Neurological improvement and prognosis after occipito-thoracic fusion in patients with mutilating-type rheumatoid arthritis

Abstract

Introduction Mutilating-type rheumatoid arthritis, the most aggressive type of rheumatoid arthritis, is frequently associated with destructive cervical involvement, both at the high-cervical and subaxial levels, causing significant neurological deficit, and their natural course of the disease and the survival are discouraging. For such cases, we have been actively performing occipito-thoracic fusion since 1991. Although medical treatment for rheumatoid patients has represented a marked improvement, it could not treat all of these patients because of several reasons. Therefore, it is still important to evaluate the past treatment results. Methods We investigated the neurological improvement and prognosis in 51 mutilating-type rheumatoid arthritis patients who underwent occipito-thoracic fusion between 1991 and 2010. The neurological status was evaluated using modified Ranawat classification; class IIIB was subdivided into IIIBa (able to sit upright) and IIIBb (bedridden). Results The preoperative neurologic status was IIIBa in 19 patients and IIIBb in 17 patients. 15 of the 19 patients with class IIIBa improved to being able to walk (79 %), whereas only 3 of the 17 patients with class IIIBb improved to being able to walk (18 %) after surgery. Of the 51 patients, 28 died during follow-up; the mean age at death was 67.2 years. The postoperative 5-and 10-year survival rates were 60.3 and 26.4 %, respectively. Conclusion The neurological improvement and prognosis after surgery was poorer in class IIIBb patients than in the other patient groups. Occipito-thoracic fusion can improve the neurological symptoms and prognosis. However, early surgical intervention is recommended, before a patient becomes bedridden (class IIIBb).

Occipitosacral Fusion for Multiple Vertebral Fractures with Kyphotic Deformity in a Patient with Mutilating Rheumatoid Arthritis: A Case Report

“…For such severe destructive cervical disorders, we have performed O-T fusion and reported clinical results and complications. 11,12 In our previous report, distal vertebral fractures were most frequent complication, and most of distal vertebral fractures were cured by conservative treatment like this patient.…”

Adjacent-level failures after occipito-thoracic fusion for rheumatoid cervical disorders

“…In this surgery, the occipitocervical motion was completely lost. In our previous report [5], adjacent-level failures were the most frequent complications after occipito-thoracic fusion. Since we had started to apply occipito-thoracic fusion, other compilations had decreased, contrasting with increased adjacentlevel failures [6].…”

“…In our previous report [5], adjacent-level failures were the most frequent complications after occipito-thoracic fusion. Since we had started to apply occipito-thoracic fusion, other compilations had decreased, contrasting with increased adjacentlevel failures [6]. In this study, we therefore evaluated the incidence and risk factors of adjacent-level failures after occipito-thoracic fusion for rheumatoid cervical disorders.…”

“…PS pedicle screw, MTH multiple thoracic hooks Fig. 1 Schema of multiple thoracic hooks (Reprinted from [5]). multiple thoracic hooks are combination of transverse hooks and facet hooks.…”

“…In addition, even in patients with the more erosive subset (MES) and with the less erosive subject (LES), additional surgery is sometimes necessary due to new cervical and/or upper thoracic involvements after atlanto-axial or occipito-cervical fusion [4]. In these cases, we had actively performed occipitothoracic fusion since 1991 [5]. In this surgery, the occipitocervical motion was completely lost.…”