Radical Debridement Radical debridement without bone grafting is sufficient in cases with: Radical debridement is the key to successful surgery predominant epidural abscess absence of significant vertebral or intradiscal involvement absence of gross bony destruction, deformity, and instability Radical Debridement and Bone Grafting Radical debridement and bone grafting are indicated in patients: with intraspinal abscesses without gross bony destruction, deformity, or instability Primary bone grafting is preferred There is still debate on the timingofthebonegrafting. The main concern in pri- mary bone grafting is the resolution of the graft by the infection. On the other hand, secondary bone grafting requires reoperation with theoretically increased morbidity. In the absence of conclusive data in the literature, the present author prefers primary bone grafting unless radical debridement is not achieved. In this case, a second-look operation is imperative and, depending on the local situa- tion, bone grafting is performed during the latter intervention. Radical Debridement, Bone Grafting, and Instrumentation Radical debridement and bone stable reconstruction of the spine are favored as the surgical technique of choice based on the good results obtained with surgical treatment of spinal tuberculosis [23, 32, 33] ( Table 5): Table 5. Rationales for radical debridement and stable reconstruction of the spine improvement of general condition after abscess drainage prevention of secondary deformity rapid progress of infection is prevented in early stages, extirpation of infected focus is easy late recurrence is less frequent putative shorter hospitalization and earlier return to work Instrumentation has increasingly been used without recurrent infection While the use of spinal instrumentation in the presence of spinal infection has been controversial in the literature, an increasing number of articles indicate that instrumentation is not contraindicated in cases where radical debridement is achieved [14]. There are no sufficient data in the literature to allow a conclusive statement on the role of instrumentation in spinal infection. However, there is no evidence to suggest that instrumentation prevents the healing of the spinal infec- tion. The additional stability instead promotes clinical resolution of the infection and related symptoms ( Table 6). Anterior Approach. Asingle-stage anterior approach is best suited for cases with: predominant anterior column involvement effective radical debridement absence of gross deformity or instability Anterior instrumentation appears not to have an adverse effect unless radical debridement is not achieved [12]. The use of anterior cages in the absence of a structural auto- or allograft remains controversial. However, early reports in the literature indicate that this approach can be successful [21]. Posterior Approach. A single posterior approach is only indicated in cases with a lesion with difficult anterior access, e.g., at the upper thoracic spine T2-4. In Infections of the Spine Chapter 36 1033 Table 6. Surgical treatment of spinal infections with instrumentation Author Cases Type of infection Follow-up Technique Complications/outcome Conclusions Moon et al. (1995) [33] 44 44 tuberculosis 3.6 (2 –11) years 44 posterior instrumenta- tion and anterior debride- ment with fusion 1 loss of correction 0 recurrent infection Posterior instrumental stabilization and ante- rior interbody fusion were found helpful in arresting the disease early, providing early fusion, preventing progression of kyphosis and correcting the kyphosis Carragee (1997) [8] 17 17 pyogenic 2 years 15 anterior debridement and posterior debridement and instrumentation 2 instrumentation failure, 1 wound dehiscence, 2 thrombosis, 1 symptomatic pseudarthrosis, 0 neurological deterioration, 0 recurrent infection Spinal infection in selected cases allows early mobilization and does not compromise the ability to clear infection Eysel et al. (1997) [12] 55 32 pyogenic, 12 tuberculosis, 11 unknown 2 years 32 combined anterior debridement and posterior instrumentation vs 23 anterior debridement and instrumentation alone 3 superficial infection, 1 