**5. Conclusion**

270 Rheumatoid Arthritis – Etiology, Consequences and Co-Morbidities

The presence of a significant interaction term (*p*=0.015) indicates that the hazard for death changes over time postoperatively for the group with cervical neurological findings. The hazard ratio for this group compared with the group without relevant neurology starts at 2.69 for the first time period following operation decreasing to 2.47 at about 6 years postoperatively, indicating that the postoperative hazard ratio is different for the group with relevant neurology than for the group without. The older the patient is at operation, the hazard for death increases with 6% for each year of age (*p*<0.001), and the patients with relevant neurology have a 169% increased hazard each year (*p*=0.001). We also calculated that males have a 40% higher annual risk, but this difference was not statistically significant

Age at operation 1.06 1.04 - 1.08 < 0.001 Neurology as indication for operation 2.69 1.48 - 4.88 0.001 Time of follow-up 0.92 0.85 - 0.99 0.03 Gender 1.40 0.97 - 2.00 0.07

Table 5. Cox Proportional Hazard Ratio Regression for Survival in Operated Patients with

Postoperatively 7 (9%) of the patients experienced residual neurological symptoms or signs. None of these were alive at the end of the study, indicating a poor prognosis for patients

In 4 patients (5%) reoperation was performed: rearthrodesis in 3 patients, fistula with removal of cement in 1. Additional operation with local superficial release of the greater

Among those still alive at the end of the follow-up 18 patients had had an arthrodesis performed, and all of these developed bony ankylosis. In the group of patients that died during the follow-up period 49 had had an arthrodesis performed, but only 33 achieved

Only 3 of the patients without neurological symptoms or signs before the operation

RA is an independent risk factor for increased mortality (Hakoda et al., 2005; Sihvonen et al., 2004). When the cervical spine is involved this risk is increased (Paus et al., 2008; Riise et al., 2001; Shen et al., 2004). In the RA population the estimates of the number of patients with cervical involvement varies from 12% (Naranjo et al., 2004) to 57% (Neva et

Cervical spinal disorders should be diagnosed early and treated actively to prevent severe and potentially fatal complications (Neva et al., 2006). Early surgery corrects AS and prevents further instability (Grob et al., 1999; Hamilton et al., 2001; McRorie et al., 1996). Early surgery may also reduce mortality (Grob, 2000; Paus et al., 2008; Tanaka et al., 2005). Posterior fusion reduces pain and may improve neurological symptoms or signs (Eyres et

HR indicates Cox proportional hazard ratio; CI=95% Confidence interval

and without Neurological Symptoms or signs.

with residual cervical neurology after surgery (*p*=0.015).

bony ankylosis which is a significantly poorer result (*p*=0.004).

developed relevant neurology during the follow-up period.

occipital nerve was necessary in 2 patients (Table 2)

**HR 95% CI** *P* 

(*p*=0.07) (Table 5).

**4. Discussion** 

al., 2006).

Development of neurological symptoms or signs in RA patients with cervical subluxations significantly increases the mortality rate. It is therefore important to diagnose these patients

Increased Mortality Rate in Rheumatoid Arthritis Patients with Neurological Symptoms

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432.

667.

7, pp. 884-888.

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#### **6. References**


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**16** 

*Ireland* 

**Surgical Considerations of Rheumatoid** 

Rheumatoid arthritis is a progressive systemic erosive inflammatory polyarthropathy causing symptoms both as a result of disease progression, (Zikow et al 2005, Gorter et al 2010, Klarenbeek at al 2010), and as result of medical management of the disease process itself (Haugeberg et al 2003). It affects synovial joints in 1% of the world's population (Matteson 2003) , with more than 50% of those affected experiencing involvement of the cervical spine (Cabot & Becker 1978, Yurube et al 2011, Garcia- Arias et al 2011) It is characterised by an erosive synovitis, causing destruction of the articular joint surfaces, joint capsules and supporting ligaments for the joints. The atlantoaxial joint is the most commonly affected (Dreyer et al 1999). Though the disease process can cause horrendous morphological change to the cervical joints, with concomitant changes to joint function and stability, neurological dysfunction is surprisingly uncommon. The importance of regular neurological assessment and rapid intervention lie in the rapid progression to disability with the onset of neurological deficits (Rana 1989), allied with a significantly increased

Great strides in the development and evolution of spine surgery techniques and instrumentation have been made treating individuals with cervical and craniocervical junction dysfunction. The complexities encountered when approaching the craniocervical junction of a severe rheumatoid neck, and the anatomical variability of the neural and vascular structures that may be iatrogenically breached (Bruneau 2006) mandate the use of image guidance techniques and/or conductivity detection devices (Kelleher et al 2006) to

The vertebrae of the region most commonly affected by rheumatoid degenerative disease, namely the craniocervical junction and the atlantoaxial joints, have a very complex anatomical relationship with traversing nerves, vessels, and of course the spinal cord (Oliveira et al 1985), and an appreciation of the structure and function of the components of these joints (including how degenerative changes alter the kinematics and structural

The most common causes for surgical review of the cervical spine of rheumatoid patients include basilar invagination, atlantoaxial instability and subaxial subluxation (Boden et al 1993). Despite an improvement in spine surgical techniques and technology, rheumatoid

**1. Introduction** 

mortality rate (Mikulowski et al 1975, Paus et al 2008).

limit intraoperative risk (Kotani et al 2003, Aryon et al 2008).

integrity) is integral to safe surgery in the region.

 **Disease Involving the Craniocervical** 

**Junction and Atlantoaxial Vertebrae** 

T.M. Murphy, L. McEvoy and C. Bolger

*Beaumont Hospital, Dublin,* 

Teigland, J., Ostensen, H., & Gudmundsen, T. E. (1990). Radiographic measurements of occipito-atlanto-axial dislocation in rheumatoid arthritis. *Scand.J.Rheumatol.,* Vol. 19*,* No. 2, pp. 105-114.
