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228 V Miscellaneous
Suggested Reading
Christodoulou AG, Givissis P, Symeonidis PD, et al. Reduction of postoperative spinal infections based on
an etiologic protocol. Clin Orthop Relat Res 2006;444:107–113
Cunningham ME, Girardi F, Papadopoulos EC, et al. Spinal infections in patients with compromised im-
mune systems. Clin Orthop Relat Res 2006;444:73–82
Kim CW, Perry A, Currier B, et al. Fungal infections of the spine. Clin Orthop Relat Res 2006;444:92–99
Lim MR, Lee JY, Vaccaro AR. Surgical infections in the traumatized spine. Clin Orthop Relat Res
2006;444:114–119
Spock CR, Miki RA, Shah RV, et al. Necrotizing infection of the spine. Spine 2006;31:E342–E344
Swanson AN, Pappou IP, Cammisa FP, et al. Chronic infections of the spine: surgical indications and
treatments. Clin Orthop Relat Res 2006;444:100–106
Tsiodras S, Falagas ME. Clinical assessment and medical treatment of spine infections. Clin Orthop Relat
Res 2006;444:38–50
Table 20–3 Risk Factors for Postoperative Infections
Diabetes mellitus
Chronic corticosteroid use
Chemotherapy
Revision surgery
Prolonged operative time (4 h)
Morbid obesity
Preoperative/postoperative infectious condition
• Tooth abscess
• Urinary tract infection
• Pneumonia
• Open sores
Prolonged drainage from the surgical wound
229
21
Rheumatoid Arthritis
I. Rheumatoid arthritis
A. Clinical findings
1. Most commonly affects the cervical spine
2. Within 5 years of serological diagnosis, 30 to 50% develop subluxation.
3. Most common during the third decade
4. Three-to-one female-to-male ratio
5. Insidious onset, symmetrical polyarthritis, constitutional symptoms,
and variable clinical course
a. Patients are at risk for sudden death.
B. Pathogenesis
1. Unknown antigens
a. Epstein-Barr virus
b. Bacteria cell wall products
c. Collagen II
d. Mycoplasma
2. Genetically susceptible individuals
a. HLA-DR4 type
3. Antibody formation and cellular interaction
a. Monocyte
b. B and T lymphocytes
c. Immune complex formation
(1) Rheumatoid factor—immunoglobulin M
4. Phagocytosis of immune complexes
a. Synovial cells type A and polymorphonuclear neutrophilic leuko-
cytes (PMNs)
(1) Complement activation
5. Chemotaxis of inflammatory cells
a. Production of proteolytic enzymes and prostaglandins
6. Cartilage destruction
a. Collagenase
b. Proteolytic enzymes from PMNs
230 V Miscellaneous
c. Synovial cells and chondrocytes
7. Periarticular osteoporosis due to disuse and prostaglandins
8. Subluxation, dislocation, deformity, and ankylosis
C. Pathology
1. Synovium
a. Synovitis with villi infiltrated with lymphocytes and plasmacytes
b. Surrounding edema and fibrin
2. Pannus
a. Proliferation of mesenchymal cells and vascular granulation invad-
ing the cartilage from the periphery
3. Rheumatoid nodules
a. Fibrinous necrosis in the center with surrounding layer of palisading
epithelial cells
D. Cervical spine deformity
1. Instability depends on the severity of the disease process
2. Subluxation appears one decade after the disease onset
3. Radiographic progression of subluxation has been observed in 35 to
80% of patients.
a. Five-year mortality rate of 17%
4. Atlantoaxial subluxation (Fig. 21–1)
a. The normal anterior atlantodens interval (AADI) is 3 mm in adults
and 4 mm in children.
(1) AADI greater than 5 mm represents instability.
Figure 21–1 (A) Lateral radiograph of a rheumatoid arthritis patient with C1–C2 instability. The
atlantodens interval is measured to be 17 mm, and the PADI/SAC is only 8 mm on flexion. A SAC of
13 mm or less represents a significant risk for the development of neurological compromise.
A
Chapter 21 Rheumatoid Arthritis 231
(2) Critical limit of AADI that predicts an impending paralysis and
indicates a need for surgery is 8 mm.
(3) AADI is an unreliable predictor of paralysis because of poor cor-
relation between the AADI and the degree of cord compression
as shown by magnetic resonance imaging (MRI).
(4) Posterior atlantodens interval (PADI) has been found to be a
better predictor of paralysis.
(a) Critical lower limit is 14 mm.
(b) Important to note that PADI is not the same as space avail-
able for the cord.