intraoperative aorta rupture, 1gastriculcer, 3 neurological compromise, 0 recurrent infections No adverse effect of anterior instrumentation was observed Kroedel et al. (1999) [25] 33 19 pyogenic, 4 tuberculosis, 10 unknown mean 22 (13–53) months 33 radical anterior debride- ment and extrafocal poste- rior instrumentation 1 septic brain abscess, 1 peritonitis owing to bowel laceration, 2 superficial infection, 2 implant failures, 0 recurrent infection Posterior extrafocal stabilization offers the advantage of braceless rehabilitation without life-threatening complications Faraj and Webb (2000) [14] 31 31 pyogenic mean 3.8 (1–12) years Anterior radical debride- ment and 30 posterior stabilization or 1 anterior stabilization 1 graft dislodgement, 1 nosocomial chest infection (died), 3 wound infection, 1 implant failure, 2 recurrence of spinal infection, 2 recurrent spinal deformities, 0 recurrent infection Spinal instrumentation is indicated when after radical debridement of infected verte- brae, disc material, and bone grafting, the stability of the spine is still compromised 1034 Section Tumors and Inflammation those cases, a costotransversectomy approach is necessary to allow for adequate decompression of the anterior column. Combined Approach. This is the most widely used approach [8, 12, 19, 25, 42] consisting of short-segmental posterior pedicle screw fixation, followed by radi- cal anterior debridement and bone grafting ( Fig. 6). In the cervical spine, a two or a bc d ef Case Study 2 An 81-year-old woman developed progressive, severe back pain. Despite initial analgesics and physiotherapy, the patient continued to get worse. The patient developed a slight increased fever and felt sick. After severe pain with ambu- lation, a radiograph ( a) was taken, demonstrating a collapsed L1/2 disc space with partial destruction of the lower end- plate of L1. The MRI exhibits typical signs of a spinal infection. Note the high signal intensity in a T2W MR sagittal image ( b) and a paravertebral abscess in the psoas muscles (c, d ). In a first stage the spine was stabilized from T11 to L3 with a titanium pedicle screw system. In a second stage, during the same operation, the paravertebral abscess and the disc space and adjacent vertebral bodies L1/2 were debrided. The bone quality was osteoporotic. A tricortical bone graft was harvested from the iliac crest, but broke during insertion because of poor bone quality. Rather than leaving a large ante- rior gap, a titanium mesh cage was implanted, supporting the anterior cortex of the severely osteoporotic vertebrae ( e, f). At 6 months follow-up the patient was ambulating without aid without limiting her daily activities, but she still had occasional back pain. There was no sign of recurrent infection during a further 1-year follow-up. Infections of the Spine Chapter 36 1035 more level involvement requires additional posterior stabilization. However, in cases where the general health status does not allow an additional posterior approach, external splinting is imperative until the bone graft has healed. In cases of poor bone quality, e.g., in an osteoporotic spine, longer instrumentation may become necessary. In those cases, anterior buttress support is necessary to allow for stable construction. In cases where a tricortical bone graft is too brittle (osteoporo- sis), a titanium mesh cage can be applied. As a prerequisite, radical debridement has to be achieved prior to cage implantation and bone grafting ( Case Study 2 ). Recapitulation Epidemiology. In an era of very powerful antibiot- ics, it is sometimes forgotten that spinal infections are still a potentially life-threatening disease.To- day, spinal infections predominantly occur in the el- derly and immunocompromised patient, but the in- cidence of spinal tuberculosis in younger patients is again increasing in industrialized countries. Pathogenesis. Spinal infections in adults appear to start from the vertebral endplates. The most fre- quent pathomechanism is a spread of microorgan- isms via the blood vessels from urogenital, pulmo- nary, or diabetic foot infections. Spinal infections are most frequently classified according to the causative