Cervical Instability In Patients Research Articles

Atlantoaxial Instability in the Course of Rheumatoid Arthritis in Relation to Selected Parameters of Sagittal Balance.

Background: Atlantoaxial instability is the most common cervical instability in patients with rheumatoid arthritis (RA). Its course may differ in different patients and may have different degrees of severity and symptoms. Methods: There are a number of studies on systemic factors associated with the development of this instability, but there are few publications in the scientific literature on the influence of biomechanical factors on the development of cervical instability. One of the areas that allows the study of biomechanical factors influencing spine pathologies is the analysis of sagittal balance using radiological parameters. The study of radiological parameters of sagittal balance has contributed to understanding the pathology of selected spine diseases and is currently an indispensable tool in planning surgical treatment. Results: The presented study, conducted on a group of RA patients with cervical instability, was performed to look for a relationship between C1-C2 instability and sagittal balance parameters. Conclusions: Among the examined selected parameters, a statistically relationship between C1-C2 instability and the Cobb angle C1-C7 and OD-HA parameters has been found. This confirms the need for further in-depth research on this areas.

Relationship between Cervical Instability in the Course of Rheumatoid Arthritis and Pelvic Parameters of Sagittal Balance.

The aim of the study is to search for a relationship between cervical instability in the course of rheumatoid arthritis (RA) and pelvic parameters of sagittal balance and lumbar lordosis (LL). The study included 47 patients with rheumatoid arthritis with instability of the cervical segment, who were referred for a consultation to assess indications for surgical treatment. The patients underwent a radiological functional examination of the cervical region and postural examination of the entire spine. The basic parameters of the lumbar section and pelvis of these patients were compared with the population values. Then, using statistical methods, the correlation between radiological parameters of various types of instability and lumbar lordosis (LL), pelvic parameters (PI, SS, PT), as well as the patient's age and duration of the disease was assessed. A statistical correlation was found between the instability in the cervical spine C2-C3 level and the value of the PT and PI angles. A statistically significant correlation was discovered between C1-C2 instability and younger patient age. There was no significant difference in the values of the pelvic parameters and lumbar lordosis in patients with rheumatoid arthritis compared to the population values. Preliminary results suggest that there is a relationship between selected pelvic parameters and the development of instability in patients with rheumatoid arthritis. This may be important in planning treatment and assessing disease progression. Further studies on a larger group of patients are needed, as well as studies evaluating the correlation between other sagittal balance parameters and cervical instability in patients with RA.

Presentation and physical therapy management of upper cervical instability in patients with symptomatic generalized joint hypermobility: International expert consensus recommendations.

Experts in symptomatic generalized joint hypermobility (S-GJH) agree that upper cervical instability (UCI) needs to be better recognized in S-GJH, which commonly presents in the clinic as generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome. While mild UCI may be common, it can still be impactful; though considerably less common, severe UCI can potentially be debilitating. UCI includes both atlanto-occipital and atlantoaxial instability. In the absence of research or published literature describing validated tests or prediction rules, it is not clear what signs and symptoms are most important for diagnosis of UCI. Similarly, healthcare providers lack agreed-upon ways to screen and classify different types or severity of UCI and how to manage UCI in this population. Consequently, recognition and management of UCI in this population has likely been inconsistent and not based on the knowledge and skills of the most experienced clinicians. The current work represents efforts of an international team of physical/physiotherapy clinicians and a S-GJH expert rheumatologist to develop expert consensus recommendations for screening, assessing, and managing patients with UCI associated with S-GJH. Hopefully these recommendations can improve overall recognition and care for this population by combining expertise from physical/physiotherapy clinicians and researchers spanning three continents. These recommendations may also stimulate more research into recognition and conservative care for this complex condition.

An Updated Algorithm for Radiographic Screening of Upper Cervical Instability in Patients With Down Syndrome

Study DesignRetrospective evaluation of cervical spine images from 2006–2012 for the purposes of “screening” children with Down syndrome for instability. ObjectiveTo determine whether a full series of cervical spine images including flexion/extension lateral (FEL) radiographs was needed to avoid missing upper cervical instability. Summary of Background DataThe best algorithm, measurements, and criteria for screening children with Down syndrome for upper cervical instability are controversial. Many authors have recommended obtaining flexion and extension views. We noted that patients who require surgical stabilization due to myelopathy or cord compression typically have grossly abnormal radiographic measurements on the neutral upright lateral (NUL) cervical spine radiograph. MethodsThe atlanto-dental interval, space available for cord, and basion axial interval were measured on all films. The Weisel-Rothman measurement was made in the FEL series. Clinical outcome of those with abnormal measurements were reviewed. Sensitivity, specificity, and positive and negative predictive values of NUL and FEL radiographs for identifying clinically significant cervical spine instability were calculated. ResultsA total of 240 cervical spine series in 213 patients with Down syndrome between the ages of 4 months and 25 years were reviewed. One hundred seventy-two children had an NUL view, and 88 of these patients also had FEL views. Only one of 88 patients was found to have an abnormal atlanto-dental interval (≥6 mm), space available for cord at C1 (≤14 mm), or basion axial interval (>12 mm) on an FEL series that did not have an abnormal measurement on the NUL radiograph. This patient had no evidence of cord compression or myelopathy. ConclusionsObtaining a single NUL radiograph is an efficient method for radiographic screening of cervical spine instability. Further evaluation may be required if abnormal measurements are identified on the NUL radiograph. We also propose new “normal” values for the common radiographic measurements used in assessing risk of cervical spine instability in patients with Down syndrome. Level of EvidenceLevel IV.

