The Open Orthopaedics Journal




ISSN: 1874-3250 ― Volume 13, 2019

Surgical Management of Cervical Spondyloarthropathy in Hemodialysis Patients



Panayiotis Spinos1, Charalambos Matzaroglou*, 2, Meni Partheni1, Deli Angeliki2, Menelaos Karanikolas3, Dimitrios Konstantinou4
1 Department of Neurosurgery, Patras University Hospital, Rion, Greece
2 Department of Orthopaedic Surgery, Patras University Hospital, Rion, Greece
3 Department of Anaesthesiology and Critical Care Medicine, University of Patras School of Medicine, Rion, Greece
4 Department of Neurosurgery, University of Patras School of Medicine, Rion, Greece

Abstract

Dialysis-related spondyloarthropathy is a rare cause of spinal deformity and cervical myelopathy. Optimal management of cervical spine spondyloarthropathy often requires circumferential reconstructive surgery, because affected patients typically have both the anterior column and the facet joints compromised. The occasional presence of noncontiguous or "skip lesions" adds an additional level of complexity to surgical management, because decompression and fusion in an isolated segment of neural compression can worsen spine deformity by applying increased stress to adjacent cervical spine segments. We report two cases of hemodialysis patients who presented with cervical myelopathy and initially had anterior cervical discectomy or corpectomy. Because symptoms recurred due to hardware failure, both patients required posterior spine fusion as well. In retrospect, because of the hardware failure, both of these patients might have benefited from a circumferential (combined anterior and posterior) cervical spine reconstruction as their initial treatment.

Keywords: Hemodialysis, spondyloarthropathy, surgical management..


Article Information


Identifiers and Pagination:

Year: 2010
Volume: 4
First Page: 39
Last Page: 43
Publisher Id: TOORTHJ-4-39
DOI: 10.2174/1874325001004010039

Article History:

Received Date: 2/12/2009
Revision Received Date: 21/12/2009
Acceptance Date: 22/12/2010
Electronic publication date: 19/1/2010
Collection year: 2010

Article Metrics:

CrossRef Citations:
0

Total Statistics:

Full-Text HTML Views: 1879
Abstract HTML Views: 1131
PDF Downloads: 328
Total Views/Downloads: 3338

Unique Statistics:

Full-Text HTML Views: 890
Abstract HTML Views: 583
PDF Downloads: 197
Total Views/Downloads: 1670
Geographical View

© Spinos et al.; Licensee Bentham Open.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.5/) which permits unrestrictive use, distribution, and reproduction in any medium, provided the original work is properly cited.


* Address correspondence to this author at the Department of Orthopaedics, University of Patras, Rion, Greece; Tel: +30 2610 999556; Fax: +30 2610 994579; E-mail: orthopatras@yahoo.gr





INTRODUCTION

Since first described by Kuntz in 1984, dialysis-related spondyloarthropathy has been recognized as a rare cause of cervical myelopathy and deformity [1Kuntz D, Naveau B, Bardin T, Drueke T, Treves R, Dryll A. Destructive spondylarthropathy in hemodialyzed patients. A new syndrome Arthritis Rheum 1984; 27(4): 369-75.]. Deposition of β2 microglobulin amyloid, which is seen in nearly all hemodialysis patients at post-mortem [2Danesh F, Ho LT. Dialysis-related amyloidosis: history and clinical manifestations Semin Dial 2001; 14(2): 80-5.], seems to be a key factor in the development of hemodialysis-related complications, because amyloid deposition in cartilage surfaces, tendons, and ligaments leads to destruction of joints and surrounding bone. Frequently encountered clinical manifestations of amyloid deposition in dialysis patients include carpal tunnel syndrome and generalized chronic arthropathy. In the spine, thickening of the posterior longitudinal ligament may cause spinal cord compression and destructive spondyloarthropathy (DSA), especially in the cervical spine [3Cuffe MJ, Hadley MN, Herrera GA, Morawetz RB. Dialysisassociated spondylarthropathy. Report of 10 cases J Neurosurg 1994; 80(4): 694-700.-5Shiota E, Naito M, Tsuchiya K. Surgical therapy for dialysisrelated spondyloarthropathy: Review of 30 cases J Spinal Disord 2001; 14(2): 165-71.], but renal osteodystrophy is also a possible cause of DSA.