organism (pyogenic, parasitic, fungal in- fections, tuberculosis) or the location (i.e., discitis, spondylitis, epidural, and paravertebral abscess). Clinical presentation. The key feature of spinal in- fections is the delayed diagnosis. Cardinal symp- toms are slowly progressive, continuous pain with pain exacerbation during rest and at night. Fever and septic states are rare. It is mandatory to search for predisposing factors such as diabetes, intrave- nous drug abuse, immunodeficiency, diabetic ul- cers, and previous septic conditions. The physical findings are often non-specific unless neurologic deficits are present. Diagnostic work-up. The key to diagnosis is to con- sider spinal infections. CRP and BSR are almost al- ways elevated while the WBC can remain normal. The major drawback of standard radiography is the delay in the appearance of radiographic signs. The sequence of changes demonstrable on radiographs is blurred endplates, disc space collapse, develop- ment of osteolysis and a paravertebral shadow, re- active sclerosis and kyphotic deformity. MRI is the imaging modality of choice. Characteristic findings on MRI suggestive of spinal infections are de- creased vertebral endplate signal intensity on T1W images, loss of endplate definition, increased signal intensity on T2W images, and contrast enhance- ment of the disc and vertebral endplates. The isola- tion of the causative organism is very important andmustbeattemptedineverycase.CT-guided biopsy is the method of choice because it allows the sample to be taken from inside the lesion. The most frequently found organisms are Staphylococ- cus aureus (30 –55%), E. coli, Salmonella, Enterococ- cus, Proteus mirabilis, Pseudomonas aeruginosa (in 65%ofdrugabusers),Streptococcus viridans,and epidermatitis. In the absence of a life-threatening condition, treatment should not be started without vigorous attempts to isolate the causative organ- ism. The likelihood of isolating the organism after the beginning of antibiotic treatment is minimal. Non-operative treatment. The general objectives of treatment are to eradicate the infection, relieve pain, prevent or reverse a neurologic deficit, re- store spinal stability, correct spinal deformity, and prevent recurrence. Antibiotic treatment is the therapy of choice for uncomplicated cases. Che- motherapy should not be stopped prior to normal- ization of the infectious parameters (CRP, BSR, WBC) and is usually given for 6 –12 weeks. Early ambulation is attempted and a corset can be used optionally. In cases of spinal tuberculosis, a triple (isoniazid, rifampin, and pyrazinamide) or quadru- ple chemotherapy (plus ethambutol) is recom- mended for 2 –3 months. After this period, chemo- therapy should be continued with isoniazid and ri- fampin in the absence of resistance or side effects. While there is still debate on the duration of treat- ment, a total of 12 months is favored by the majori- ty of experts. Operative treatment. Surgery is indicated in cases of disease progression despite adequate antibiotic treatment, progressive spinal deformity and insta- bility,andneurological compromise.Thekeyto 1036 Section Tumors and Inflammation successful surgery is radical debridement. This has been well demonstrated for the treatment of spinal tuberculosis, but is applicable to pyogenic infec- tions as well. Radical debridement and bone graf- ting are indicated in patients with intravertebral abscess and without gross bony destruction, defor- mity, and instability. However, in many cases addi- tional spinal stabilization is required. Instrumenta- tion is still controversial in the literature, but an increasing number of articles have demonstrated that implants can be used without side effects. Spi- nal instrumentation promotes rather than prevents resolution of the infection because of the added stability. Posterior instrumentation with correction of the deformity, followed by anterior radical debridement and bone grafting, is the method of choice for a spinal infection with predominant anterior column involvement of the thoracolumbar spine. Implants can be used atthesiteofinfection (e.g., in the cervical spine) with the prerequisite that radical debridement