Surgery on the rheumatoid cervical spine for the non-ambulant myelopathic patient—too much, too late?

Summary Background Opinions differ on the timing of surgery for rheumatoid arthritis patients with atlanto-axial subluxation. Some clinicians wait for development of neurological signs; others favour prophylactic fusion and decompression. We examined the results of surgery in relation to neurological state at the time of operation. Methods 134 patients underwent surgery for rheumatoid involvement of the cervical spine, after development of objective signs of myelopathy. Surgical outcomes were examined prospectively in two groups—patients who were still ambulant at the time of presentation (Ranawat class III A) and patients who had lost the ability to walk (Ranawat class III B)—by means of neurological and functional grading systems in conjunction with standard measures of postoperative morbidity and mortality. Findings 58% of the ambulant patients attained Ranawat neurological grades I or II compared with only 20% of the non-ambulant patients (p