(i) In rheumatoid arthritis patients, retro-odontoid syn-
ovial pannus may occupy as much as 3 mm of space.
b. Weak transverse ligament and synovitis of atlantoaxial and atlanto-
odontoid joints
c. Symptoms
(1) Neck pain
(2) Headache
(3) Myelopathy
(a) Paresthesias
(b) Abnormal gait
(c) Bowel/bladder difficulties
(d) Difficulty with fine motor control
5. Atlantoaxial impaction or basilar invagination
a. Characteristics
(1) Superior migration of the odontoid (SMO)
(2) Vertical subluxation of the axis
(3) Pseudobasilar invagination
b. Synovitis and cartilage destruction of the occipitoatlantal and
atlantoaxial joints
Figure 21–1 (Continued) (B) Sagittal T2-weighted MRI taken of the same patient demonstrating
that the spinal cord is decompressed in extension.
B
232 V Miscellaneous
c. Symptoms include occipital headache, myelopathy, or brain stem
compression signs
d. Radiographic landmarks
(1) McGregor’s line
(a) Connects the posterior margin of the hard palate to the
most caudal point of the occiput
(b) Positive if 4.5-mm odontoid projection above the fora-
men magnum
(2) Ranawat’s C1–C2 index
(a) Distance between the center of the pedicle of the axis and
the transverse axis of the atlas
(b) Less than 13 mm in women and 15 mm in men are ab-
normal.
(3) McRae’s line
(a) Connects the anterior and the posterior margins of the
foramen magnum
(i) Tip of the odontoid should lie 1 cm below this line.
(4) Redlund-Johnell occiput-C2 index
(a) Perpendicular distance from the middle of the lower end
plate of the axis to McGregor’s line
(b) Less than 34 mm in men and 29 mm in women are ab-
normal.
6. Subaxial subluxation
a. Synovitis of facet joints, intervertebral disks (spondylodiscitis), and
ligament involvement
b. Multiple-level involvement
(1) Particularly common at C2–C3 and C3–C4 region
(2) Degenerative involvement typically occurs at C5–C6
c. End plate erosions are present in 12 to 15% of patients.
d. MRI is indicated whenever there is suspicion of instability on plain
radiographs.
II. Predictors of neurological recovery
A. Ranawat classification
1. More severe preoperative neurological deficits tends to have a poorer
neurological recovery.
B. Location of disease
1. The more proximal the pathology, the worse the prognosis.
C. Preoperative PADI of 14 mm or greater predicts a potentially significant
motor recovery after appropriate surgery.
1. In contrast, PADI 10 mm has a poor prognosis.
D. Postoperative subaxial canal diameter 14 mm indicates a poor prognosis.
III. Indications for surgical stabilization (Fig. 21–2)
A. Definite indications
1. Intractable pain
2. Neurological defect
B. Atlantoaxial subluxation
1. PADI 14 mm warrants an MRI scan.
Chapter 21 Rheumatoid Arthritis 233
2. Space available for the cord (SAC) 13 mm
3. Cervicomedullary angle 135 degrees
4. Spinal cord diameter 6 mm
C. Superior Migration of the Odontoid (SMO)
1. Any demonstrable SMO on any radiographic modality
a. High morbidity and poor prognosis with surgery in progressive
basilar invagination
D. Subaxial subluxation (SAS)
1. SAS exceeding 4 mm requires an MRI scan evaluation.
2. SAC 13 m m
IV. Surgical stabilization
A. General considerations
1. Preoperative halo traction can provide pain relief, correct deformity,
and arrest or reverse neurological deterioration.
2. Awake fiber-optic intubation without neck extension is indicated.
Figure 21–2 A lateral radiograph of a patient who underwent a Brooks C1–C2 wiring. An 18-gauge
wire was passed under the arch of C1 and C2 with an iliac crest graft fitted into the C1–C2 interval.
234 V Miscellaneous
B. Specific conditions
1. Atlantoaxial subluxation
a. Posterior atlantoaxial fusion
b. C1–C2 transarticular screw fixation (Magerl)
(1) May not be technically possible depending on the deformity
and course of the vertebral artery
c. C1–C2 lateral mass/pedicle screw fixation
2. Superior migration of the odontoid (21–3)
a. Posterior occipitocervical fusion
b. Anterior decompression via transoral resection of the odontoid is
indicated when there is evidence of significant anterior pannus or
marked vertical translocation of the odontoid (5 mm).
