Papadopoulos S M, Dickman C A, Sonntag V K
Section of Neurosurgery, University of Michigan, Ann Arbor.
J Neurosurg. 1991 Jan;74(1):1-7. doi: 10.3171/jns.1991.74.1.0001.
Atlantoaxial subluxation in patients with rheumatoid arthritis is common. Operative stabilization is clearly indicated when signs and symptoms of spinal cord compression occur. However, many recommend early operative fusion before evidence of appreciable neural compression occurs because 1) the myelopathy in these patients may be irreversible; 2) the overall prognosis is poor once symptoms of cord compression are present; and 3) the risk of sudden death associated with atlantoaxial subluxation is increased even in asymptomatic patients. The authors believe that rheumatoid arthritis patients in relatively good health without advanced multisystem disease and less than 65 years of age should be considered for operative stabilization if mobile atlantoaxial subluxation is greater than 6 mm. Seventeen patients with severe rheumatoid arthritis and atlantoaxial subluxation treated with a posterior arthrodesis are presented. A new method of fusion, devised by the senior author (V.K.H.S.), was utilized in all cases. Indications for operative therapy in these patients included evidence of spinal cord compression in 11 patients (65%) and mobile atlantoaxial subluxation greater than 6 mm but no signs or symptoms of cord compression in six patients (35%). Thirteen patients developed a stable osseous fusion, two patients a well-aligned fibrous union, one patient a malaligned fibrous union, and one patient died prior to evaluation of fusion stability. The details of the operative technique and management strategies are presented. Several technical advantages of this method of fusion make this approach particularly useful in patients with rheumatoid arthritis. Because of multisystem involvement of this disease, a high rate of osseous fusion is often difficult to achieve.
类风湿性关节炎患者的寰枢椎半脱位很常见。当出现脊髓受压的体征和症状时，手术稳定治疗显然是必要的。然而，许多人建议在出现明显神经受压证据之前尽早进行手术融合，原因如下：1）这些患者的脊髓病可能是不可逆的；2）一旦出现脊髓受压症状，总体预后较差；3）即使是无症状患者，与寰枢椎半脱位相关的猝死风险也会增加。作者认为，身体健康、无晚期多系统疾病且年龄小于65岁的类风湿性关节炎患者，如果活动性寰枢椎半脱位大于6mm，应考虑进行手术稳定治疗。本文介绍了17例严重类风湿性关节炎伴寰枢椎半脱位患者接受后路关节融合术的情况。所有病例均采用了由资深作者（V.K.H.S.）设计的一种新的融合方法。这些患者的手术治疗指征包括：11例患者（65%）有脊髓受压证据，6例患者（35%）有大于6mm的活动性寰枢椎半脱位但无脊髓受压的体征或症状。13例患者形成了稳定的骨融合，2例患者形成了对位良好的纤维性骨连接，1例患者形成了对位不良的纤维性骨连接，1例患者在评估融合稳定性之前死亡。文中介绍了手术技术和管理策略的细节。这种融合方法的几个技术优势使其在类风湿性关节炎患者中特别有用。由于这种疾病累及多系统，往往难以实现高骨融合率。