is thoroughly achieved. Key Articles Hodgson AR (1964) Report on the findings and results in 30 0 cases of Pott’s disease treated by anterior fusion of the spine. J West Pacific Orthop Assoc 1:3–7 Landmark paper favoring surgical treatment of spinal tuberculosis in a series of 300 cases. MoonMS,WooYK,LeeKS,HaKY,KimSS,SunDH(1995) Posterior instrumentation and anterior interbody fusion for tuberculous kyphosis of dorsal and lumbar spines. Spine 20:1910 – 6 This paper summarizes present knowledge of spinal tuberculosis and its management. Antituberculosis agents remain the mainstay of management, with chemotherapy for 12 months preferred to shorter courses. Anterior surgery consisting of radical focal debride- ment without fusion does not prevent vertebral collapse. Patients who present late with deformity are candidates for anterior debridement and stabilization with corrective instrumentation. Posterior stabilization with instrumentation has been found to help arrest the disease and to bring about early fusion. Posterior instrumented stabilization to prevent kyphosis in early spinal tuberculosis is indicated, however, only when anterior and posterior elements of the spine are involved, particularly in children. Carragee EJ (1997) Instrumentation of the infected and unstable spine: a review of 17 cases from the thoracic and lumbar spine with pyogenic infections. J Spinal Disord 10:317 – 24 In a retrospective review of 17 consecutive cases of spinal instrumentation for pyogenic vertebral osteomyelitis (PVO) with follow-up of 2 years, the authors demonstrated that spinal instrumentation in selected cases of PVO allows for early mobilization and did not seem to compromise the ability to clear infection. In certain recalcitrant cases, stabiliza- tion seemed to promote clinical resolution of the infection. References 1. Barnes PF, Bloch AB, Davidson PT, Snider DE Jr (1991) Tuberculosis in patients with human immunodeficiency virus infection. N Engl J Med 324:1644–50 2.Batson OV (1942) The role of vertebral veins in metastatic processes. Ann Intern Med 16:38–45 3. Belzunegui J, Del Val N, Intxausti JJ, De Dios JR, Queiro R, Gonzalez C, Rodriguez-Valverde V, Figueroa M (1999) Vertebral osteomyelitis in northern Spain. Report of 62 cases. Clin Exp Rheumatol 17:447–52 4. Beronius M, Bergman B, Andersson R (2001) Vertebral osteomyelitis in Goteborg, Sweden: a retrospective study of patients during 1990–95. Scand J Infect Dis 33:527–32 5. Brancker A (1991) Tuberculosis in Canada, 1989. Health Rep 3:92–6 6. Breasted JH (1930) The Edwin Smith Surgical Papyrus. Chicago: University of Chicago Press, 1930: 425–426. 7. BrugieresP,GastonA,VoisinMC,RicolfiF,ChakirN(1992)CT-guidedpercutaneousbiopsy of the cervical spine: a series of 12 cases. Neuroradiology 34:358–60 8. Carragee EJ (1997) Instrumentation of the infected and unstable spine: a review of 17 cases fromthethoracicandlumbarspinewithpyogenicinfections.J.SpinalDisord.10:317–24 Infections of the Spine Chapter 36 1037 9. Chelsom J, Solberg CO (1998) Vertebral osteomyelitis at a Norwegian university hospital 1987 –97: clinical features, laboratory findings and outcome. Scand J Infect Dis 30:147– 51 10. Colmenero JD, Jimenez-Mejias ME, Sanchez-Lora FJ, Reguera JM, Palomino-Nicas J, Martos F, Garcia de las Heras J, Pachon J (1997) Pyogenic, tuberculous, and brucellar vertebral oste- omyelitis: a descriptive and comparative study of 219 cases. Ann Rheum Dis 56:709–15 11. Dagirmanjian A, Schils J, McHenry M, Modic MT (1996) MR imaging of vertebral osteomy- elitis revisited. AJR Am J Roentgenol 167:1539– 43 12. Eysel P, Hopf C, Vogel I, Rompe JD (1997) Primary stable anterior instrumentation or dorso- ventral spondylodesis in spondylodiscitis? Results of a comparative study. Eur Spine J 6:152–7 13. Fam AG, Rubenstein J (1993) Another look at spinal tuberculosis. J Rheumatol 20:1731–40 14. Faraj AA, Webb JK (2000) Spinal instrumentation for primary pyogenic infection report of 31 patients. Acta Orthop Belg 66:242–7 15. Fernandez M, Carrol CL, Baker CJ (2000) Discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics 105:1299–304 16. Glazer PA, Hu SS (1996) Pediatric spinal infections. Orthop Clin North Am 27:111–23 17. Haaker RG, Senkal M, Kielich T, Kramer J (1997) Percutaneous lumbar discectomy in the treatment of lumbar discitis. Eur Spine J 6:98–101 18. Hadjipavlou AG, Crow WN, Borowski A, Mader JT, Adesokan A, Jensen RE (1998) Percuta- neous transpedicular discectomy and drainage in pyogenic spondylodiscitis. Am J Orthop 27:188–97 19. