title: The surgical management of the rheumatoid spine: Has the evolution of surgical intervention changed outcomes?
abstract: BACKGROUND
  Surgery for the rheumatoid cervical spine has been shown to stabilize the unstable spine; arrest/improve the progression of neurological deficit, help neck pain, and possibly decelerate the degenerative disease process. Operative intervention for the rheumatoid spine has significantly changed over the last 30 years.
  
  
  OBJECTIVE
  The purpose of this study was to review all cases of cervical rheumatoid spine requiring surgical intervention in a single unit over the last 30 years.
  
  
  METHODS
  A prospectively-maintained spine database was retrospectively searched for all cases of rheumatoid spine, leading to a review of indications, imaging, Ranawat and Myelopathy Disability Index measures, surgical morbidity, and survival curve analysis.
  
  
  RESULTS
  A total of 224 cases were identified between 1981 and 2011. Dividing the data into three time-epochs, there has been a significant increase in the ratio of segment-saving Goel-Harms C1-C2: Occipitocervical fixation (OCF) surgery and survival has increased between 1981 and 2011 from 30% to 51%. Patients undergoing C1-C2 fixation were comparatively less myelopathic and in a better Ranawat class preoperatively, but postoperative outcome measures were well-preserved with favorable mortality rates over mean 39.6 months of follow-up. However, 11% of cases required OCF at mean 28 months post-C1-C2 fixation, largely due to instrumentation failure (80%).
  
  
  CONCLUSIONS
  We present the largest series of surgically managed rheumatoid spines, revealing comparative data on OCF and C1-C2 fixation. Although survival has improved over the last 30 years, there have been changes in medical, surgical and perioperative management over that period of time too confounding the interpretation; however, the analysis presented suggests that rheumatoid patients presenting early in the disease process may benefit from C1 to C2 fixation, albeit with a proportion requiring OCF at a later time.
authors.affiliation: Department of Orthopaedic Surgery, The Great Western Hospital, Swindon, UK ; Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK.
authors.forename: Robin
authors.initials: R
authors.lastname: Bhatia
authors.affiliation: Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK.
authors.forename: Nikolas
authors.initials: N
authors.lastname: Haliasos
authors.affiliation: Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK.
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Vergara
authors.affiliation: Norwich Medical School, Norwich, UK.
authors.forename: Caroline
authors.initials: C
authors.lastname: Anderson
authors.affiliation: Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK.
authors.forename: Adrian
authors.initials: A
authors.lastname: Casey
keywords: Atlantoaxial subluxation; C1-C2 fixation; basilar invagination; occipitocervical fixation; rheumatoid cervical spine