title: Surgery on the rheumatoid cervical spine for the non-ambulant myelopathic patient-too much, too late?
abstract: BACKGROUND
  Opinions differ on the timing of surgery for rheumatoid arthritis patients with atlanto-axial subluxation. Some clinicians wait for development of neurological signs; others favour prophylactic fusion and decompression. We examined the results of surgery in relation to neurological state at the time of operation.
  
  
  METHODS
  134 patients underwent surgery for rheumatoid involvement of the cervical spine, after development of objective signs of myelopathy. Surgical outcomes were examined prospectively in two groups-patients who were still ambulant at the time of presentation (Ranawat class III A) and patients who had lost the ability to walk (Ranawat class III B)-by means of neurological and functional grading systems in conjunction with standard measures of postoperative morbidity and mortality.
  
  
  RESULTS
  58% of the ambulant patients attained Ranawat neurological grades I or II compared with only 20% of the non-ambulant patients (p<0.0001). The non-ambulant group also fared worse in terms of postoperative complication rate, length of hospital stay, functional outcome, and ultimately survival. Radiologically, the non-ambulant patients were characterised by a smaller cross-sectional spinal cord area.
  
  
  CONCLUSIONS
  The strong likelihood of surgical complications, the poor survival, and the limited prospects for functional recovery in non-ambulant patients make a strong case for earlier surgical intervention. At a late stage of disease most patients will have irreversible cord damage.
authors.affiliation: Department of Surgical Neurology, London, UK.
authors.forename: A T
authors.initials: AT
authors.lastname: Casey
authors.forename: H A
authors.initials: HA
authors.lastname: Crockard
authors.forename: J M
authors.initials: JM
authors.lastname: Bland
authors.forename: J
authors.initials: J
authors.lastname: Stevens
authors.forename: R
authors.initials: R
authors.lastname: Moskovich
authors.forename: A O
authors.initials: AO
authors.lastname: Ransford
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001172:Arthritis, Rheumatoid / Q000150:complications / Q000601:surgery*; D001268:Atlanto-Axial Joint; D002574:Cervical Vertebrae / Q000601:surgery*; D004185:Disability Evaluation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D004204:Joint Dislocations / Q000150:complications; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D011379:Prognosis; D011446:Prospective Studies; D011782:Quadriplegia / Q000209:etiology; D012720:Severity of Illness Index; D013118:Spinal Cord Diseases / Q000209:etiology* / Q000401:mortality; D015996:Survival Rate; D016896:Treatment Outcome