Trauma in Patients with Rheumatoid Arthritis of the Cervical Spine

h1 class=”calibre8″>18 Trauma in Patients with Rheumatoid Arthritis of the Cervical Spine

Joseph D. Smucker and Rick C. Sasso

Abstract

Patients with rheumatoid arthritis (RA) have a predisposition to nontraumatic cervical spine disorders and neurological concerns that may result from these changes. With improvements in medical treatment of RA, the incidence of significant cervical spine involvement appears to be declining and/or may be less significant when present. Medical management of RA may predispose this patient population to unique challenges that may necessitate unique perioperative morbidity related to wound healing, instrumentation placement and bone quality, healing of arthrodesis, and bracing requirements. Nonsurgical and surgical management of traumatic injuries in the cervical spine must account not only for the nature of the traumatic concern, but also baseline changes in the cervical spine related to RA and ongoing medical management of RA. With careful consideration of the patient and these principles, successful management of traumatic injuries in the cervical spine can be effectively accomplished.

Keywords: cervical spine, trauma, rheumatoid arthritis, nonoperative management, operative management, spinal instrumentation, case examples

18.1 Introduction

Over past two decades, treatment of rheumatoid arthritis (RA) has advanced to a degree that has allowed less frequent involvement of cervical spine pathology in RA patients. ¹^,² While patients with RA always benefit from careful consideration with respect to cervical spine concerns, neck pain, and neurological issues, many of the former concerns with this disease process were nontraumatic in nature and were more frequently related to the progressive changes associated with the inflammatory rheumatologic concern. ²

RA does predispose patients to cervical spine concerns including C1–C2 instability, subaxial spondylolisthesis, pannus formation, destructive joint disease, diminished bone quality, and nontraumatic cervical radiculopathy, and/or cervical myelopathy. ¹^,²^,³^,⁴^,⁵^,⁶^,⁷ In addition, treatments for RA have a potential to create negative effects on the patient’s bone health, soft-tissue healing characteristics, bone healing characteristics, and perioperative morbidity. ¹^,⁸^,⁹ For this reason, any surgical intervention on a patient with RA does have the potential for increased morbidity either secondary to the disease process or to the treatment of the disease process over time. These same characteristics, therefore, affect a surgeon’s consideration of treatment of a patient with a traumatic lesion to the cervical spine who has baseline RA.

Despite the potential for decreasing rheumatoid cervical spine lesions with medical management over time, a physician evaluating a patient with a history of RA must recognize the difference between baseline rheumatologic cervical spine disease and acute traumatic lesions. ²^,³^,⁵^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴ In addition, subsequent treatment must take into consideration the potential for increased morbidity in this unique patient population.

18.2 Incidence of Injury

To the authors’ knowledge, there has been no definitive account of the incidence of traumatic cervical spine injuries in patients who also have RA. It is appropriate to consider these two populations’ patients as intersecting only with a potential traumatic event. It is, therefore, incumbent upon evaluating health care providers to obtain an appropriate patient history including past medical history and medication history, in addition to the standard trauma history that accompanies a recent history of injury. ¹^,²^,³^,⁵^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵ This has the potential to affect not only the treating physicians, but also those who are involved in interpreting radiographic studies and assessing the potential for perioperative risk, including the risk of infection and anesthesia risks and complications.

18.3 Patient Assessment

The assessment of the cervical spine in the setting of trauma has been well described. ¹⁶^,¹⁷^,¹⁸^,¹⁹^,²⁰^,²¹^,²²^,²³ Assessments of patients with a history of RA require a similar, prescribed, workup. ³^,⁴^,⁵^,¹⁴ This includes a thorough history, a comprehensive physical examination, and appropriate radiographic evaluation. Computed tomography (CT) imaging of the spine has increased the sensitivity and specificity of diagnosis of traumatic cervical spine injury in the acute setting. This same imaging technology is appropriate for an initial assessment of patients with RA as well. However, a negative CT scan may not be appropriate for final assessment or exclusion of injury in patients with trauma and a history of RA. Consideration of dynamic CT examinations may be of importance in this unique population of patients. ²⁴ Rheumatoid concerns in the cervical spine are well known to produce compressive pathology including the possibility of retrodental pannus. ⁶ In addition, spondylolisthesis maybe underappreciated on supine imaging, or CT only imaging. A low threshold for magnetic resonance imaging (MRI) and awake, active, upright dynamic radiographs should be present in a patient with trauma and known RA. Patients with new or increased neck pain should always be carefully screened both clinically and radiographically as part of a complete spine workup. In the context of RA, the threshold for consultation of a spine specialist may be diminished in this same, unique, patient population. ¹^,³^,¹¹^,²⁵ For example, the difference between rheumatologic instability at C1–C2 and traumatic instability may be difficult to distinguish in even the most skilled hands. ²⁴^,²⁶ Serial follow-up and appropriate initial immobilization may be the key to safe patient care following the index injury.

