Adjacent-level failures after occipito-thoracic fusion for rheumatoid cervical disorders

The natural history of cervical spine lesions in rheumatoid arthritis (RA) is variable. We have actively performed occipito-thoracic fusion for severe destructive rheumatoid cervical disorders and reported its clinical results and complications. In our previous study, the most frequent complication was the adjacent-level failures caused by the fragile spine. The objective of this study was to determine risk factors for adjacent-level failures after occipito-thoracic fusion.

Subjects were 35 RA patients (31 females and 4 males) who underwent occipito-thoracic fusion using RRS Loop Spinal System^® (Robert Reid Inc. Tokyo, Japan), and the incidence and characteristics of adjacent-level failures were investigated. Furthermore, the adjacent-level failures were divided into two types according to their levels, fracture at the lowest level of the fusion area and that at the level inferior to the fusion area, and the characteristics of each type were evaluated.

Nine (26 %) of 35 patients suffered adjacent-level failures (10 vertebral fractures). Adjacent-level failures occurred when the distance of fixation was “O–T4” or longer. The long fusion might cause adjacent-level failures due to greater mechanical stress. Seven fractures occurred at the lowest level of the fusion area, and all of them were cured without symptoms by conservative treatment. Three fractures occurred at the level inferior to the fusion area, and one of them needed additional surgery due to sudden paraplegia resulting from collapse of the adjacent vertebra. After occipito-thoracic fusion, burst fractures at the level inferior to the fusion area might cause sudden paraplegia, and therefore a careful observation should be required for patients with these fractures.