stenosis due to rheumatoid arthritis occipital cervical junction

1. Occipital Cervical Posterior Fusion for
rheumatoid arthritis and stenosis
Spine Conference August 27, 2019

2. 73 year old woman cc: neck pain R>L UE pain
HPI: presented April 2015; referred by neighbor.
Pain occiput to neck, radiates to trapezial area,
lateral arm not past elbow, numbness entire
hand R=L IF worse, ataxia, 4 falls in last month,
difficulty and weakness with hands opening
things, taking money out of wallet and slow with
buttons. 1st spinal consult did not recommend
surgery.
PMH: thoracic PSF 1971, c4c7 acdf 2001, L2L5
PSF 2010, T12L5 PSF 2012, B TKA, R hip ORIF
2014, DVT, gastric ulcer surgery, severe arthritis
SH: RHD divorced mother of 5 grown children.
Retired deli manager 1998. Smoke 0.5 pack/day
11 years, 1-2 glass wine at night, 15
grandchildren and 4 great grandchildren
MEDS: Effexor, HCTZ, Lopressor, Norvasc,
Protonix, ASA, Calcium, Cyanocobalamin, MVI,
Senekot,
Exam: 4’11” 93 pounds, no neck extension,
minimal flexion, 10 degrees rotation, R>L
weakness, 4/5 right, 5/5 left, neg hoffmans no
clonus

4. April 2015

5. April 2015

6. 4/3/15

8. 2012 2015

9. Problem list:
1. 73 year old woman
occipito cervical
instability with clinical
myelopathy of falls,
upper and lower
dysfunction
2. cephalomedulary
angle 126 degrees
3. C4C7 ACDF
4. smoker
5. cachectic
6. dens erosion
7. rheumatoid
osteoporotic bone
8. pain

10. Cervical spine is the most common
site of disease in RA after the
hands and feet

11. Epidemiology of RA
• 1% of adults have RA, of those 10% have cervical spine
manifestations
• 3x more women and men
• RA affects cervical spine
• Ankylosing spondylitis affects SI joints and ALL
• RA manifestations in the cervical spine
• Atlantoaxial subluxation (19-79%)
• Subaxial subluxation (7-88%)
• Cranial settling (basilar impression or invagination, atlantoaxial
impaction, superior migration of the odontoid)
• 25-88% prevalence of cervical spine involvement in RA patients
• 7-34% will have neurologic symptoms that require surgical
consultation
• Lumbar spine rarely involved

12. Atlantoaxial Instability (C1-C2)
• Anterior, posterior, and rotatory subluxations
• Anterior: most common
• C1 anterior to C2
• Destruction of the transverse, apical and alar ligaments (most common)
• Atraumatic dens fracture
• Dens erosion
• RA pannus around the synovial joint between the dens and anterior arch
of C1 can result in additional compromise of SAC (space available for cord)
• Erosive pannus formation at the C1-C2 joints, bone
destruction --> laxity of the transverse atlantal ligament
• Normal anterior atlantodens interval <3mm (Adult)
• Atlantoaxial instability --> increase anterior atlantodens interval AND
decrease in space available for cord--> compression of spinal cord

13. Pannus?
theories on the pathogenesis of rheumatoid arthritis suggest that the synovial cells of these patients chronically express an antigen that triggers
oduction of rheumatoid factor (RF), an immunoglobulin molecule directed against other autologous immunoglobulins. An inflammatory response is
ed, involving immune complex formation, activation of the complement cascade, and infiltration of polymorphonuclear leukocytes. The proliferating
asts and inflammatory cells produce granulation tissue, known as rheumatoid pannus, within the synovium. The pannus produces proteolytic
es capable of destroying adjacent cartilage, ligaments, tendons, and bone. The destructive synovitis results in ligamentous laxity and bony erosion
esultant cervical instability and subluxation

14. Subaxial Subluxation
• Autoimmune destruction of the
facet joints
• Results in listhesis, kyphosis or
staircase deformity
• Subluxation defined:
• >3.5mm translation OR
• >20% vertebral body slip OR
• 11 deg of angular instability
• May have multiple levels involved,
leading to a staircase deformity

15. Cranial Migration
• Erosion of O-C1 and C1-C2 joints such that the
odontoid go into the foramen magnum.
• Occurs when there is a high degree of destruction
of
• Occipitoatlantal condyles
• Atlantoaxial facet joint
• C1 lateral mass destruction (most common)
• The head settles caudally --> compression of the
ventral brain stem around the dens  death

16. Clinical Presentation
• 33-50% of all RA patients with cervical instability are ASYMPTOMATIC
• Neck pain, decreased ROM, neurological symptoms, altered mental
status
• Occipital headaches
• Secondary impingement of the greater or less occipital nerves (medial divisions
of the dorsal rami of C2 and C3 nerve roots
• C2 nerve claudication may cause pain in the face, ear, mastoid
• C1-C2 instability
• Vertigo, syncope, nystagmus, dysarthria, sleep apnea, swallowing difficulty,
facial parathesias
• Cervical myelopathy
• Muscle weakness, atrophy, numbness, tingling, paraesthesias, bowel/bladder
incontinence, hyperreflexia, loss of proprioception, gait instability
• Occurs in 10% of patients with RA who have cervical involvement

17. Laboratory Findings
• RF= 80% of patients
• Low specificity
• Antinuclear antibodies: 30% of patients
• ESR/CRP/serum globulin levels
• CRP shown to predict the risk of joint deterioration
• Anti-CCP, anti-MCV
• High sensitivity and specificity
• Predictive and prognostic in RA
• Anti-MCV:
• Good for +RF and +anti-CCP-2
• Patients who are seronegative for RF but positive for anti-
CCP have increased radiographic progression and poorer
functional outcomes than other patients with RA

