1	The spine in rheumatoid arthritis a surgeons view Dieter Grob Zürich Switzerland
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3	„The rheumatoid spine“ General RA Ligamentous (discs) structures Bone arrosion
4	Rheumatoid spine Most frequent problems encountered Instability cervical spine/lumbar spine Osteoporosis > fractures - kyphotic deformity Stenosis > narrowing of the spinal canal
5	Cervical Spine: Morphological Changes Subluxations 15-20% Structural changes ca. 15% Disc failure Lig. insufficiency Bone resorption Endplate erosion Ankylosis Bulging pannus
6	Surgery at all? Decreased pain Reduced myelopathy Improved prognosis
7	Surgery at all? Survival rate
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9	Upper CS: Possible course of RA Normal horizontal instability (C1/2) pannus formation osseous resorption vertical instability myelocompression „sudden death“
10	Timing for surgery?
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13	Pannus study (retrospective) 22 Patients with RA of upper CS 18 females, 4 males Av. age at surgery: 58 yrs History of RA: av. 16.8 yrs until fusion Preoperative MRI Follow-up: av. 40 (24-55) months Surgical indication Intractable pain 20 Progression of instability 8 Compressive myelopathy 9
14	General course of RA Steinbroker pre/post: Deterioration: 3 III > II 2 No change 17
15	Pannus study : Exclusion criterias Anterior (transoral) surgery Previous surgery Pseudarthrosis C1/2 No preop. MRI
16	Pannus study : Methods Classification of retrodental pannus I = no pannus (< 3 mm) II = small pannus (3-6mm) III = large pannus (> 6 mm), compression in flexion IV = large pannus (> 6 mm), compression in neutral Assessment of clinical results
17	Pannus Study : Results (summary)
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19	Pannus Study: Conclusion
20	Vertical migration after C1/2 18 Pat. minimal FU 8.5 yrs.
21	C1/C2 fusion: Prevention of upward migration?
22	Our cases: C1/2 Fixation in RA 54 patients with RA (only C1/2) (87-1999) Indication: isolated atlantoaxial instability 75 females, 23 males Av. age 59 (25-81) years Follow up: av. 6 (2-13 )yrs One surgeon
23	Surgery: Transarticular screw fixation in RA patients (N=54) Surgery av. 78 min (50-145) Blood loss av. 250 ml (50-1500)
24	Results C1/2 in RA %
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29	Y-plate Biomechanical considerations:
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31	Subaxial problems: (app. 20%) Occiput included: extensive fusion (T1/2) Occiput excluded: x-rays analysis
32	Occiput Lit. review. Kraus et al. (Spine 1991) Isolated C1/2 5.5% required surgery after 9 years Inclusion of occiput 36% required surgery after 2.6 years
33	Cervical spine: conclusion Timing of surgery decides on extent of surgery Generous indication for atlantoaxial fusion subaxial: individually (radiology: ankylosis, subluxation) Occiput included: extensive fusion to the T- spine Influence on local progression Pain reduction
34	Thoracic/lumbar spine Rheumatoid spine = osteoporotic spine Insufficient bone quality Load Deformity Stenosis
35	Discrepancy between stability of bone and implant
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37	Results Pain reduction 70-90% Kyphoplasty: ca 50% reduction
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39	Rheumatoid spine 78 yrs 9 orthopaedic interventions (Shoulder, Elbow, hand, knee, hip) 1995: OC fusion, subaxial compensated 2000: osteoprotic fracture L 3: vertebroplasty 2001: Painful thoracic spine
40	Rheumatoid spine 78 yrs 2001: vertebroplasty th-spine 2005: recurrent pain > extensive vertebroplasty
41	Rheumatoid spine 78 yrs Increased deformity, pain
42	New: Motion Preserving
43	The surgical cascade: what applies for RA? Invasivity
44	63 yrs, RA patient, previous cervical surgery
45	Hard ware removal (loosening) reinstrumentation
46	Conclusions Cervical spine /lumbar spine: different strategy motion C1/2 load Common problems osteoporosis destructive process (RA)
47	Conclusions II (cervical spine) Indications: Timing of surgery Neuroprotection > pain Generous indication for atlantoaxial fusion Occiput included: extensive fusion to the T- spine Satisfactory results: pain, progression
48	Conclusions III : lumbar/thoracic spine indication: pain, neuroprotection, deformity osteoporosis/load: Minimal invasive Maximal invasive (sagittal balance, anchoring points) frequent re-interventions (ASD)
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