風(fēng)濕關(guān)節(jié)炎頸椎英文版

1、風(fēng)濕關(guān)節(jié)炎頸椎英文版Cervical spine instability in rheumatoid arthritis(RACSI)AbbreviationsCS 頸椎A(chǔ)AS 寰樞椎脫位CrS 顱底凹陷癥SAS 下頸椎脫位AADI 寰齒前間隙PADI 寰齒后間隙CMA 延髓脊髓角SSCD下椎管直徑 Introduction1、High incidence: 85% in the patients with RA CS is the most commonly involved segment , after hands and feet. 2、Severe sequelae: Neurolo

2、gic decits even sudden death Introduction3、Difficult to diagnosis： Asymptomatic Similar to peripheral diseases4、Difficult to treatment: Poor conservative treatment The optimal timing for surgery Pathophysiology1、 The same process that affects the peripheral joints in patients with RA also affects th

3、e neck. destroy 2、 pannuschronic synovitisligaments, tendons, cartilage and boneRACSIPathophysiology3、 Patterns of instability：atlantoaxial subluxation (AAS) 65%cranial settling (CrS) 20%subaxial subluxation (SAS) 15-25% PathophysiologyAASa4mm，b11SASPathophysiologylarge range of motion 4、 UCSpurely

4、synovial jointsPathophysiologyPathophysiologyNatural history benign clinical coursefrequently progressive potentially devastatingNonoperative treatment did not prevent progression of existing cervical disease.Myelopathic patients treated conservatively have poor functional recovery and low survival

5、rates.Natural history Yurube : 140 patients with RA, in 5 years, 43.6 % cervical instabilities, 12.9 % severe.Pellici : 106 patients with RACSI, over 5 years and found progression of radiologic ndings in 80 % of patients and neurologic deterioration in 36 %. Matsunaga : Myelopathic patients without

6、surgical intervention, 76 % of patients had neurologic deterioration, being bedridden in 3 years after the onset of the myelopathy.Crockard and Grob: If left untreated, 50 % of myelopathic patients die within 1 year. Clinical manifestations1 、Cervicalsymptoms： The most common and earliest ndings but

7、 nonspecicNeck painHeadacheOccipital neuralgiaClinical manifestations2 、 Myelopathy ： difficulttodiagnose due to the peripheral RApathologic reflexclumsiness of the handgait disturbances sensation of heaviness or fatigability in the legs Clinical manifestations3、 Vertebrobasilar insufciency ： vertig

8、o, syncope, tinnitus, nauseaImaging studies PADI： predictive value. PADI14mm, neurologic abnormalitiesa=AADI, b=PADIImaging studies CMA：135， vertical settling and myelopathy. a= CMA cervicomedullary angleaImaging studies SSCD： 10mm,abnormal. 6mm,predictive value.a=SSCDaImaging studies1、Plain X-rays

9、remain the initial imaging modality of choice in RA patients. 2、MRI allows a more correct determination than the X-rays, since it measures the pannus size in the canal. Conservative treatment versus surgerySurgery contributes to prolonging the life span of rheumatoid patients with myelopathy . Conse

10、rvatively treated patients have a much higher mortality rate and a lower probability of neurologic improvement. If surgery is not taken in consideration, progression of neurologic decits is expected.Conservative treatment versus surgeryRanawat classication of rheumatoid myelopathyClass IClass IIClas

11、s IIIAClass IIIBNeurologically intactSubjective weaknessObjective weaknessQuadriparesisHyperreexia and dysesthesiaLong tract signsNonambulatoryAmbulatoryConservative treatment versus surgeryRanawat classication of rheumatoid myelopathyClass IClass IIClass IIIAClass IIIB無神經(jīng)功能障礙主觀虛弱客觀虛弱四肢癱瘓腱反射亢進(jìn)感覺異常長(zhǎng)束

12、征不能行走能行走Conservative treatment versus surgery Ranawat I and II： both treatments have a good neurologic outcome and survival.Ranawat IIIA and IIIB ： mortality appears to be common for both treatments.Conservative treatment did not prevent progression of cervical disease.Surgery ：a chance of neurologi

13、c improvement.Conservative treatment versus surgeryCasey :Three of the Class IIIB patients chose not to proceed with surgery and all of them died within 6 months.Sunahara: No survivors in patients who developed myelopathy and were treated conservatively for up to 7 years.Nannapaneni :follow-up of 39

14、 months, 56 % of class IIIB patients were able to ambulate after surgery.Surgical indicationsGoals: Relieve neural compression, Achieve stabilization of affected segments, Reduce pannus, Improve pain.Surgical indicationsAbsolute surgical indications : AAS with intractable pain AAS with neurologic de

15、cits Severe CrSSurgical indicationsControversy：Signicant cervical instability or subluxationWithout neurologic decit and with minimal pain. What can we doSurgical indicationsShen ：PADI 14 mmSAC 13 mmSSCD 6 mmCMA 14 mmObservationSurgery as a prophylactic procedureNo consensus on the optimal timing fo

16、r surgical intervention（1）Unpredictability of radiologic progression. （2）The poor correlation between AADI and the development of neurologic signs.（3） Neurologic abnormalities are notoriously difcult to establish.Surgery as a prophylactic procedureRecommend early surgical intervention （1） Prophylact

17、ic surgery is a valid option in an asymptomatic patient. （2） Operation for patients with myelopathy is recommended.ConclusionsRACSI： Signicant morbidity and mortality. Myelopathic： The rate of longterm mortality increases and the chance of neurologic recovery decreases.ConclusionsRecommend early and aggressive surgical intervention ： avoid cervical spine deterioration, preserve remaining function and prevent further n