Retrospective Study of Cervical Arthrodesis in Patients With Various Types of Skeletal Dysplasia

Retrospective prognostic study. To evaluate the safety and efficacy of cervical arthrodesis for cervical instability in patients with skeletal dysplasia. Individuals with certain skeletal dysplasias have a high incidence of cervical instability, which can lead to compression of the spinal cord and subsequent severe spinal cord symptoms, progressive neurologic decline, quadriplegia, and death. The charts of 25 patients with skeletal dysplasia (spondyloepiphyseal dysplasia, spondyloepimetaphyseal dysplasia, pseudoachondroplasia, Morquio, or Kniest) who had undergone cervical arthrodesis to treat instability were reviewed for evidence of fusion, neurologic improvement, and complications. Of the 25 patients, 23 (92%) achieved a solid bony fusion, and 5 (20%) experienced surgery-related complications. One of the two patients who did not achieve fusion had a stable pseudarthrosis without neurologic complications, and additional surgical intervention was unnecessary; the second patient is contemplating revision surgery. Of 16 patients with preoperative neurologic manifestations, 14 (88%) experienced improvement. Cervical arthrodesis can be a safe and effective treatment for patients with skeletal dysplasia and cervical instability, despite the inherent complications associated with a dysplastic skeleton. The procedure can preserve and/or improve neurologic function while minimizing the risk of neurologic injury from spinal cord compression.

Natural history of rheumatoid arthritis of the cervical spine.

This article reviews the natural history of rheumatoid arthritis involving the cervical spine with special attention given to predictors of paralysis. Understanding the natural history of rheumatoid arthritis of the cervical spine is necessary to determine the benefit of various interventions. The primary treatment goal for cervical instability is prevention of irreversible neurologic injury. The natural history of rheumatoid arthritis for a period of 10 years or more is one of significant disease progression. The natural history of cervical instability in patients with rheumatoid arthritis is more variable, with only some patients having a neurologic deficit develop. Recent studies support prophylactic stabilization of the rheumatoid cervical spine to prevent paralysis in high risk patients. However, proponents for prophylactic arthrodesis must acknowledge that not all cervical instability in rheumatoid arthritis progresses to neurologic deficit, and surgical intervention in patients with rheumatoid arthritis incurs added morbidity and mortality. Identifying the risk factors for progression of cervical instability is the first step in eliminating morbidity and mortality from spinal cord and brain stem compression. Surgical stabilization is indicated not only for those patients with paralysis, but for the subgroups of patients with cervical rheumatoid disease who are at risk for spinal cord and brain stem compression. The posterior atlantodental interval is the most reliable screening tool and predictor of progressive neurologic deficit.

Complications and long-term outcome of upper cervical spine arthrodesis in patients with Down syndrome.

A retrospective review of 15 patients with Down syndrome who had undergone arthrodesis of the upper cervical spine for instability. To determine the complication rate and long-term outcome after posterior cervical arthrodesis for upper cervical instability in patients with Down syndrome. Atlantoaxial instability is common in patients with Down syndrome, and fusion of the upper cervical spine has been recommended for patients who have instability, with or without myelopathy. Unfortunately, the results of posterior cervical arthrodesis are not well reported, and the natural history of this condition is unknown. Fifteen patients with an average follow-up period of 74.6 months (range, 24-142 months) were reviewed after posterior arthrodesis of the upper cervical spine. Twelve patients were reexamined by the investigators specifically for the purpose of this study, and three patients had long-term follow-up results available from chart review. Eleven of 15 patients (73%) sustained 23 major complications including nonunion, loss of reduction, neurologic deterioration, late subaxial instability, infection, and wound dehiscence. Six patients (40%) required seven reoperations to address a complication. Ultimately, 12 patients (80%) obtained osseous union, but a definite clinical improvement was identifiable in only three patients, whereas two others had worsened neurologically at latest follow-up evaluation. A high complication rate should be anticipated after posterior arthrodesis of the upper cervical spine in patients with Down syndrome. A cautious approach to asymptomatic instability in this condition is advocated.

Cervical instability in patients with Downʼs syndrome and other related genetic disorders

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Pathomechanism, Pathogenesis, and Results of Treatment in Cervical Spondylotic Myelopathy Caused by Dynamic Canal Stenosis

In this study, the pathomechanism and pathogenesis of dynamic canal stenosis caused by cervical instability in patients with cervical spondylotic myelopathy and the validity of the concept of instability are clarified by analyzing the results of treatment in 53 cases. In cases of cervical spondylotic myelopathy caused by dynamic canal stenosis, the authors found that the posterior slide of the vertebral body occurs as a result of degeneration in the cervical spine due to aging changes, and that the dynamic sagittal diameter of the spinal canal decreases with an increase of the degree of posterior slide. This is followed by gradual aggravation of the clinical symptoms. Continuous cervical traction was found to be the first choice of treatment. Surgical treatment is indicated in cases in which the traction was ineffective, or even when it was effective, in cases in which the Japanese Orthopaedic Association (JOA) score remained low or when there was a tendency toward rapid aggravation of symptoms. It was demonstrated that the shorter the duration of the myelopathy, the better the results of treatment obtained. A limit of the dynamic sagittal diameter of the spinal canal of 12 mm was considered as valid.