What parts make up the spine and neck?
The spine is made of a column of bones. Each bone, or vertebra,
is formed by a round block of bone, called a vertebral body. A bony
ring attaches to the back of the vertebral body, forming a canal.
This bony ring
is formed by two sets of bones. One set, the pedicle bones, attaches to
the back of each vertebral body. A lamina bone connects to the other
end of the pedicle, one on the left and one on the right. The lamina
bones form a protective roof over the back of the spinal cord. When the vertebra
bones are stacked on top of each other, the canal forms a long tube that surrounds
and protects the spinal cord as it passes through the spine.
An intervertebral disc fits between each vertebral body and provides
a space between the spine bones. The disc works like a shock absorber. Between
each two vertebra are two synovial joints called facet joints. Together with
the disc, these joints connect the two vertebra together and allow motion at
each level of the spine.
The first two cervical vertebrae are very specialized to allow us to turn our head from side to side. The first cervical vertebra (or C1) is called the atlas. The second cervical vertebra (C2) is called the axis. The C1 vertebra connects the skull to the cervical spine. Between C1 and the skull are synovial joints.
The C1 vertebra is formed like a ring that sits on top of C2. The C2
vertebra has a bony knob that fits into the front portion of the ring
of the C1 vertebra. This bony knob is called the odontoid process.
It is held in place by a special ligament that holds it tightly to the
front of the ring of the C1 vertebra. The spinal cord enters the skull
through a hole in the base of the skull called the foramen magnum. Two blood vessels also enter the foramen magnum, one on the left and one on the right. These blood vessels, called the vertebral arteries, supply the back portion of the brain.
Like each spinal segment, between the C1 vertebra and the C2 vertebra there
are a pair of synovial joints--one on each side of the spinal canal.
The symptoms of rheumatoid arthritis in the cervical spine are
extremely varied. Pain is the earliest symptom and may be part of the
overall joint inflammation that occurs with the arthritis. As the
disease progresses, the symptoms that are most worrisome are those that
suggest that the spinal cord is being affected.
Pain at the base of the skull is common and can indicate that the
nerves that exit the skull and the upper spine are being irritated or
compressed. Pressure on the vertebral arteries can lead to blackout
spells when the blood flow through these arteries is diminished with
certain movements of the head and neck.
A change in the ability to walk can signal increasing pressure on
the spinal cord. In some cases this can be a spastic gait with weakness
and problems with balance. This is an indication that the spinal cord
is being compressed. Any change in the ability to walk should be
brought to the attention of your doctor. Feelings of tingling,
weakness, or a loss of coordination can affect the arms or legs.
Changes in bowel or bladder control such as incontinence or inability
to urinate can also occur.
Because the area of the spinal cord that is being affected is so
high up, the changes in strength, balance, and sensation may vary and
be difficult to interpret.
The diagnosis of rheumatoid cervical spine problems begins with a
thorough history and physical examination. You doctor will want to know
about changes in your ability to walk and get around especially if this
has gotten worse rapidly. Changes in your bowel or bladder function are
also important. Any neurological symptoms that have changed such as
weakness, numbness, or loss of fine motor skills are important.
An important part of evaluating the neck includes X-ray of the
cervical spine. This may include special X-rays where you are asked to
bend your head forward as far as possible and back as far as possible.
These are called flexion and extension X-rays and can show how much
instability is present between the vertebrae of the neck.
The MRI scan is the most important test for showing the nerves and
soft tissues of the cervical spine. This test uses magnetic waves to
create slices through the spine. Using this test, the degree of
compression on the spinal cord can be assessed more accurately than
with X-rays alone.
Finally, special electrical tests may be ordered by your doctor and
performed by a neurologist. These tests are useful to determine how the
spinal cord is functioning.
Nonsurgical Treatment
The primary nonsurgical treatment of the cervical spine problems
associated with rheumatoid arthritis begins with good medical control
of the rheumatoid arthritis. This treatment is normally managed by a
specialist in rheumatology rather than the spine surgeon. Within the
past several years, there have been significant advances in the
development of new medications that can control the destructive effects
of the arthritis on the joints. Your rheumatologist will manage these
medications.
Once there is evidence that the rheumatoid arthritis has affected
the stability of the cervical spine, the most important part of spine
care is close followup. X-rays may be needed from time to time to
assess the degree of instability and follow the progression of the
disease. Mild instability with no evidence that the instability is
causing any pressure on the nerves or spinal cord may not require any
additional treatment. Patients with X-ray signs of instability may need
to protect their neck with a special neck brace, especially when riding
in a car. This is mainly to prevent damage to the spinal cord should a
cervical spine injury occur.
Surgical Treatment
When signs of pressure on the spinal cord become apparent, many
surgeons feel that surgical stabilization should be considered. The
goal of surgery is to stabilize the unstable portion of the cervical
spine, to remove pressure from the spinal cord and to relieve the pain
caused by the underlying instability.
