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World J Orthop. Jul 18, 2014; 5(3): 292-303
Published online Jul 18, 2014. doi: 10.5312/wjo.v5.i3.292
Advances in the treatment of cervical rheumatoid: Less surgery and less morbidity
Grant W Mallory, Sasha R Halasz, Michelle J Clarke
Grant W Mallory, Sasha R Halasz, Michelle J Clarke, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, United States
Author contributions: All authors contributed to draft and critically revise the intellectual content of this article; The concept and design was initially devised by Mallory GM and Clarke MJ and further modified by Halasz SR; References were compiled by Mallory GM and Halasz SR; Supplemental figures and tables were constructed by Halasz SR; all authors gave final approval of the version to be published.
Correspondence to: Michelle J Clarke, MD, Associate Professor of Neurosurgery, Department of Neurologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States.
Telephone: +1-507-7746840 Fax: +1-507-2845206
Received: December 21, 2013
Revised: March 8, 2014
Accepted: April 17, 2014
Published online: July 18, 2014

Rheumatoid arthritis is a chronic systemic inflammatory disease that often affects the cervical spine. While it was initially thought that cervical involvement was innocuous, natural history studies have substantiated the progressive nature of untreated disease. Over the past 50 years, there has been further elucidation in the pathophysiology of the disease, as well as significant advancements in medical and surgical therapy. The introduction of disease modifying drugs and biologic agents has reduced the amount of patients with advanced stages of the disease needing surgery. Advancement in instrumentation techniques has improved patient outcomes and fusion rates. The introduction of endoscopic approaches for ventral decompression may further lower surgical morbidity. In this review, we give a brief overview of the pertinent positives of the disease. A discussion of historical techniques and the evolution of surgical therapy into the modern era is provided. With improved medical therapies and less invasive approaches, we will likely continue to see less advanced cases of disease and less surgical morbidity. Nonetheless, a thorough understanding of the disease is crucial, as its systemic involvement and need for continued medical therapy have tremendous impact on overall complications and outcomes even in patients being seen for standard degenerative disease with comorbid rheumatoid.

Keywords: Atlantoaxial instability, Cranial settling, Subaxial subluxation, Cervical, Surgery, Morbidity, Rheumatoid arthritis

Core tip: This review summarizes the pertinent features of cervical rheumatoid arthritis. A discussion of important preoperative considerations and surgical approaches in a modern era with advancing medical therapy is provided. The evolution of surgical techniques and outcomes are also highlighted.