Outside of imaging assessments, repeat clinical and neurological assessments have a potential to play a key role in patients with traumatic injuries. Distracting injuries should be successfully treated and appropriately managed prior to full clearance of the cervical spine in this unique patient population. In addition, if rheumatoid pathology is discovered in the cervical spine, this may play a role in anesthesia care and careful intubation, even if no traumatic injury is ultimately identified in the cervical spine. ²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²^,³³

18.4 Nonoperative Management

Nonoperative management of patients with cervical spine trauma and RA is directed in accordance with the potential for bone healing. ⁴^,³⁴ If no traumatic injury is identified yet patients continue to have cervical spine pain, clearance in the Emergency Department or hospital setting may not be indicated in this patient population. In this circumstance, delayed dynamic radiographs at the discretion of a spine-care specialist are often considered, even to complement a normal appearing CT or MR scan.

Discontinuation of cervical immobilization may proceed at the discretion of the treating physician when acute, dynamic instability has been effectively ruled out. This may be a difficult threshold to reach. If the patient has baseline pain, new or increased pain must be carefully evaluated. Acute, muscular injury/strain or “whiplash” is a diagnosis of exclusion rather than an assumption in all patients. This is especially true in patients with RA. A concerted effort should be made in this circumstance to identify any former imaging that may have been performed in a patient with trauma, prior to the traumatic event. This has the potential to differentiate an acute injury from baseline concerns. Awake patient assessments over time are also critical to immobilization discontinuation and progression to additional nonsurgical care.

In the absence of an acute fracture and at the exclusion of an acute ligamentous instability, gentle and active (nonpassive, nonmanipulative) physical therapy and close clinical assessments may proceed with a focus on appropriate pain management and nonsteroidal anti-inflammatory drug (NSAID) utilization. Certain medications may be excluded from consideration based upon the patient’s innate risk for medication-induced complications and baseline use of NSAIDS. Serial assessments of progress are made over time in the clinical setting, and time can allow for improvement in patient-reported pain and function.

Clinical and/or radiographic follow-up of patients may be discontinued when pain has returned either to baseline or has resolved, and when function has returned to baseline and neurological assessments have remained stable. Coordination and communication with the patient’s rheumatologist is critical over the course of posttrauma treatment and at the time of discontinuation of posttrauma follow-up. Patient education and communication remains critical in continued index suspicion for a new concern over time.

18.5 Operative Management

With very few exceptions, operative treatment of traumatic injuries in the cervical spine in patients with RA is similar in principle and design to treatment of patients with cervical spine trauma in the absence of RA. Modern cervical instrumentation has revolutionized the treatment of patients with cervical spine disorders including patients with cervical trauma, rheumatologic diseases of the cervical spine, and degenerative diseases of the cervical spine (▶ Fig. 18.1). Moving beyond single plane wiring techniques, multipoint posterior screw/rod fixation systems using the novel screw placement is now the standard of care. Anterior only versus anterior/posterior treatment is of consideration in all patients, but may be especially important to consider in patients with diminished bone quality or bone healing potential. Posterior instrumentation currently includes consideration of powerful fixation techniques such as pedicle screw placement, translaminar screw placement, and C1 lateral mass screw fixation. The cranial and caudal aspects of instrumentation must be especially secure in this patient population. Attachment of these novel bone/screw techniques to a vertical, rod-based stabilization system is currently facilitated by modern instrumentation systems by way of polyaxial screw heads, novel offset connection systems, articulated vertical rod and screw systems, prebent vertical rod systems, multidiameter rod systems, and improved surgical techniques. Computer-assisted spinal navigation has revolutionized the surgeon’s understanding of cervical spine anatomy, traumatic injury anatomy, and instrumentation placement.

$Operative treatment of a traumatic fracture of the dens/C2 is identified on radiographs and reduction was accomplished in a patient with baseline rheumatoid arthritis. Treatment was performed with a s$

Fig. 18.1 Operative treatment of a traumatic fracture of the dens/C2 is identified on radiographs and reduction was accomplished in a patient with baseline rheumatoid arthritis. Treatment was performed with a single odontoid screw technique resulting in initially diminished pain but, progressing later to pseudoarthrosis.

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