Kim David H, Hilibrand Alan S
Department of Orthopaedic Surgery, Tufts University School of Medicine, Boston, MA, USA.
J Am Acad Orthop Surg. 2005 Nov;13(7):463-74. doi: 10.5435/00124635-200511000-00006.
The cervical spine often becomes involved early in the course of rheumatoid arthritis, leading to three different patterns of instability: atlantoaxial subluxation, atlantoaxial impaction, and subaxial subluxation. Although radiographic changes are common, the prevalence of neurologic injury is relatively low. The primary goal of treatment is to prevent permanent neurologic injury while avoiding potentially dangerous and unnecessary surgery. Strategies include patient education, lifestyle modification, regular radiographic follow-up, and early surgical intervention, when indicated. Magnetic resonance imaging is indicated when neurologic deficit (myelopathy) occurs or when plain radiographs show atlantoaxial subluxation with a posterior atlantodental interval < or =14 mm, any degree of atlantoaxial impaction, or subaxial stenosis with a canal diameter < or =14 mm. Surgery should be considered promptly for any of the following: progressive neurologic deficit, chronic neck pain in the setting of radiographic instability that does not respond to nonnarcotic pain medication, any degree of atlantoaxial impaction or cord stenosis, a posterior atlantodental interval < or =14 mm, atlantoaxial impaction represented by odontoid migration > or =5 mm rostral to McGregor's line, sagittal canal diameter <14 mm, or a cervicomedullary angle <135 degrees.
颈椎常于类风湿关节炎病程早期受累,导致三种不同类型的不稳定:寰枢椎半脱位、寰枢椎撞击和下颈椎半脱位。虽然影像学改变很常见,但神经损伤的发生率相对较低。治疗的主要目标是预防永久性神经损伤,同时避免潜在危险和不必要的手术。策略包括患者教育、生活方式改变、定期影像学随访以及在有指征时进行早期手术干预。当出现神经功能缺损(脊髓病)或平片显示寰枢椎半脱位且寰齿后间隙≤14 mm、任何程度的寰枢椎撞击或椎管直径≤14 mm的下颈椎狭窄时,应进行磁共振成像检查。出现以下任何一种情况时应立即考虑手术:进行性神经功能缺损、影像学不稳定情况下对非麻醉性止痛药物无反应的慢性颈部疼痛、任何程度的寰枢椎撞击或脊髓狭窄、寰齿后间隙≤14 mm、齿状突相对于麦格雷戈线向头侧移位≥5 mm所代表的寰枢椎撞击、矢状径椎管直径<14 mm或颈髓角<135度。