When two or more vertebrae are stabilized, however, available
movement in the neck is reduced. For example, rotating the neck from
side to side occurs mainly between C1 and C2. Surgery that joins C1 and
C2 together reduces neck rotation up to 50 percent. Posterior cervical
fusion (described below) stops all forward and backward motion between
the fused vertebrae.
The decision when to operate should be made based on your symptoms,
your expectations, and your overall medical condition. These operations
are extremely complex and carry significant risks that need to be taken
into consideration.
Cervical Fusion
When the instability involves the lower cervical spine (C3 to the bottom of
the cervical spine) a posterior fusion is
usually preferred. A fusion of the spine is also called an arthrodesis. In
this type of operation, the surfaces of the vertebrae to be fused are roughened
to create fresh bleeding bone. Bone graft taken from the hip is then placed
between and across the back of the vertebrae to be fused. These vertebrae are
held together with some type of hardware, called instrumentation. Many
surgeons feel this may increase the success rate of the fusion and also may
reduce the need for the more cumbersome external braces. The traditional way
of holding the vertebrae together is to wrap wire around the spinous processes
of the vertebrae to be fused. (The spinous process is the bony bump on the
back surface of the vertebra.) This holds the vertebra in place while the bone
graft heals fusing the vertebra into a solid block of bone.
C1-C2 Posterior Fusion
When the primary problem is instability between the C1 and C2
vertebrae, a fusion between these two spine bones is usually
recommended. The traditional method of fusing these two vertebrae is to
place wedges of bone graft between the two vertebrae and then to wire
the two vertebrae together. Fusion causes the two vertebrae to form a
single bone. The goal is to stop the progression of the instability and
relieve the pressure on the spinal cord.
Occiput-C3 Posterior Fusion
Perhaps the most serious condition from rheumatoid arthritis of the
cervical spine is the settling that occurs when the joints between the
skull, the C1 vertebra, and the C2 vertebra are destroyed. Settling
allows the odontoid to slowly place more pressure on the spinal cord
and brain stem and can lead to paralysis and even sudden death.
The surgical procedure to stabilize this situation requires a fusion
between the skull and the first three cervical vertebrae (C1, C2, and
C3). The traditional procedure
to fuse these bones together is very complex. Bone graft is taken from
the pelvis and fashioned into two small plates of bone that will cover
the area from the base of the skull to the C3 vertebra. In advanced
cases, the pressure may need to be relieved from the spinal cord. The
surgeon may do this by removing a portion of the skull and the back
portion of the C1 vertebra. In select cases, the surgeon may need to
work on the front of the spine by operating through the mouth, called a
transoral approach (see below).
When all pressure is removed from the spinal cord, the bone graft is
placed. Small holes are drilled into the skull and first three cervical
vertebrae. Wire is inserted through the holes in order to hold the
graft in place. Recently, instrumentation has been developed to hold
the bones and bone graft in place while the bones fuse. Several
different types of metal rods and metal plates
have been developed that can hold the skull and upper cervical vertebra
together while the fusion heals. Many spine surgeons feel that these
newer techniques and instrumentation will increase the success rates of
these types of fusions.
As the bone graft heals, the first three cervical vertebrae fuse to
the skull. A successful fusion stops the instability and protects the
spinal cord from additional pressure.
These posterior fusion operations are all performed through an incision in
the back of the neck. The fusion usually takes at least 12 weeks to become
solid, but it may take as long as one year.
Transoral Approach
In some cases of advanced rheumatoid arthritis of the cervical spine, the
posterior fusion alone is not enough to take the pressure off of the spinal
cord. This can occur in two ways.
First, the cranial settling may be so great that a fusion cannot
remove the pressure that the odontoid is placing on the spinal cord.
Second, the pannus that occurs due to the rheumatoid disease may put
pressure on the spinal cord. Pannus is formed by most joints afflicted
with rheumatoid arthritis. This material is formed by the synovium (or
the joint lining) and grows and expands like a tumor. As it grows
larger it can put pressure on the spinal cord. Usually, once a fusion
has been successful the pannus actually shrinks, and the pressure on
the spinal cord is reduced.
If either of these conditions is causing too much pressure on the
spinal cord, a second operation may be needed to remove the pressure on
the spinal cord. Because the pressure is on the front of the spine and
spinal cord, the operation must also be done from the front of the
spine. When surgery on the front of the spine is necessary in the upper
cervical spine it must be performed through the back of the mouth. This
is called a transoral approach ("transoral" means through the mouth).
The operation begins with the transoral approach when it is certain
that pressure must be removed from the front of the spinal cord. This
is followed by a posterior fusion during the same operation.
In some cases, the posterior fusion may be done alone at first to
see if this reduces the pressure. If the posterior fusion alone is not
successful, a second operation using the transoral approach may be done
at a later date to remove the continuing pressure on the spinal cord.
During the transoral approach, the surgeon makes an incision in the
back of the throat while the mouth is held open with special
retractors. The source of compression is identified and removed to
reduce the pressure on the spinal cord. Surgeons do the operation with
the aid of an operating microscope to be able to see the incision
better.
