What are the indications for surgical treatment for RA involving the cervical spine

Indications for surgical treatment include neck pain, neurologic dysfunction, or abnormal imaging parameters (instability). Often patients present with a combination of these factors:

1. Pain: Neck pain or occipital pain has multiple etiologies. If pain is secondary to spinal instability or neurologic compression (e.g. radiculopathy, myelopathy), surgery is recommended

2. Neurologic dysfunction: Cervical myelopathy is an indication for surgery to prevent neurologic deterioration and facilitate recovery

3. Abnormal imaging parameters:

A. ATLANTOAXIAL SUBLUXATION (AAS)

• AADI greater than 10 mm

• Spinal cord diameter less than 6 mm in neutral or flexed position (MRI)

• Spinal canal diameter less than 10 mm in flexed position (MRI)

• Inflammatory tissue behind the dens greater than 10 mm

B. ATLANTOAXIAL IMPACTION (AAI)

• Cervicomedullary angle less than 135 degrees on sagittal MRI

• Cranial migration distance less than 31 mm (Redlund-Johnell measurement)

• Migration of odontoid greater than 5 mm above McGregor's line

• Surgery is generally recommended following development of AAI due to risk of neurologic injury

C. SUBAXIAL SUBLUXATION (SAS)

• Subaxial canal diameter of 13 mm or less

• SAS associated with neurologic deficit

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