Dr. Rampersaud Teaching 11/14/2016

Posted bythespinebookadminPosted inInflammatory and Systemic, Topics

Rheumatoid Cervical 

  • ADI = 3 (unstable), 10 (surgery) 
  • SAC (PADI) = 13 (neurologic recovery) prognosis 
    • Boden et al (JBJS 1993) (Spine 1994) 
  • Look at Posterior laminar line 
  • Rule 
    • C1 arch – 1/3 dens 1/3 cord 1/3 posterior elements 
  • Basilar invagination (lateral SKULL xray is the best XR for this) 
    • Cardiac arrythmia/ arrest 
    • Respiratory arrest 
    • Ranawat 
    • Clark Station 
      • C1 arch is at 1/2 or 2/3 or 3/3 of odontoid 
    • McGregor (most reliable – Dr. Ramp preference) 
      • Palate to base of occiput 
        • If tip of the dens is 4.5 mm above this line = invagination 
      • Useful because too much overlap on XR to see odontoid itself 
  • Subaxial instability 
    • 4mm translation on flex extension 

MRI indications 

  • PADI<14 
  • Neuro deficit 
  • Basilar invagination 

ABCDS for Non-Spine Surgeon in Management of Rheumatoid Arthritis 

  • A – anesthesia/ airway 
    • TMJ involvement – mouth 
    • Arytenoid involvements (vocal cords) – hoarseness of voice preop 
  • B – breathing/ bone 
    • Pulmonary fibrosis 
    • Bone quality 
  • C – cervical spine 
    • C12 
    • Basilar invagination 
    • Subaxial 
  • D – drugs 
    • See JAAOS article 2016 
  • S – soft tissue 
    • Tissue friability 
    • Vascular flow 
    • Soft tissue coverage 

Rheumatoid Arthritis 

  • Background 
    • Autoimmune 
    • Woman 3:1 men 
    • Synovail 
  • Spine 
    • Neck pain – 80% 
    • Subluxation 
      • C12 – 80% 
      • Subaxial – 20% 
      • Basilar invagination – 20% 
    • Neurologic  

Surgical indications 

  • Neurology 
    • Ranawat Classification 
      • Used by Rheum 
      • 123 score  (3b – non-ambulatory) 
  • Intractable pain 
  • High risk patients 
    • Instability 
      • PADI <14 
      • SAC <13 
      • ADI>10 
      • Basilar invagination 
        • Cervical medullary angle 
          • <135 degrees 
    • Minimal or no pain 
    • Subtle or no neuro findings 

Ankylosing Spondlyitis 

  • Bamboo spine 
  • SI joint 
  • Marginal syndesmophyte 
  • Andersson lesion 
    • Inflammatory disc lesion 
    • Early in disease 
    • Incomplete ossification 
    • Multiple lesion 
    • Multiple pathologic fractures possible 
  • Path fracture 
    • Hits apex of curve (max force transmission) 
    • Lack of elasticity 
    • Breaks into extension 
    • If standing – can fall back into flexion 
    • ***epidural hematoma 
      • Anticoagulant is very poor prognosticator 
  • Clinical 
    • Loss of horizontal gaze 
    • 35% have non spine fracture 
    • Reasons 
      • Loss of balance because of kyphosis 
      • Gaze 
      • Neuromuscular component 
    • Any injury or pain – need to assess for fracture 
    • CBVA – chin brow to vertical angle 
    • Compensaotyr knee and hip flexion to maintain horizontal gaze 
  • Operative 
    • Correction 
      • Life is a kyphosing event 
      • Do not overcorrect >10 degrees 
  • CT or MRI considerations 
    • Be careful not to extend patient in scanner 
    • Scan sideways if needed