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ (2000) Hematogenous pyogenic spi- nal infections and their surgical management. Spine 25:1668–79 20. Halsey JP, Reeback JS, Barnes CG (1982) A decade of skeletal tuberculosis. Ann Rheum Dis 41:7–10 21. Hee HT, Majd ME, Holt RT, Pienkowski D (2002) Better treatment of vertebral osteomyelitis using posterior stabilization and titanium mesh cages. J Spinal Disord Tech 15:149–56; dis- cussion 156 22. Hlavin ML, Kaminski HJ, Ross JS, Ganz E (1990) Spinal epidural abscess: a ten-year perspec- tive. Neurosurgery 27:177–84 23. Hodgson AR (1964) Report on the findings and results in 300 cases of Pott’s disease treated by anterior fusion of the spine. J West Pacific Orthop Assoc 1:3–7 24. Jellis JE (1995) Bacterial infections: bone and joint tuberculosis. Baillieres Clin Rheumatol 9:151–9 25. Krodel A, Kruger A, Lohscheidt K, Pfahler M, Refior HJ (1999) Anterior debridement, fusion, and extrafocal stabilization in the treatment of osteomyelitis of the spine. J Spinal Disord 12:17–26 26. Krogsgaard MR, Wagn P, Bengtsson J (1998) Epidemiology of acute vertebral osteomyelitis in Denmark: 137 cases in Denmark 1978–1982, compared to cases reported to the National Patient Register 1991–1993. Acta Orthop Scand 69:513–7 27. Lannelongue OM (1897) On acute osteomyelitis. Miscellaneous, pathological and practical medicine tracts. Paris: 1897 28. Loke TK, Ma HT, Chan CS (1997) Magnetic resonance imaging of tuberculous spinal infec- tion. Australas Radiol 41:7–12 29. Lu CH, Chang WN, Lui CC, Lee PY, Chang HW (2002) Adult spinal epidural abscess: clinical features and prognostic factors. Clin Neurol Neurosurg 104:306–10 30. Luk KD (1999) Tuberculosis of the spine in the new millennium. Eur Spine J 8:338–45 31. Makins GH, Abbott FC (1896) On acute primary osteomyelitis of the vertebrae. Ann Surg 23:510–539 32. Moon MS (1997) Tuberculosis of the spine. Controversies and a new challenge. Spine 22:1791–7 33. Moon MS, Woo YK, Lee KS, Ha KY, Kim SS, Sun DH (1995) Posterior instrumentation and anterior interbody fusion for tuberculous kyphosis of dorsal and lumbar spines. Spine 20:1910–6 34. Omarini LP, Garcia J (1993) CT-guided percutaneous puncture-biopsy of the spine. Review of 104 cases. Schweiz Med Wochenschr 123:2191 – 7 35. Pertuiset E (1999) Medical therapy of bone and joint tuberculosis in 1998. Rev Rhum Engl Ed 66:152–7 36. Pertuiset E, Beaudreuil J, Liote F, Horusitzky A, Kemiche F, Richette P, Clerc-Wyel D, Cerf- Payrastre I, Dorfmann H, Glowinski J, Crouzet J, Bardin T, Meyer O, Dryll A, Ziza JM, Kahn MF, Kuntz D (1999) Spinal tuberculosis in adults. A study of 103 cases in a developed coun- try, 1980–1994. Medicine (Baltimore) 78:309–20 37. Pott P (1779) Remarks on that kind of palsy of the lower limbs which is frequently found to accompany a curvature of the spine. London: I. Johnson, 1779 38. Rieder HL, Cauthen GM, Kelly GD, Bloch AB, Snider DE, Jr (1989) Tuberculosis in the United States. JAMA 262:385–9 39. Rieneck K, Hansen SE, Karle A, Gutschik E (1996) Microbiologically verified diagnosis of infectious spondylitis using CT- guided fine needle biopsy. APMIS 104:755–62 1038 Section Tumors and Inflammation 40. Rigamonti D, Liem L, Sampath P, Knoller N, Namaguchi Y, Schreibman DL, Sloan MA, Wolf A, Zeidman S (1999) Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol 52:189–96; discussion 197 41. Ring D, Johnston CE, 2nd, Wenger DR (1995) Pyogenic infectious spondylitis in children: the convergence of discitis and vertebral osteomyelitis. J Pediatr Orthop 15:652–60 42. Safran O, Rand N, Kaplan L, Sagiv S, Floman Y(1998) Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteo- myelitis of the lumbar spine. Spine 23:1885–90 43. Sapico FL, Montgomerie JZ (1979) Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis 1:754– 76 44. Sapico FL, Montgomerie JZ (1990) Vertebral