Abstract
Subluxation of the cervical spine in rheumatoid arthritis is well known. Surgical treatment of severe cervical myelopathy caused by combined lesions of the atlanto-axial and subaxial levels in the rheumatoid spine was done on two cases.
Case 1 was a 58-year-old woman. Atlanto-axial subluxation combined with an unstable subaxial lesion was revealed. A modified Gallie's procedure combined with posterior fusion of C3 down to C6 was performed with success; however, subluxation of the C6/C7 level occurred one year and four months after surgery as a progression of the mutilans change. The extent of fusion seemed to be insufficient. A halo-vest distraction was applied again and a subtotal vertebrotomy of the C7 body with anterior fusion was carried out.
Case 2 was a woman of 71. She had combined atlanto-axial subluxation and a stable lower cervical lesion. Myelography revealed a complete block of the contrast medium at the atlanto-axial level and anterior and posterior defects at the C4/C5 and C5/C6 levels. Reduction of the atlanto-axial subluxation was done applying halo-vest distraction. A modified Gallie's procedure was performed for the upper level and enlargement of the spinal canal of C5 and C6 combined with postero-lateral fusion of C3 down to C7 with successful results.
A combined procedure should be considered for combined upper and lower lesions if both levels are thought to play major roles as causative factors. Posterior atlanto-axial fusion is indicated for mobile reducible atlanto-axial subluxation. Posterior fusion is commonly indicated for an unstable spine if neural involvement is evident without a myelographic abnormality. Posterior decompressive procedure combined with spinal fusion is indicated if myelography shows the evidence of compression. Fusion always accompanies this procedure because postoperative instability may develop even in the case of a stable spine. Halo-vest distraction is available to control a cervical spine before, during and after surgery.
