Summary
There are few reports in the literature of the surgical treatment of cervical myelopathy secondary to rheumatoid arthritis below the level of the axis. Three cases are presented. All had severe motor and sensory loss in the upper and lower extremities. The cause of myelopathy differed in each case: in the first, the dura mater was infiltrated with rheumatoid material; the second was due to a stenotic spinal canal narrowed by a fixed subluxation of the cervical spine; in the third, traction myelopathy resulted from sub-axial subluxation and posterior angulation combined with cervical instability.
Neurological assessment is particularly difficult in patients with rheumatoid arthritis of the cervical spine. Skull or halo traction is useful to gauge neurological improvement, to reduce the dislocation and to immobilise the cervical spine before, during and after surgery. Surgery is considered where conservative treatment is either ineffective or not tolerated, and is indicated if severe myelopathy is evident or progressive. Anterior interbody fusion is the operation of choice for mobile subluxation. Laminectomy is recommended in fixed subluxation where compression of the cord is demonstrated on myelography.
Résumé
Il n'existe qu'un petit nombre de publications concernant le traitement chirurgical des myélopathies secondaires à une polyarthrite rhumatoïde siégeant audessous de l'axis. Les auteurs en rapportent trois cas. Tous les malades présentaient un déficit sensitivomoteur sévère au niveau des membres supérieurs et inférieurs. Dans chacun des cas la cause de la myélopathie était différente: chez le premier malade, la duremère était infiltrée de productions rhumatoïdes; chez le second, il existait une sténose du canal rachidien due à une subluxation permanente des vertèbres cervicales; chez le troisième, une myélopathie par élongation résultait d'une subluxation sous-axoïdienne et d'une angulation postérieure, associées à une instabilité cervicale.
Le bilan neurologique est particulièrement difficile à établir chez les malades atteints d'une polyarthrite rhumatoïde du rachis cervical. La traction crânienne ou par halo est utile pour apprécier l'amélioration neurologique, pour réduire la luxation et pour immobiliser le rachis cervical, avant, pendant et après l'intervention. Le recours à la chirurgie doit être envisagé lorsque le traitement conservateur est inefficace ou mal toléré, et il est indiqué si une myélopathie sévère est évidente ou évolutive. L'intervention de choix, en présence d'une subluxation mobile, est l'arthrodèse corporéale antérieure. La laminectomie est préconisée dans les cas de subluxation fixée, quand la myélographie met en évidence une compression médullaire.
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Kataoka, O., Hirohata, K. & Kurihara, A. The surgical treatment of myelopathy secondary to rheumatoid arthritis of the lower cervical spine. International Orthopaedics 3, 103–110 (1979). https://doi.org/10.1007/BF00266879
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DOI: https://doi.org/10.1007/BF00266879