McRorie E R, McLoughlin P, Russell T, Beggs I, Nuki G, Hurst N P
Rheumatic Diseases Unit, Western General Hospital, Edinburgh, United Kingdom.
Ann Rheum Dis. 1996 Feb;55(2):99-104. doi: 10.1136/ard.55.2.99.
To review the outcome of surgery undertaken to stabilise the neck in patients with rheumatoid arthritis performed over a five year period, to compare the results with those of previous reports, and to identify factors that may predict surgical outcome.
Outcome was assessed at time of discharge from hospital after surgery by review of patients' notes, and at follow up by patient interview, clinical examination, anonymous questionnaire, and cervical spine radiograph. The Ranawat classification of neurological impairment and Steinbrocker functional classification were used.
Thirty nine patients underwent 44 procedures; 28 patients were available for review after a mean period of 29.8 months (range 12-65 months). Fourteen patients had preoperative neurological impairment and were available for follow up; 13 returned the questionnaire. Four (29%) had improved Ranawat class, nine were unchanged, and one had deteriorated. Nine (69%) reported a subjective improvement in neurological symptoms by questionnaire, even though the Ranawat class was unchanged in five. Twenty five of the patients reviewed had pain before operation; 21 returned the questionnaire. Pain relief was reported by direct questioning and questionnaire in 76% and 67% of patients, respectively. Overall, 67% felt that surgery had been successful. Surgery was more successful in producing symptomatic relief in patients with neck or radicular pain than in those with neurological deficit, but did prevent progression of neurological symptoms.
Our results are similar to those from other centres. Overall patient satisfaction with surgery was good. Surgery was more likely to produce symptomatic relief in patients with neck or radicular pain before operation than in those with neurological deficit. The greater subjective improvement in neurological symptoms as judged by questionnaire probably reflects the relative insensitivity of the Ranawat classification in detecting change in neurological status; previous reports of poor outcome for patients with neurological symptoms who undergo surgery may in part be a reflection of the insensitivity of this method of assessment. No clear factors emerged which allowed prediction of those patients at greatest risk of operative mortality. In particular, an increased risk of neurological compromise appeared to confer no additional risk of immediate perioperative death. Our data support the suggestion that early surgery to correct symptomatic atlantoaxial subluxation may prevent progression of instability.
回顾过去五年中为类风湿关节炎患者进行颈部稳定手术的结果，与既往报告的结果进行比较，并确定可能预测手术结果的因素。
术后出院时通过查阅患者病历评估结果，随访时通过患者访谈、临床检查、匿名问卷调查和颈椎X线片进行评估。采用拉纳瓦特神经功能障碍分类法和斯坦布罗克功能分类法。
39例患者接受了44次手术；平均29.8个月（12 - 65个月）后，28例患者可供复查。14例患者术前存在神经功能障碍并可供随访；13例返回了问卷。4例（29%）拉纳瓦特分级改善，9例无变化，1例恶化。9例（69%）通过问卷调查报告神经症状有主观改善，尽管其中5例拉纳瓦特分级无变化。接受复查的患者中有25例术前有疼痛；21例返回了问卷。分别有76%和67%的患者通过直接询问和问卷调查报告疼痛缓解。总体而言，67%的患者认为手术成功。手术缓解颈部或神经根性疼痛患者的症状比缓解神经功能缺损患者的症状更成功，但确实预防了神经症状的进展。
我们的结果与其他中心的结果相似。总体而言，患者对手术的满意度良好。手术缓解术前颈部或神经根性疼痛患者症状的可能性大于缓解神经功能缺损患者。问卷调查显示神经症状有更大的主观改善，这可能反映了拉纳瓦特分级在检测神经状态变化方面相对不敏感；既往关于神经症状患者手术效果不佳的报告可能部分反映了这种评估方法的不敏感性。没有明确的因素能够预测哪些患者手术死亡风险最高。特别是，神经功能损害风险增加似乎并未带来额外的围手术期即刻死亡风险。我们的数据支持早期手术纠正症状性寰枢椎半脱位可能预防不稳定进展这一观点。