18. Radiographic Findings
• Standard AP, PA, lateral flex-extension, open mouth
view
• CT better than open mouth view
• Atlantodens interval (ADI)
• Men <3.0mm
• Women<2.5mm
• Instability: ADI>5mm
• ADI>10mm --> complete loss of the structural integrity of the
transverse, apical and alar ligaments
• Space Available for Cord
• More reliable indicator for neurological compromise
• <13-14mm indication for surgery

19. Natural History
• Without treatment of RA, the spine can be
associated with progressive disability resulting from
atlantoaxial dislocation along with the risk of
sudden death caused by cord or brain stem
compression
• 7 year survival is low in patients with myelopathy
2/2 to atlantoaxial subluxation who refuse surgical
tx

20. Nonsurgical Management
• Physical Therapy
• Soft collar for comfort
• Hard collar for known spinal instability
• No evidence that they reduce neurological progression or prevent
further subluxation
• External immobilization does not control instability
• Poorly tolerated due to involvement of temporomandibular joint
• DMARDS
• Methotrexate, hydroxychloroquine, leflunomide, sulfasalazine
• TNF inhibitor
• Adalimumab, certolizumab, pegol, etanercept, golimumab,
infliximab_
• Biologic
• Abatacept, rituximab, tocilizumab

22. Surgical Management
• Atlantoaxial instability
• C1-C2 Posterior Fusion
• Superior Migration
• Early: C1-C2 fusion
• Late: Suboccipital craniotomy and C1 laminectomy
• Persistent compression: Transoral dens resection
• Subaxial
• Laminectomy and PSF

24. Synovial bursa between the transverse atlantal
ligament and the odontoid process; Occiput C1
C2 have no discs (not affected by rheumatoid
disease)

25. Odontoid process
erosion is a hallmark
of RA

26. C1C2 instability 65%: can be anteroposterior, rotatory or lateral; last two
can cause torticollis

28. Posterior
atlantodental
interval <14mm
is an indication
for surgery

29. Basilar invagination 20%
atlantoaxial impaction, collapse lateral masses, worse prognosis, C1C2 roots can be
compressed, compression of CN nuclei, respiratory compression, brainstem injury,

30. Basilar invagination
Atlantoaxial impactio
Superior migration of
the odontoid (SMO)
cranial settling,
pseudobasilar
invagination, or
vertical/upward
translocation of the
odontoid

31. Staircase deformity
Facets and uncovertebral
joints destroyed
Lack of osteophyte
formation unlike OA
a/w kyphosis
Subaxial subluxation 15%

32. Cephalomedullary
angle: line parallel to
brainstem and
cervical spial cord
135-175 degrees
normal range

41. ALERT TEST QUESTION: ADI>10mm complete
loss of transverse as well as checkrein (apical
and alar) ligaments

50. - Ranawat's line:
- center of C2 pedicle to a line
connecting the anterior and posterior C1
arches;
- normal measurement in men is 17
mm, whereas in women it is 15 mm;
- distance of < 13 mm is consistent with
impaction;
- less than 7 mm is associated with
medullary compression on MR image
- McRae's line:
- defines the opening of the foramen
magnum;
- the tip of the dens may protrude
slightly above this line, but if the dens is
below this line then impaction is not present;
- McGregor's line:
- line drawn from the posterior edge of
the hard palate to the caudal posterior
occipit curve;
- cranial settling is present when the tip
of dens is more than 4.5 mm above this line;
- this measurement can be difficult
when there is dens errosion;
- problem w/ this measurement is that
the hard palate position may vary w/ mid
facial anomalies;
- Chamberlain's line:
- line from dorsal margin of hard palate
to the posterior edge of the foramen
magnum;
- this line is often hard to visualize on
standard radiographs;
- if dens is > 6 mm above this line,
consistent w/ impaction

54. 88 year old man with cc:
headaches R neck pain
HPI: Frontal headaches with
R posterior neck pain.
Supine position helps relieve
pain, dizzy spells last 6
months, need for a walker
the last 2-3 years
PMH: HTN, A fib, Pacemaker
2011, B THA, BPH,
SH: widower,
PE: 5 feet 9 inches 165 lb,
wide based slow cadence,
bent forward posture

55. 2008 2013

62. The occiput has a keel that can accept instrumentation

63. Inion

64. Screws inserted
below superior
nuchal line to
avoid intracranial
transverse venous
sinus penetration

66. C2 pars
screw

67. C2 pars
screw

74. http://youtu.be/Mzk7XDJkdEE go to 27:34, 29:30

76. Problem list:
1. occipito cervical
instability with clinical
myelopathy of falls,
upper and lower
dysfunction
2. cephalomedulary
angle 126 degrees
3. C4C7 ACDF
4. smoker
5. cachectic
6. dens erosion
7. rheumatoid
osteoporotic bone
8. pain
treatment?

77. DOS 4/23/15
Occiput C7 PSF, posterior
laminectomy C1 through C6, L
PICBG,
IVF: 4.5 liters
EBL: 1.2 liters
Operative time 5 hours
UO: 500cc
C1C2 ligamentum flavum adherent
to dura but peeled off without
incident

78. 4/24/15

79. Preop Imagine removing lamina, where
does spinal cord shift to?

80. 4/23/15

81. 6/3/15

82. 8/5/15

83. 6/15/17 2 years later
Neck pain pop
AKA WC
Now what?

85. 10/5/17

86. 10/7/17

87. 2/5/18 6 months postop

88. THANKS!

100. SLIDES NOT
USED FOR TALK

101. 7/11/12

103. 6/5/17

112. Proximal fixa

132. Rheumatoid pathologyhttp://youtu.be/ZcTi28aBY1s

134. http://youtu.be/K1HvU9-9Fpk go
to 3:20