Spine Surgery for Rheumatoid Arthritis.
Edited By: Jens R. Chapman, M.D.
Last updated Wednesday, December 29, 2004
Review of the conditionCharacteristics of rheumatoid arthritis of the spine As with any joint in the body, the small joints of the spine can be
destroyed by rheumatoid arthritis. This can lead to instability, pain
and in advanced cases to compression of the spinal cord and nerve roots
emerging from it. This occurs most commonly in the upper neck, but may
affect the lower neck or lower back as well.Incidence and risk factors One in five to one in three patients with RA have spinal involvement.Diagnosis Aside from a physical examination, which includes assessment of the
patient’s neurologic function, radiographs (X-rays) are obtained. These
usually include neck X-rays in which the patient is first asked to bend
their head forward, then backward. Obviously, if the patient has
symptoms in other areas of the spine, X-rays of other areas of the
spine may have to be obtained as well. If these X-rays show reason for
concern an MRI scan will usually be ordered next. Sometimes, a CAT scan
(CT) or Bone-scan may be added.Medications In early stages of RA, anti-inflammatory medications can be effective
in decreasing pain and may slow the progression of joint destruction
caused by RA.Exercises Once joint destruction of the spine has set in, there are no
specific exercises that can stop or arrest the development of spinal
instability. Maintenance of a normal body posture and a low-impact
exercise program are necessary to avoid severe secondary problems, such
as spontaneous spine fractures and maintain reasonable levels of
cardiopulmonary fitness. Chiropractic manipulation of RA patients with
spinal involvement is, however, clearly contraindicated due to the risk
of causing spinal instability to worsen. Cases of paralysis after spine
manipulation have been reported.
Possible benefits of spine surgery for rheumatoid arthritis Spine surgery can improve the quality of life of an affected RA patient in several major ways:
- By resecting a diseased joint and creating a
permanent bond between the affected vertebrae (in a procedure referred
to as "fusion"), rheumatoid arthritis and its related symptoms are
extinguished from that area.
- Restoration of a normal spinal alignment prevents deterioration of basic vital functions, such as cardiopulmonary fitness.
- Stabilization
and, if necessary, realignment of the spine can protect the patient’s
spinal cord from potentially catastrophic injury.
- Decompression
of compromised nerves can decrease pain, halt progressive loss of nerve
function and may even lead to improved function.
Who should consider spine surgery for rheumatoid arthritis? RA patients who have unrelenting pain, experience loss of neurologic
function, such as dexterity in hands and feet, or have progressive loss
of spine stability as shown on X-rays should consider such surgery.What happens without surgery? The best case scenario includes ocasional neck and back pain
necessitating anti-inflammatory medication use and soft neck collar
with the patient maintaining an active life-style.
A worst case scenario might be sudden death through acute spinal cord compression in an area right below the skull. Surgical options Stabilization of the spine may be necessary in areas where the
arthritis has led to unacceptable pain and instability. Such a
procedure ("fusion") is nowadays carried out with resection of the
involved joint, placement of a small bone graft taken from the pelvis
into the former joint and stabilization with small titanium screws,
rods and plates.Effectiveness Once a solid fusion is obtained, the results are permanent. Eighty-five
per cent of RA patients with fusions report good or excellent relief of
their preoperative symptoms.Urgency Should a spinal cord or nerve compression be manifest, surgical care
should be considered with urgency (within weeks). In absence of
neurologic concerns, a patient with RA can be followed serially with
X-rays and examinations on an annual or semi-annual basis.Risks The most common risks of spine surgery in RA historically were
surgical wound infections and failure of the spinal hardware to provide
adequate stability to the spine. With the advent of modern spinal
instrumentation systems and improved understanding of medical care
needs of RA patients, these occurrences have dramatically decreased.
One in ten patients with a spine fusion performed ten years or more
ago may experience increased pain in their spine due to instability at
a level below a fusion. If this is noticed the previous fusion may have
to be extended to include the newly affected levels. Managing risk Surgical wound infections or hardware failures may require repeat
surgery. Infections will also require intravenous antibiotics given for
several weeks.Costs For the University of Washington systems please contact the Spine Care patient coordinators:
- Diane Maguire: (206) 598-4290
- Sue Stone: (206) 731-2331
Surgical team Spine surgery in a patient with RA requires an experienced,
fellowship trained spine surgeon, either from an Orthopaedic Surgery or
Neurological Surgery background. The resources of a large hospital with
immediate access to multiple specialties and an in-house MRI scan are
important due to the potential complexities of care that patients with
RA may encounter.
Finding an experienced surgeon Contact:
- MEDCON (206) 543-5300
- American Academy of Orthopaedic Surgeons: 1 800 346 AAOS
- Washington State Medical Society: (206) 441-9762. Will connect to local County Medical Society.
Facilities A large hospital, usually with academic affiliation and equipped with
state of the art radiologic imaging equipment and Intensive Medicine
Care Unit, is clearly preferable in the care of patients with spinal RA.Technical details The surgeon will expose the affected area of the spine through an
incision in the back or occasionally in the front of the neck. Using a
high-speed dental-type drill the diseased joints of the spine are then
resected. A small bone graft is removed from the patient’s pelvis
through a separate incision. Occasionally, bone graft substitutes
derived from non-organic sources can be used instead. Under digital
fluoroscopy (a form of "live" X-rays) precision drill holes are then
placed into specific bony sections of the spine. These are then filled
with small titanium screws and connected with rods or plates.
Occasionally a supplemental cable is placed between adjacent bone
segments to secure a bone graft. Should the spinal cord or nerves need
to be decompressed, this is then usually performed under a microscope
with specialized microscopic instruments. A meticulous skin closure is
then performed to ensure rapid wound healing. Usually, a patient can
then be mobilized within a day from surgery using a neck collar.
Occasionally, patients with very poor bone stock (such as osteoporosis)
may require immobilization with a Halo and vest (a graphite ring placed
around the head and secured with posts to a body vest).Anesthetic A general anesthetic is essential for this type of surgery.Length of spine surgery for rheumatoid arthritis Depending upon the number of levels to be fused and complexities of
decompression of neurologic structures, surgery takes between 2 and 8
hours.
Pain and pain management Typically, the first two days after surgery can be quite painful to
patients with spine fusion surgery. Therefore patients are usually
given intravenous patient controlled analgesia machines. These
programmable machines supply pain medication to a patient
automatically, yet allow the patient to add further doses if needed
within safe limits. After the first 2 days patients usually require
oral pain medication for 2 to 12 weeks.Hospital stay Patients with complex spine surgery or multiple medical problems
usually are observed in an Intensive Care Unit for 1-2 days. A hospital
stay of 3-7 days is usually necessary.
Recovery and rehabilitation in the hospital Patients are usually mobilized into an upright position or even out
of the bed towards the end of the Intensive Care Unit stay. Patients
are returned to most regular activities of daily living within 3 – 5
days.
Hospital discharge Spine fusion patients are usually asked to wear a supportive and
protective neck brace for 2-3 months after surgery. These braces should
usually be worn around the clock. We strongly recommend an early return
to a light aerobic conditioning program.Convalescent assistance We recommend help with showering, domestic maintenance, such as
cooking and utilization of a driver for a minimum of 3 weeks, sometimes
more.
Surgery for Rheumatoid arthritis of the spine at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-6293 to make an appointment.
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