C1-2 Instability (Rheumatoid Arthritis)

Contributor:

Dr. Chris Ekong

Consultants:

Dr. Richard Fox
Dr. Joseph Buwembo
Dr. Michael Fehlings
Dr. Daryl Fourney
Dr. Renn Holness
Dr. Derek Fewer
Dr. John Hurlbert
Dr. Stephan duPlessis

Case 13

Age: 74

Sex: Female

History: This lady with severe rheumatoid arthritis had C1-2 wiring and fusion for C1-2 instability in 2000

Wednesday, February 2, 2005 - Dr. Chris Ekong, Neurosurgeon, Regina

She did very well post-operatively until November 2004 when she presented with recurrent neck pain. Examination showed multiple joint deformities but no evidence of spinal cord compression. Cervical spine x-rays and CT showed broken wire and C1-2 instability (5 mm movement between flexion and extension). XRay, CT, and MRI images are shown below.

Wednesday, February 2, 2005 - Dr. Chris Ekong, Neurosurgeon, Regina

Her neck pain is significantly improved with a soft collar. The collar also results in satisfactory reduction of the dislocation at C1-2.

What would you do next in your practice?

Chris

Saturday, February 5, 2005 - Dr. Renn Holness, Neurosurgeon, Halifax

Chris--I am assuming she will be cleared medically - would then get fine cut CTs and CTA to see the vertebral arts. Then plan transarticular screw fixation + fusion.

Renn

Sunday, February 6, 2005 - Dr. Michael Fehlings, Neurosurgeon, Toronto

The patient has a nonunion at C1-C2 with reducible atlantoaxial subluxation. I would revise the C1-C2 fusion with transarticular screw fixation and iliac crest autograft. I would remove the broken wire and fashion a revision Gallie construct to supplement the transarticular screws.

MGF

Monday, February 7, 2005 - Dr. Daryl Fourney, Neurosurgeon, Saskatoon

Chris,

She is Ranawat Class 1 (pain, but no neuological deficit). She has pain from atlantoaxial subluxation, but fortunately there is no basilar impression. From your notes, her subluxation reduces in the neutral position. I would like to see axial CT of C1-2 to get a better look at her lateral masses. It appears from the reconstructed views that she has adeqaute bony stock for either transarticular screws or C1 lateral mass/C2 pars screws. I still prefer the transarticular screws if the amount of bone makes it feasible, because in my hands I have occasionally seen a fair bit of blood loss from the perivertebral venous plexus with the lateral mass screws.

The other thing that sometimes does not permit transarticular screws in older women is a prominent thoracic kyphosis. I do my transarticular screws through a percutaneous access, but a midline opening at C1-2 is still necessary to decorticate the C1-2 joints and to revise the bone graft and cable fusion (I use a Sonntag type cable). A lot of people use BMPs in this situation, but I still use a good iliac crest graft because the Health Region here won't allow purchase of BMPs.

Daryl

Monday, February 7, 2005 - Dr. Chris Ekong, Neurosurgeon, Regina

Thank you for your comments. Our approach was similar.

We removed the broken wire and performed C1 lateral mass screw and C2 pedicle screw fixation and fusion. We used commercial bank bone. She has done well.

http://www.aans.org/education/journal/neurosurgical/jan02/12-1-5.pdf

Chris

Tuesday, February 8, 2004 - Dr. John Hurlbert, Neurosurgeon, Calgary

Dear Chris,

In view of her non-union and continued disabling symptoms I would offer revisional surgery. From the CT and MR sequences I don't believe cranial settling to be an issue at the present time. Indeed, in my experience once a C1/2 fusion is successful the chance of C0/C1 involvement seems significantly reduced.

I would favor a posterior approach to take out the wire and granulation

tissue between C1 and C2. C1/2 transarticular screws augmented by a modified Brooks wiring to hold an interspinous C1/2 tricortical iliac crest graft provides me with >95% fusion rate. If the patient cannot tolerate a post-op collar because of rheumatoid TMJ problems I would place her in a halo.

The issue of vertebral artery ectasia must be considered. However, in our

hands the need to abandon a transarticular screw in a rheumatoid patient is rare.

Chevalier JF, Casha S, Bouchard J, Cho RK, Salo P, DuPlessis SJ, Hurlbert RJ: Vertebral artery ectasia and posterior C1/2 transarticular screw fixation: real or perceived limitations? Canadian Journal of Neurological Sciences 31:S11, 2004

Thanks for asking my input.

John

A Project of The Emmanuel Charitable Foundation