Wolfs Jasper F C, Kloppenburg Margreet, Fehlings Michael G, van Tulder Maurits W, Boers Maarten, Peul Wilco C
Leiden University Medical Center, Leiden, The Hague, The Netherlands.
Arthritis Rheum. 2009 Dec 15;61(12):1743-52. doi: 10.1002/art.25011.
Rheumatoid arthritis commonly involves the upper cervical spine and can cause significant neurologic morbidity and mortality. However, there is no consensus on the optimal timing for surgical intervention: whether surgery should be performed prophylactically or once neurologic deficits have become apparent.
A systematic review of the literature was performed to analyze neurologic outcome (Ranawat) and survival time (Kaplan-Meier) after surgical or conservative treatment using the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation system) criteria.
Twenty-five observational studies were selected. No randomized controlled trials (RCTs) could be found. All of the studies had a high risk of bias. Twenty-three studies reported the neurologic outcome after surgery for 752 patients. Neurologic deterioration rarely occurred in Ranawat I and II patients. Ranawat III patients did not fully recover. The 10-year survival rates were 77%, 63%, 47%, and 30% for Ranawat I, II, IIIA, and IIIB, respectively. The Ranawat IIIB patients had a significantly worse outcome. Another 185 patients treated conservatively were described in 7 studies. Neurologic deterioration rarely occurred in Ranawat I patients, but was almost inevitable in Ranawat II, IIIA, and IIIB patients. The Kaplan-Meier analysis showed a 10-year overall survival rate of 40%.
There are no RCTs that compared surgery with conservative treatment. In observational studies, surgical neurologic outcomes were better than conservative treatment in all patients with cervical spine involvement, and in asymptomatic patients with no neurologic impairment (Ranawat I) the outcomes were similar; however, the evidence is weak. Survival time of surgical and conservative treatment could not be compared.
类风湿关节炎常累及上颈椎，可导致严重的神经功能障碍和死亡。然而，对于手术干预的最佳时机尚无共识：手术应预防性进行还是在神经功能缺损明显时进行。
采用MOOSE（流行病学观察性研究的Meta分析）和GRADE（推荐分级、评估、制定与评价系统）标准，对文献进行系统回顾，分析手术或保守治疗后的神经功能结局（Ranawat分级）和生存时间（Kaplan-Meier法）。
选取了25项观察性研究。未找到随机对照试验（RCT）。所有研究均有较高的偏倚风险。23项研究报告了752例患者手术后的神经功能结局。Ranawat I级和II级患者很少发生神经功能恶化。Ranawat III级患者未完全恢复。Ranawat I级、II级、IIIA级和IIIB级患者的10年生存率分别为77%、63%、47%和30%。Ranawat IIIB级患者的结局明显更差。7项研究描述了另外185例接受保守治疗的患者。Ranawat I级患者很少发生神经功能恶化，但Ranawat II级、IIIA级和IIIB级患者几乎不可避免。Kaplan-Meier分析显示10年总生存率为40%。
尚无比较手术与保守治疗的RCT。在观察性研究中，对于所有颈椎受累患者，手术的神经功能结局优于保守治疗，对于无症状且无神经功能损害的患者（Ranawat I级），结局相似；然而，证据不足。无法比较手术和保守治疗的生存时间。
