheumatoid cervical myelopathy underwent surgical decompression and stabilization. Thirty-two of the patients (mean age, 66.81 +/- 10.25 yr) with CVJ rheumatoid arthritis were in Class IIIb, and all had atlantoaxial subluxation. A halo brace was applied before surgery and continued during surgery. Eleven patients with reducible atlantoaxial subluxation underwent direct posterior fusion. Twenty-one patients with fixed atlantoaxial subluxation underwent transoral decompression and then posterior fusion while they were under anesthesia. RESULTS: At a mean follow-up of 39 months, four patients improved to Class 11 and 14 improved to Class Ilia, whereas six remained in Class Illb. Neck pain was relieved in all patients. There was one perioperative death after transoral surgery (posterior fusion not done), and seven other patients died subsequently of causes unrelated to surgery. The morbidity of surgery included construct failure, cerebrospinal fluid leak, superficial wound or graft donor site infection, transient dysphagia, and lung infection. CONCLUSION: A large subset of patients with CVJ rheumatoid myelopathy may reach Class Illb. These patients have unique management considerations. Surgery (despite high morbidity) often remains the best therapeutic option available to them. Improvement of even one grade in their Ranawat score from Class Illb to Class IIIa brought about by surgery confers on them a significant benefit in terms of their quality of life and survival.
Author(s): Nannapaneni R, Behari S, Todd NV
Publication type: Article
Publication status: Published
Journal: Neurosurgery
Year: 2005
Volume: 56
Issue: 4
Pages: 706-714
ISSN (print): 0148-396X
ISSN (electronic): 1524-4040
Publisher: Lippincott Williams & Wilkins
URL: http://dx.doi.org/10.1227/01.NEU.0000156202.80185.32
DOI: 10.1227/01.NEU.0000156202.80185.32
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