Case Report
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Jul 18, 2016; 7(7): 458-462
Published online Jul 18, 2016. doi: 10.5312/wjo.v7.i7.458
Operative stabilization of the remaining mobile segment in ankylosed cervical spine in systemic onset - juvenile idiopathic arthritis: A case report
Lovro Suhodolčan, Marko Mihelak, Janez Brecelj, Rok Vengust
Lovro Suhodolčan, Janez Brecelj, Rok Vengust, Department of Orthopaedic Surgery, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
Marko Mihelak, Department of Orthopaedic Surgery, General Hospital Celje, 3000 Celje, Slovenia
Author contributions: Suhodolčan L gathered data of presented manuscript, made interpretation of data, wrote the majority of manuscript, processed figures, predominantly involved in designing and drafting manuscript; Mihelak M gathered literature regarding manuscript, participated in presenting data and designing manuscript body; Brecelj J made clinical examination and follow-up visits, made all surgical interventions on patient’s lower limbs previous to surgical intervention presented in this manuscript, made substantial contribution in designing manuscript, participated coordination and helped to draft the manuscript; Vengust R made the surgical intervention presented in this manuscript, has been involved in drafting the manuscript and revising it critically for important intellectual content.
Institutional review board statement: This case report was exempt from the Institutional Review Board standards at University of Ljubljana, Slovenia.
Informed consent statement: Patient gave informed consent.
Conflict-of-interest statement: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Lovro Suhodolčan, MD, PhD, Consultant Orthopaedic Surgeon of the Department of Orthopaedic Surgery, University Medical Centre Ljubljana, Zaloška 9, 1000 Ljubljana, Slovenia.
Telephone: +386-1-5224174 Fax: +386-1-5222474
Received: January 21, 2016
Peer-review started: January 22, 2016
First decision: March 24, 2016
Revised: April 4, 2016
Accepted: May 31, 2016
Article in press: June 2, 2016
Published online: July 18, 2016

We describe a case of a 19-year-old young man with oligoarthritis type of juvenile idiopathic arthritis, who presented with several month duration of lower neck pain and progressive muscular weakness of all four limbs. X-rays of the cervical spine demonstrated spontaneous apophyseal joint fusion from the occipital condyle to C6 and from C7 to Th2 with marked instability between C6 and C7. Surgical intervention began with anterolateral approach to the cervical spine performing decompression, insertion of cage and anterior vertebral plate and screws, followed by posterior approach and fixation. Care was taken to restore sagittal balance. The condition was successfully operatively managed with multisegmental, both column fixation and fusion, resulting in pain cessation and resolution of myelopathy. Postoperatively, minor swallowing difficulties were noted, which ceased after three days. Patient was able to move around in a wheelchair on the sixth postoperative day. Stiff neck collar was advised for three months postoperatively with neck pain slowly decreasing in the course of first postoperative month. On the follow-up visit six months after the surgery patient exhibited no signs of spastic tetraparesis, X-rays of the cervical spine revealed solid bony fusion at single mobile segment C6-C7. He was able to gaze horizontally while sitting in a wheelchair. Signs of myelopathy with stiff neck and single movable segment raised concerns about intubation, but were successfully managed using awake fiber-optic intubation. Avoidance of tracheostomy enabled us to perform an anterolateral approach without increasing the risk of wound infection. Regarding surgical procedure, the same principles are obeyed as in management of fracture in ankylosing spondylitis or Mb. Forestrier.

Keywords: Juvenile idiopathic arthritis, Cervical ankylosis, Spastic tetraparesis, Multilevel both column fixation, Unstable cervical segment

Core tip: The spontaneous cervical apophyseal joint fusion is rare and only seen in juvenile type rheumatoid arthritis, where spontaneous fusions of more than three cervical segments are extremely uncommon. We present a patient with fusion of all but C6-C7 level. The single mobile segment became highly unstable, producing mechanical pain with symptoms of myelopathy. Prior to the surgery, awake fiber-optic intubation was used. Surgical intervention began with the anterolateral approach to the cervical spine performing decompression, insertion of cage and anterior vertebral plate and screws, followed by posterior approach and fixation. Care was taken to restore sagittal balance.