osteomyelitis. Infect Dis Clin North Am 4: 539–50 45. Schmitz A, Risse JH, Grunwald F, Gassel F, Biersack HJ, Schmitt O (2001) Fluorine-18 fluo- rodeoxyglucose positron emission tomography findings in spondylodiscitis: preliminary results. Eur Spine J 10:534–9 46. Shanley DJ (1995) Tuberculosis of the spine: imaging features. AJR Am J Roentgenol 164: 659–64 47. Stumpe KD, Zanetti M, Weishaupt D, Hodler J, Boos N, Von Schulthess GK (2002) FDG posi- tron emission tomography for differentiation of degenerative and infectious endplate abnormalities in the lumbar spine detected on MR imaging. AJR Am J Roentgenol 179: 1151–7 48. Tyrrell PN, Cassar-Pullicino VN, McCall IW (1999) Spinal infection. Eur Radiol 9:1066 – 77 49. Wenger DR, Bobechko WP, Gilday DL (1978) The spectrum of intervertebral disc-space infection in children. J Bone Joint Surg Am 60:100–8 50. Wiley AM, Trueta J (1959) The vascular anatomy of the spine and its relation to pyogenic vertebral osteomyelitis. J Bone Joint Surg 41B:796– 809 Infections of the Spine Chapter 36 1039 37 Rheumatoid Arthritis Dieter Grob Core Messages ✔ Rheumatoid arthritis (RA) most commonly affects the cervical spine ✔ Tissue destruction causes instability of the atlantoaxial segment ✔ Compressive myelopathy is the consequence of instability and repetitive trauma ✔ The “wait and see” policy is rarely advocated ✔ Early surgery prevents extensive and risky inter- ventions ✔ Marked osteoporosis requires anterior and pos- terior procedures in advanced stages of the dis- ease ✔ Consider structural weakness of bone in the planning of the extent of fusion (adjacent seg- ment decompensation) ✔ Inclusion of the occiput into the fusion usually requires fusion of the whole cervical spine Epidemiology Rheumatoid arthritis (RA) is a worldwide disease. The original theory, that RA only occurs in areas with cold and wet weather conditions, turned out to be wrong; however, its incidence does seem to vary between countries [1]. Anterior atlantoaxial dis- placement is the most frequent cervical instability encountered in RA In about 40% of all patients with RA, the cervical spine is involved with neck pain, and of these patients, approximately 50% show instability of the upper cer- vical spine complex (occiput to C2) [17]. The most common instability is the anterior translational C1/2 instability, but lateral or posterior subluxation occurs in a minority of patients. In approximately 20%, vertical migration of the dens may be observed, and 15–20% suffer from subaxial instability with subluxa- tions and spinal stenosis. In spite of the success of modern medical treatment and the decreasing inci- dence of manifest instability of the spine, surgery will remain one of the treat- ment options in advanced stages of the disease. While in the second half of the Despite the success of modern medical treatment, surgery will remain a valid option for non-responders last century decompressive and stabilizing surgery was the only solution for severe alterations due to RA and thus represented some kind of last resort for neglected RA patients, surgery in the future will be the option for non-respond- ers to modern chemical treatment or untreated “leftovers” [7]. Pathogenesis Rheumatoid arthritis affects synovial tissue, finally forming an inflammatory pannus, which represents an aggressive tissue with consecutive destruction of discoligamentous structures and bony elements around the facets. Due to the anatomical configuration of the atlantoaxial segment, the manifestation of RA is most often observed in the upper cervical spine. The three-dimensional motion in the atlantoaxial segment is controlled exclusively by the joint capsule and the Tumors and Inflammation Section 1041 a b c d e Case Introduction At the time of first pre- sentation the patient was 52 years old and had suf- fered from rheumatoid arthritis for 4 years. Due totheaggressivecourse of the disease she had had her hips and knees replaced due to rheuma- toid destruction of these joints. Her neck problem was revealed by the flex- ion radiograph of her cervical spine, where a reducible subluxation of the atlas was detected ( a). Due to persisting pain, atlantoaxial