Evaluation of cervical spine radiographs in hemodialysis patients demonstrates that DSA is common, but frequently asymptomatic, presumably due to the absence of deformity or neural compression [6Leone A, Sundaram M, Cerase A, Magnavita N, Tazza L, Marano P. Destructive spondyloarthropathy of the cervical spine in longterm hemodialyzed patients: A five-year clinical radiological prospective study Skeletal Radiol 2001; 30(8): 431-1.]. Length of dialysis treatment appears to be a predictive factor for development of the disease [6Leone A, Sundaram M, Cerase A, Magnavita N, Tazza L, Marano P. Destructive spondyloarthropathy of the cervical spine in longterm hemodialyzed patients: A five-year clinical radiological prospective study Skeletal Radiol 2001; 30(8): 431-1.]. Destruction of adjacent endplates can make differentiation from discitis and vertebral osteomyelitis difficult on imaging grounds alone [7Flipo RM, Cotten A, Chastanet P, et al. Evaluation of destructive spondyloarthropathies in hemodialysis by computerized tomographic scan and magnetic resonance imaging J Rheumatol 1996; 23(5): 869-73.].

We present two hemodialysis patients with cervical myelopathy due to DSA. Both patients initially had anterior column surgery (discectomy or corpectomy, instrumentation and fusion) but later required revision combined with posterior instrumentation due to hardware failure and myelopathy recurrence.

PATIENT 1

A 68-year-old man with a 7-year history of hemodialysis presented with a six-month history of progressively worsening neck pain, hand numbness and gait disturbance. Neurologic examination was unremarkable, except for bilateral decrease in pinprick sensation affecting the hands in a non-dermatomal distribution, and bilateral positive Hoffman's reflexes. Laboratory evaluation, including complete blood count and serum electrolytes was unremarkable, except for high blood urea and serum creatinine, consistent with renal failure. Lateral cervical spine flexion-extension radiographs showed cervical spondyloarthropathy with vertebral body degeneration, C3-C4 and C4-C5 instability and spurs (Figs. 1, 2), whereas cervical spine MRI demonstrated spinal cord impingement at the C3-C4 level (Fig. 3).

Fig. (1)

Lateral cervical spine extension X-Ray showing spondyloarthropathy with vertebral body degeneration, C3-C4 and C4-C5 instability and spurs.



Fig. (2)

Lateral cervical spine flexion X-Ray showing spondyloarthropathy with vertebral body degeneration, C3-C4 and C4-C5 instability and spurs.



Fig. (3)

Cervical spine MRI demonstrating spinal cord impingement at the C3-C4 level. Red arrows show the point of cord impingement.



Based on these findings, the patient had anterior cervical discectomy and fusion at C3-C4 and C4-C5 using PEEK allograft, and anterior fixation with dynamic plate and screws from C3 to C5 (Fig. 4). Postoperatively, the patient experienced marked improvement: hand numbness and neck pain completely resolved while gait disturbance improved significantly. However, 14 months later he returned to the Outpatient Clinic with recurrence of neck pain and gait disturbance over a 2-month period. Although repeat cervical spine MRI scan did not reveal any abnormal findings, lateral cervical spine flexion-extension radiographs revealed hardware failure with cervical spine instability (Figs. 5, 6). Based on these findings, the patient underwent supplemental posterior cranio-cervical stabilization and fusion with occipital and lateral mass screws, rods and allograft (Fig. 7). Postoperatively, the patient experienced immediate symptom improvement, and was discharged home on postoperative day 4. Two years later, the fusion remains stable; the patient is doing well, and denies any symptom recurrence.

Fig. (4)

Lateral cervical spine X-Ray showing anterior cervical discectomy and fusion at C3-C4, C4-C5 using PEEK allograft, and anterior fixation with dynamic plate and screws from C3 to C5.



Fig. (5)

Lateral cervical spine flexion X-Ray, which, in conjunction with extension X-Ray (Fig. 6) reveals hardware failure with cervical spine instability.



Fig. (6)

Lateral cervical spine extension X-Ray, which, in conjunction with flexion X-Ray (Fig. 5) reveals hardware failure with cervical spine instability.



Fig. (7)

Lateral cervical spine X-Ray showing posterior craniocervical stabilization and fusion with occipital and lateral mass screws, rods and allograft.



PATIENT 2

A 77-year-old patient, who had been on hemodialysis for 4 years, came to the Emergency Room for evaluation of bilateral proximal upper extremity weakness, progressively worsening over a 4-day period. The patient also reported worsening neck pain radiating to both arms (C4 and C5 distribution) for 2 months. Neurologic examination demonstrated bilateral deltoid and biceps muscle weakness, but no other abnormal findings. Laboratory evaluation showed elevated urea and serum creatinine levels, consistent with end-stage renal disease. Plain cervical spine films and computed tomography revealed partial destruction of the C3 and extensive destruction of the C4 and C5 vertebral bodies (Figs. 8, 9). MRI scan demonstrated mild compression of the anterior subarachnoid space and impingement of the C5-C6 roots, but no spinal cord abnormalities.

