摘要：
Background:Cervical spine involvement in the rheumatoid patient is common, especially in upper cervical ver-tebrae, and results in compression of spinal cord and instability of occipitoatlantoaxial joints and lower cervical vertebrae. It was often misdiagnosed. Objective: To investigate the clinical manifestation and surgical indication of cervical RA. Methods:Clinical data of 13 patients with cervical RA treated by surgery in our hospital between February 2010 and April 2015 were analyzed retrospectively. Results:There were 12 females and one male with an average age of 51 years (range, 42-69 years). The average course of disease was 6.2 years (range, 2.1 to 11 years). The mean duration of follow-up was 1.7 years (range, 3 months to 3 years). There were 8 cases with intractable neck pain and 5 cases with neurologic deficits (grade Ⅰ in 2 cases, grade Ⅱ in 2 cases, grade ⅢA in 1 case by Ranawat criteria). Preoperative X-ray showed osteopenia in 12 cas-es, subluxation of atlantoaxial articulation in 11 cases, and 3.5 mm sagittal translation of inferior cervical vertebrae in 3 cas-es. Preoperative mean anterior atlantodental interval (AADI) was 8 mm (range, 4-11 mm) and posterior atlantodental inter-val (PADI) was 14 mm (range, 10-16 mm). Irregular osseous destruction at the tip of odontoid process, lateral mass, occipi-tal condyle and the attachment of horizontal ligament and small sequestrum was found in 8 cases and atlantoaxial vertical dislocation in 5 cases by CT and 3D-CT scanning. Preoperative cervicomedullary angle (CMA) ranged from 127° to 166° with a mean of 146° by MRI. There were 7 cases of periodontoid pannus and 6 cases of the compression of brain stem and (or) spinal cord. Eight patients underwent posterior reduction and stabilization of the C1-C2 segment with combination later-al mass and isthmic screws into C1 and C2 and autografts. The fixation and fusion was performed in 3 patients and the fixa-tion was extended to C6 in 2 patients. There was no injury of dura mater, vertebral artery or spinal cord. Postoperative wound infection occurred in one case. The pain disappeared in 8 patients. Neurologic disorders relieved in 4 patients and did not worsen in one patient (gradeⅢA). Postoperative cervicomedullary angle (CMA) ranged from 138° to 166° with a mean of 159°. No breakage, loosening or instability occurred during follow-up. Conclusions:The treatment of cervical RA should be individualized based on general condition, degree of osteopenia and location of involvement. Surgical intervention should be as soon as possible for those with neurologic involvement and impending neurologic involvement resulting from cervical instability and intractable pain because of the progressive destruction of RA.%背景:颈椎类风湿性关节炎(rheumatoid arthritis,RA)起病隐匿,易于漏诊.在脊柱最常累及上颈椎,并可同时累及下颈椎,导致颈椎不稳、脊髓受压.目的:总结颈椎RA的临床表现,探讨其手术适应证.方法:回顾性分析2010年2月至2015年4月我科手术治疗颈椎RA 13例,结合病史、临床表现、影像资料及术后随访结果分析.结果:13例颈椎RA患者,女12例,男1例;年龄42~69岁,平均51岁.病程2.1~11年,平均6.2年,随访3个月~3年,平均1.7年.表现为顽固性颈痛者8例,颈痛伴脊髓受压症状者5例.神经功能评估按Rannawat分级,Ⅰ级2例,Ⅱ级2例,ⅢA级1例.术前X线示骨质疏松12例,寰枢脱位11例,下颈椎矢状位上移大于3.5 mm 3例;CT及三维CT示寰齿前间距4~11 mm,平均8 mm;寰齿后间距10~16 mm,平均14 mm;齿状突尖、侧块、枕骨髁及横韧带附着处不规则破坏、米粒大小死骨8例,寰枢椎垂直脱位5例.MRI示术前延髓脊髓角127°~166°,平均146°;MRI示齿突后方滑膜血管翳形成7例,颈脊髓受压6例.行颈后路寰枢融合术8例,枕颈固定融合术3例,延长固定至下颈椎2例.术中均无神经、血管及硬脊膜损伤等并发症,1例术后切口感染.4例术后神经功能障碍均得到1~2级改善,其中1例(ⅢA级)患者症状无明显缓解但也无进展.术后寰齿前间距2~6 mm,平均4 mm;术后寰齿后间距14~18 mm,平均16 mm.术后延髓脊髓角138°~166°,平均159°.术后颈痛消失8例,明显改善4例,1例无效;随访期间未发现内置物松动、断裂及相邻节段的不稳.结论:颈椎RA应根据患者全身情况、骨质疏松的程度及累及的范围进行个性化治疗.由于其破坏呈进行性,对颈椎不稳定导致的颈脊髓受压或将发生脊髓受压及顽固性颈痛的患者应早期积极手术治疗.
