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Conditions

Rheumatoid arthritis

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) is an autoimmune disease that affects all of the synovial joints in the body. This includes the commonly known joints such as the elbows, shoulders, knees, hips, and also the joints in the spine called the facet joints. The destruction caused by the rheumatoid disease process affects different joints in the body. For a patient with rheumatoid arthritis affecting the cervical spine, the effects of the arthritis on the C-spine can vary from minimal symptoms to life threatening pressure on the spinal cord that requires complex surgery to stabilize the spine and reduce the pressure on the spinal cord.

What causes rheumatoid arthritis?

Rheumatoid arthritis occurs when the body’s immune system mistakenly attacks its own cells. Patients should note that RA is not caused by wear and tear as is osteoarthritis. RA causes the destruction of synovium, the lining of the joints, leading to inflammation, pain, and if left untreated, bone erosion. RA in the cervical spine is particularly dangerous; once the facet joints are destroyed, the connection between each vertebra becomes unstable. The upper vertebra is able to slide forward on top of the one below. This slippage is called spondylolisthesis. In the lower part of the neck, this can lead to pressure on the nerve roots and the spinal cord.

Typical diagnosis

The diagnosis of rheumatoid arthritis problems begins with a thorough history and physical examination. You doctor will want to know about changes in your ability to walk and get around especially if this has gotten worse rapidly. Changes in your bowel or bladder function are also important. Any neurological symptoms that have changed such as weakness, numbness, or loss of fine motor skills are important.

Imaging tests

X-ray

The diagnosis of rheumatoid arthritis problems begins with a thorough history and physical examination. You doctor will want to know about changes in your ability to walk and get around especially if this has gotten worse rapidly. Changes in your bowel or bladder function are also important. Any neurological symptoms that have changed such as weakness, numbness, or loss of fine motor skills are important.

MRI

The MRI scan is the most important test for showing the nerves and soft tissues of a joint potentially affected by RA. This test uses magnetic waves to create slices through the spine or joint. Using this test, the degree of compression on the spinal cord can be assessed more accurately than with X-rays alone (in the case of RA in the cervical spine).

Electrical tests

Finally, special electrical tests may be ordered by your doctor and performed by a neurologist. These tests are useful to determine how the spinal cord is functioning.

Symptoms

The symptoms of rheumatoid arthritis are extremely varied. Pain is the earliest symptom and may be part of the overall joint inflammation that occurs with arthritis. Early stages of RA often affect the smaller joints, such as those in the fingers or toes. As the disease progresses, the symptoms progress to the larger joints in your body. The symptoms that are most worrisome are those that suggest that the spinal cord is being affected.

Pain and pressure

Pain at the base of the skull is common and can indicate that the nerves that exit the skull and the upper spine are being irritated or compressed. Pressure on the vertebral arteries can lead to blackout spells when the blood flow through these arteries is diminished with certain movements of the head and neck.

Trouble walking or issues with balance

A change in the ability to walk can signal increasing pressure on the spinal cord. In some cases, this can be a spastic gait with weakness and problems with balance. This is an indication that the spinal cord is being compressed. Any change in the ability to walk should be brought to the attention of your doctor.

Tingling, weakness, loss of coordination/control

Feelings of tingling, weakness, or a loss of coordination can affect the arms or legs. Changes in bowel or bladder control such as incontinence or inability to urinate can also occur.

Treatments

Nonsurgical treatments

Pain medications

The primary nonsurgical treatment of the problems associated with rheumatoid arthritis begins with good medical control. This treatment is normally managed by a specialist in rheumatology rather than the spine surgeon. Within the past several years, there have been significant advances in the development of new medications that can control the destructive effects of arthritis on the joints. Your rheumatologist will manage these medications.

Imaging techniques

Once there is evidence that rheumatoid arthritis has affected the stability of the cervical spine, the most important part of arthritis care is a close follow-up. X-rays may be needed from time to time to assess the degree of instability and follow the progression of the disease.

Mild instability with no evidence that the instability is causing any pressure on the nerves or spinal cord may not require any additional treatment. Patients with X-ray signs of instability may need to protect their neck with a special neck brace, especially when riding in a car. This is mainly to prevent damage to the spinal cord should a cervical spine injury occur.

Surgical solutions

Joint replacement

In severe cases, the only relief a patient may be offered is through full joint replacement. By replacing the damaged joint with a plastic and/or metal prosthesis, the patient may be returned to a pain-free lifestyle and may be able to resume the activities that they have had to abstain from due to arthritis pain.

While knee and hip replacements are the most common, medical technology has advanced to include shoulder joint replacements, elbow joint replacements, and finger joint replacements.
While a replacement surgery may relieve arthritis associated pain, recovery time post-surgery is often long and can have complications that are non-existent with less invasive options.