3. Subaxial subluxation
a. Posterior cervical fusion with lateral instrumentation
(1) Rarely, when notable subluxation is present and cannot be re-
duced, anterior decompression with corpectomy and reconstruc-
tion with strut bone grafting may be indicated (Fig. 21–4A,B).
Figure 21–3A Preoperative sagittal MRI of a 76-year-old man with rheumatoid arthritis who pre-
sented to the emergency room with the inability to swallow and speak. A large rheumatoid pannus
is noted to cause upper cervical cord compression and destruction of the dens. (Continued)
A
Chapter 21 Rheumatoid Arthritis 235
4. Other subaxial problems
a. Subluxation below higher fusion
b. Anterior spondylodiscitis with cord compression
c. Compression from epidural rheumatoid granulation
d. Subaxial hyperlordosis
(1) Treatment: posterior fusion for myelopathy or 5-mm translation
Suggested Reading
Boden SD, Dodge LD, Bohlman HH, Rechtine GR. Rheumatoid arthritis of the cervical spine. J Bone Joint
Surg Am 1993;75-A:1282–1297
Borenstein D. Inflammatory arthritides of the spine: surgical versus nonsurgical treatment. Clin Orthop
Relat Res 2006;443:208–221
Kim DH, Hilibrand AS. Rheumatoid arthritis in the cervical spine. J Am Acad Orthop Surg 2005;13:
463–474
Roberts S, Butler RC. Inflammatory mediators as potential therapeutic targets in the spine. Curr Drug
Targets Inflamm Allergy 2005;4:257–266
Zikou AK, Alamanos Y, Argyropoulou MI, et al. Radiological cervical spine involvement in patients with
rheumatoid arthritis: a cross sectional study. J Rheumatol 2005;32:801–806
Figure 21–3B,C Postoperative anteroposterior and lateral radiographs demonstrating occipital
cervical fixation (C2 pedicle screws and C3–C6 lateral mass screws). The patient was decom-
pressed C2–4 laminectomies and traction, allowing restoration of normal cervical lordosis.
236
22
Seronegative
Spondyloarthropathies
I. Ankylosing spondylitis (Fig. 22–1)
A. General considerations
1. Affects patients in their second and third decades of life
2. Men and women are affected equally.
a. Men typically have a more severe disease expression.
b. Prevalence is 1 in 1000.
c. Mostly Caucasian (HLA-B27)
B. Pathogenesis
1. HLA-B27 positive in 88 to 96% of patients
2. Inflammatory arthritis of the spine that also involves sacroiliac and pe-
ripheral joints
a. Cartilage destruction and bony erosion
b. Earliest changes are in the sacroiliac joints.
3. Enthesitis at tendon and ligament bony insertions
a. In the spine, this occurs at the insertion of the anulus fibrosus.
C. Clinical findings
1. Insidious onset
a. One to 3 years of symptoms before diagnosis
2. Symptoms include low back pain and stiffness, which are worse in the
morning and better with activity.
3. Fifteen to 25% have peripheral joint arthritis.
4. Physical findings
a. Limitation of lumbar motion (Shober test)
b. Decreased chest expansion
c. Positive sacroiliac stress maneuver (Patrick’s test)
d. Rigid kyphotic spine
(1) Most effective measure of spinal deformity is the chin-brow to
vertical angle
e. Compensatory hip flexion contractures
Chapter 22 Seronegative Spondyloarthropathies 237
5. Nonskeletal manifestations
a. Aortic insufficiency
b. Cardiac conduction defects
c. Uveitis
d. Pulmonary fibrosis (cause of death in 10% of patients)
D. Radiographic findings
1. Sacroiliitis erosion
a. Reactive bone and fusion of the joint (on the lower portion of iliac
side first)
b. Bilateral and symmetric
2. Spine
a. Syndesmophyte formation from the margins of the vertebral bodies
(“bamboo spine”)
(1) Vertical paravertebral ossification
b. Erosion of the vertebrae (“squaring of the vertebral body”)
c. Osteoporosis, disk and apophyseal joint narrowing
3. Occult fractures
a. Occur with minimal trauma
b. Plain radiographs can be difficult to interpret
c. Computed tomography can be hard to interpret because of the
difficulty in obtaining true axial cuts.
d. Magnetic resonance imaging is the most reliable test for occult
fractures and hematoma evaluation.
Figure 22–1 (A) Lateral radiograph of an ankylosing spondylitis patient with severe sagittal plane
imbalance. (B) Anteroposterior radiograph following an L2 pedicle subtraction osteotomy. (C) Lateral
radiograph shows the osteotomy site at L2 with correction of the positive sagittal balance.