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Die Wirbelsäule 2018; 02(04): 272-278
DOI: 10.1055/a-0636-4709
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Rheumatische Fehlstellungen an der HWS unter besonderer Berücksichtigung der C1/C2-Stabilität – Aktuelle Diagnostik und Therapiestrategien

Involvement of the cervical spine in rheumatoid arthritis with special consideration of C1/C2-stability – Diagnostic and therapeutic strategies
Ralph Kothe
Klinik für Spinale Chirurgie, Schön Klinik Hamburg Eilbek, Hamburg
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Publication History

Publication Date:
13 November 2018 (online)

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Zusammenfassung

Durch den zunehmenden Einsatz von Biologika hat sich das klinische Erscheinungsbild der rheumatoiden Arthritis (RA) in der täglichen Praxis verändert. Patienten mit einer isolierten atlanto-axialen Instabilität sind seltener geworden. Dafür rücken Patienten mit therapierefraktären Schmerzsyndromen der oberen Halswirbelsäule (HWS) und komplexen rheumatischen Deformitäten mit neurologischen Problemen vermehrt in den klinischen Fokus. Biologika können die Manifestation einer rheumatischen Instabilität an der HWS bei vielen Patienten verhindern, haben aber keinen Einfluss auf den klinischen Verlauf bei bereits bestehender biomechanischer Instabilität oder hartnäckigen Schmerzsyndromen aufgrund von knöchernen Destruktionen. Hier ist die operative Therapie für die meisten Patienten die einzig sinnvolle Behandlungsoption. Für die Fusion des atlanto-axialen Gelenkes stehen verschiedene Techniken mit hoher Fusionsrate und geringer eingriffsbedingter Morbidität zur Verfügung. Dabei sind die Besonderheiten der RA zu berücksichtigen (Knochendestruktion, Erweiterung der Vertebralisfurche, Biologikatherapie). Bei komplexen zervikalen Instabilitäten sind langstreckige Fusionen vom Okziput bis in die obere BWS notwendig. Die verbesserten operativen Techniken ermöglichen auch bei dieser schwierigen Patientengruppe eine sichere und komplikationsarme operative Versorgung.

Abstract

The increasing usage of biological agents has led to a change in the clinical picture of rheumatoid arthritis (RA) patients. There are fewer patients presenting with isolated atlantoaxial instability. In contrast, the number of patients with severe neck pain and complex rheumatic deformities with neurological problems is increasing. Biological agents can prevent the development of de novo cervical spine lesions in RA patients but fail to inhibit progression of pre-existing instabilities and severe pain syndroms due to bony destruction. In these cases, surgical treatment remains the best option for the patient. Different surgical techniques for the posterior fusion of the atlantoaxial joint with high fusion rates and low surgical morbidity are available. The specific characteristics of the RA like bony destruction, high-riding vertebral artery and medical treatment with biological agents have to be taken into consideration. Advanced cervical destruction requires a longer fusion from the occiput to the upper thoracic spine. Thanks to modern operation techniques, this complex surgery is also possible in progressive disease stages and patients with a high level of comorbidity.

Schlüsselwörter

rheumatoide Arthritis - Halswirbelsäule - Atlantoaxialgelenk - Instabilität - Biologika

Keywords

rheumatoid arthritis - cervical spine - atlantoaxial joint - instability - biologicals
 

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