Chieng Lee Onn, Madhavan Karthik, Vanni Steven
Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.
Neurosurg Focus. 2015 Apr;38(4):E18. doi: 10.3171/2015.1.FOCUS14838.
Rheumatoid arthritis (RA) is one of the most debilitating autoimmune diseases affecting the craniovertebral junction (CVJ). Patients predominantly present with myelopathic symptoms and intractable neck pain. The surgical approach traditionally has been either a combined anterior and posterior approach or a posterior-only approach. In this article, the authors review pooled data from the literature and discuss the benefits of the two types of approaches.
A search of the PubMed database was conducted using key words that describe spine deformities in RA and specific spinal interventions. The authors evaluated the neurological outcomes based on the Ranawat scale in both the groups through chi-square analysis. Multiple logistic regression was carried out to further examine for potential confounders. Any adverse sequalae resulting from either approach were also documented. Because all the procedures performed via a transoral approach in the analyzed articles also involved posterior fixation, for convenience of comparison, the combined procedures are referred to as "anterior approach" or "anterior-posterior" in the present study.
The search yielded 233 articles, of which 11 described anterior approaches and 14 evaluated posterior approaches. The statistical analysis showed that patients treated with a posterior approach fared better than those treated with an anterior (combined) approach. It was noted that those patients in whom the cervical subluxations were reducible on traction predominantly underwent posterior approaches.
CVJ instability is a serious complication of RA that requires surgical intervention. Although the anterior-posterior combined approach can provide direct decompression, it is associated with morbidity, and the analysis showed no statistically significant benefit to patients. In contrast, the posterior approach has been shown to provide statistically significant superiority with respect to stabilization and subsequent pannus reduction. Surgical approaches are undertaken based on the reducibility of subluxations with traction and the vector of compressive force. However, the choice of surgical approach should be based on the individual patient's pathology.
类风湿关节炎（RA）是影响颅颈交界区（CVJ）的最具致残性的自身免疫性疾病之一。患者主要表现为脊髓病症状和顽固性颈部疼痛。传统的手术方法是前后联合入路或单纯后入路。在本文中，作者回顾了文献中的汇总数据，并讨论了这两种手术方法的益处。
使用描述RA脊柱畸形和特定脊柱干预措施的关键词在PubMed数据库中进行检索。作者通过卡方分析评估了两组基于Ranawat量表的神经学结果。进行多因素逻辑回归以进一步检查潜在的混杂因素。还记录了两种手术方法引起的任何不良后遗症。由于分析文章中所有经口入路的手术也都涉及后路固定，为便于比较，本研究中将联合手术称为“前路手术”或“前后联合手术”。
检索共获得233篇文章，其中11篇描述了前路手术，14篇评估了后路手术。统计分析表明，接受后路手术的患者比接受前路（联合）手术的患者预后更好。值得注意的是，那些牵引下颈椎半脱位可复位的患者主要接受后路手术。
CVJ不稳定是RA的一种严重并发症，需要手术干预。虽然前后联合入路可以提供直接减压，但它与发病率相关，且分析显示对患者没有统计学上的显著益处。相比之下，后路手术已被证明在稳定和随后减少血管翳方面具有统计学上的显著优势。手术方法根据牵引下半脱位的可复性和压缩力的方向来选择。然而，手术方法的选择应基于个体患者的病理情况。