fixation was performed by trans- articular screw fixation. In spite of several other subsequent interven- tions, the patient was without symptoms in her neck for several years and a routine check-up 6 years postsurgery showed solid fusion of the atlantoaxial segment in an anatomical posi- tion. Twelve years after hernecksurgery,she started to have painful sensations in her neck; however, she refused to seek medical advice, being afraid of needing further intervention (she had sustained a total of 23 interventions due to her rheumatoid disease up to that date!). The functional views revealed an subaxial instability ( b, c). However, the pain became more intensive and she noted increas- ing clumsiness of her hands. She finally presented with a stiff and painful neck. A hyperreflexia of upper and lower extremities was found together with sensory disturbances in her hands. A neurophysiological examination confirmed the presence of a significant cervical myelopathy. The radiographs showed decompensation of the adjacent levels with significant retroposition of the vertebral body C3 producing severe spinal stenosis ( d, e). 1042 Section Tumors and Inflammation fg Case Introducton (Cont.) A one-stage surgery was performed with initial anterior resection of the vertebral body of C3. With this step, decompres- sion of the spinal canal and reduction of the deformity was achieved. In the same sitting, posterior fixation was carried out to maintain reduction and stability. Laminectomy and flavectomy were performed at the same time to decompress posteriorly. Since there was no upward migration or pathology in the atlanto-occipital joint, the occiput was not included in the fixation ( f, g). After surgery, the patient recovered well and noticed an improvement in the dexterity of her hands and a reduction of the paresthesias. ligaments – with the exception of extension, in which the dens axis serves as a bony blocker. With the destruction of the capsuloligamentous elements, a mainly horizontally orientated instability ( Fig. 1) occurs, which is complicated by subse- quent bony arrosion of dens and lateral masses of the atlas, leading to an addi- tional upward migration of the atlantoaxial complex towards the foramen mag- num. Pannus formation is related to instability The inflammatory pannus seems to be one of the key factors in tissue destruction. If there is no motion, there is no pannus formation and – as a con- sequence – no tissue destruction occurs [10]. In this view, surgically induced fusion, e.g. of the atlantoaxial joint, prevents the destructive process and there- fore prevents the transformation of a horizontal instability into a vertical insta- bility [10] ( Fig. 1 ). The subaxial cervical spine may also show instability and spinal stenosis due to RA changes. Facet joint and disc destruction as well as bony erosion cause Disc/facet joint destruction and bony erosion cause subaxial instability anterolisthesis and loss of lordosis and – with increasing deformity – spinal ste- nosis with encroachment of the medulla and nerve roots. Even if the involvement of the lower cervical spine is mostly primary in the underlying disease, it may occur secondarily as a consequence of increased lever arms due to stabilizing procedures of the upper cervical spine ( Case Introduction). The lumbar spine may also be involved in RA patients; however, here the con- sequences of long-standing steroid therapy rather than disease specific alter- ations are predominant. Therefore, degenerative spondylolisthesis and vertebral fractures may be observed. Rheumatoid Arthritis Chapter 37 1043 . the findings and results in 30 0 cases of Pott’s disease treated by anterior fusion of the spine. J West Pacific Orthop Assoc 1:3–7 Landmark paper favoring surgical treatment of spinal tuberculosis. the success of modern medical treatment and the decreasing inci- dence of manifest instability of the spine, surgery will remain one of the treat- ment options in advanced stages of the disease destruction and bony erosion cause subaxial instability anterolisthesis and loss of lordosis and – with increasing deformity – spinal ste- nosis with encroachment of the medulla and nerve roots.