S7 THE SPINE IN RHEUMATOID ARTHRITIS – A SURGEON’S VIEW

Abstract

Introduction Rheumatoid arthritis also affects the spine and creates conditions that need surgical treatment. As in other parts of the body, the maintenance of function and reduction of pain are primary goals of surgical treatment, however the additional threat to the neurological structures create an additional dimension in the surgical treatment of the spine.

Destructive processes of osteoligamentous structures and severe osteoporosis may be blamed as the principle cause for pain, deformity and subsequent neurological deficit in the rheumatoid patient’s spine. Cervical spine Atlantoaxial instability is the most frequently encountered pathology in the cervical spine of the rheumatoid patient. In order to avoid late appearance of myelopathy, the timing of surgery in the presence of significant atlantoaxial instability (ADD < 5mm) has to be carefully evaluated. The tendency is towards early surgical stabilization since no spontaneous improvement is to be expected in cases with aggressive rheumatoid arthritis. Late surgery not only carries the risk of causing myelopathy by repeated micro-trauma of the myelon, but also the need for extensive surgery including the occiput and the lower cervical spine in case of advanced destructive processes.

The subaxial cervical spine has a tendency to disintegrate in the presence of aggressive course of rheumatoid arthritis. The extent of instability and site of compression has to be carefully analyzed, using MRI and neurophysiological examinations. Due to weak bone structures anterior and posterior interventions are often necessary. Lumbar spine The rheumatoid pathology in the lumbar spine is mainly influenced by the degree of osteoporosis. Typical osteoporotic fractures, often on several levels, represent the most frequent pathology, which needs surgical help. In case of persistent pain the relatively new technique of vertebroplasty offers an elegant way to reduce pain. If severe deformities occur, the osteoporotic structure of bone limits the surgical possibility of correction of the deformity.

Conclusion “Wait and see”-policy in rheumatoid patients with spinal pathology is often not appropriate (as in other joints of the body) if function and neurology should be preserved and maintained. Early surgery represents usually minor intervention and is better tolerated than extensive corrections. Osteoporosis is the main limitation for surgical treatment in the rheumatoid spine.