In cases of rheumatoid arthritis in the cervical spine, many surgeons feel that surgical stabilization should be considered when there are signs of pressure on the spinal cord. The goal of surgery is to stabilize the unstable portion of the cervical spine, to remove pressure from the spinal cord and to relieve the pain caused by the underlying instability.

The decision to operate should be made based on your symptoms, your expectations, and your overall medical condition. These operations

C1-C2 Posterior Fusion

When the primary problem is instability between the C1 and C2 vertebrae, a fusion between these two spine bones is usually recommended. The traditional method of fusing these two vertebrae is to place wedges of a bone graft between the two vertebrae and then to wire the two vertebrae together. Fusion causes the two vertebrae to form a single bone. The goal is to stop the progression of the instability and relieve the pressure on the spinal cord.

Treatments (cont.)

Cervical Fusion

When the instability involves the lower cervical spine (C3 to the bottom of the cervical spine) a posterior fusion is usually preferred. A fusion of the spine is also called an arthrodesis. In this type of operation, the surfaces of the vertebrae to be fused are roughened to create fresh bleeding bone. Bone graft taken from the hip is then placed between and across the back of the vertebrae to be fused. These vertebrae are held together with some type of hardware, called instrumentation. Many surgeons feel this may increase the success rate of cervical fusion and also may reduce the need for more cumbersome external braces.

Occiput-C3 Posterior Fusion

Perhaps the most serious condition from rheumatoid arthritis of the cervical spine is the settling that occurs when the joints between the skull, the C1 vertebra, and the C2 vertebra are destroyed. Settling allows the odontoid to slowly place more pressure on the spinal cord and brain stem and can lead to paralysis and even sudden death.

The surgical procedure to stabilize this situation requires fusion between the skull and the first three cervical vertebrae (C1, C2, and C3). The traditional procedure to fuse these bones together is very complex. A bone graft is taken from the pelvis and fashioned into two small plates of bone that will cover the area from the base of the skull to the C3 vertebra. In advanced cases, the pressure may need to be relieved from the spinal cord. The surgeon may do this by removing a portion of the skull and the back portion of the C1 vertebra. In select cases, the surgeon may need to work on the front of the spine by operating through the mouth, called a transoral approach.

When all pressure is removed from the spinal cord, the bone graft is placed. Small holes are drilled into the skull and first three cervical vertebrae. A wire is inserted through the holes in order to hold the graft in place. Recently, instrumentation has been developed to hold the bones and bone graft in place while the bones fuse. Several different types of metal rods and metal plates have been developed that can hold the skull and upper cervical vertebra together while the fusion heals.

As the bone graft heals, the first three cervical vertebrae fuse to the skull. A successful fusion stops the instability and protects the spinal cord from additional pressure. These posterior fusion operations are all performed through an incision in the back of the neck. The fusion usually takes at least 12 weeks to become solid, but it may take as long as one year.

Transoral Approach

In some cases of advanced rheumatoid arthritis of the cervical spine, the posterior fusion alone is not enough to take the pressure off of the spinal cord. This can occur in two ways.

First, the cranial settling may be so great that fusion cannot remove the pressure that the odontoid is placing on the spinal cord.

Second, the pannus that occurs due to the rheumatoid disease may put pressure on the spinal cord. Pannus is formed by most joints afflicted with rheumatoid arthritis. This material is formed by the synovium (or the joint lining) and grows and expands like a tumor. As it grows larger it can put pressure on the spinal cord. Usually, once a fusion has been successful the pannus actually shrinks, and the pressure on the spinal cord is reduced.

If either of these conditions is causing too much pressure on the spinal cord, a second operation may be needed to remove the pressure on the spinal cord. Because the pressure is on the front of the spine and spinal cord, the operation must also be done from the front of the spine. When surgery on the front of the spine is necessary for the upper cervical spine it must be performed through the back of the mouth.

The operation begins with the transoral approach when it is certain that pressure must be removed from the front of the spinal cord. This is followed by a posterior fusion during the same operation. In some cases, the posterior fusion may be done alone at first to see if this reduces the pressure. If the posterior fusion alone is not successful, a second operation using the transoral approach may be done at a later date to remove the continuing pressure on the spinal cord.

During the transoral approach, the surgeon makes an incision in the back of the throat while the mouth is held open with special retractors. The source of compression is identified and removed to reduce the pressure on the spinal cord. Surgeons do the operation with the aid of an operating microscope to be able to see the incision better.

Procedures / Surgeries

When signs of pressure on the spinal cord become apparent, many surgeons feel that surgical stabilization should be considered. The goal of surgery is to stabilize the unstable portion of the cervical spine, to remove pressure from the spinal cord and to relieve the pain caused by the underlying instability.

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