Fig. (8)

Cervical spine lateral X-Ray showing partial destruction of the C3 and extensive destruction of the C4 and C5 vertebral bodies.



Fig. (9)

Computed Tomography of the cervical spine, showing partial destruction of the C3 and extensive destruction of the C4 and C5 vertebral bodies.



Based on these findings and because upper extremity weakness was progressing, the patient had anterior C4 and C5 corpectomy and fusion using iliac crest autograft and anterior stabilization with dynamic plate and screws from C3 to C6 (Fig. 10). In the immediate postoperative period, he noted significant improvement of neck pain but radiculopathy symptoms did not improve. Then, on postoperative day 2, the patient experienced acute, severe neck pain recurrence while ambulating. Repeat cervical spine CT scan showed hardware failure at C3 with anterior shift of the autograft (Fig. 11).

Fig. (10)

Lateral cervical spine X-Ray showing anterior corpectomies and fusion using autograft and dynamic plate and screws from C3 to C6.



Fig. (11)

Postoperative cervical spine CT showing hardware failure at C3 with anterior shift of the allograft.



The patient then underwent repeat cervical spine surgery, which consisted of anterior fusion revision with replacement of the displaced screws and autograft, combined with supplementary posterior fixation and fusion using lateral mass screws from C3 to C7, rods and allograft (Fig. 12). Postoperatively, the patient experienced complete resolution of neck and arm pain and moderate improvement of upper extremities weakness. He was discharged home on postoperative day 7, and remains pain-free after 14 months.

Fig. (12)

Lateral cervical spine X-Ray showing revision of the anterior fusion with replacement of displaced screws, and posterior fusion with screws, rods and allograft from C3 to C7.



DISCUSSION

The optimal management of cervical spine DSA remains controversial. Albumi et al. believe that cervical spine DSA often requires circumferential reconstructive surgery, because affected patients typically have both the anterior columns and the facet joints compromised [4Abumi K, Ito M, Kaneda K. Surgical treatment of cervical destructive spondyloarthropathy (DSA) Spine 2000; 25(22): 2899-905.]. In contrast, Yuzawa et al. suggest that anterior long-span surgery may be too invasive in hemodialysis patients, whereas posterior decompression and fusion may be a reasonable, effective strategy for severe hemodialysis-associated cervical spondyloarthropathy with neurologic deficits [8Yuzawa Y, Kamimura M, Nakagawa H, et al. Surgical treatment with instrumentation for severely destructive spondyloarthropathy of cervical spine J Spinal Disord Tech 2005; 18(1): 23-8.]. On the other hand, Nair et al. reported two cases managed with anterior approach due to anterior compression, with one of the two requiring supplemental posterior fixation because of hardware failure and pseudarthrosis [9Nair S, Vender J, McCormack TM, Black P. Renal osteodystrophy of the cervical spine: Neurosurgical implications Neurosurgery 1993; 33(3): 349-54. Discussion 354-5]. Of note, because of poor bone quality and slow bone healing [3Cuffe MJ, Hadley MN, Herrera GA, Morawetz RB. Dialysisassociated spondylarthropathy. Report of 10 cases J Neurosurg 1994; 80(4): 694-700.,10Kumar A, Leventhal MR, Freedman EL, Coburn J, Delamarter R. Destructive spondyloarthropathy of the cervical spine in patients with chronic renal failure Spine 1997; 22(5): 573-7. Discussion 78], the incidence of loss of fixation and mechanical failure is high even with circumferential stabilization, and some patients require extension of the spinal fusion [11Sudo H, Ito M, Abumi K, et al. Long-term follow up of surgical outcomes in patients with cervical disorders undergoing hemodialysis J Neurosurg Spine 2006; 5(4): 313-9.]. Albumi et al. note that pedicles are a favorable site for fixation in DSA patients [4Abumi K, Ito M, Kaneda K. Surgical treatment of cervical destructive spondyloarthropathy (DSA) Spine 2000; 25(22): 2899-905.] because they demonstrate high pullout resistance in biomechanical studies and tend to maintain their integrity even when other spinal fixation points are diseased. Cervical pedicle screws, however, require precise placement, because injury to the spinal cord or vertebral artery may occur from an improper screw trajectory. Consequently, these concerns have led to limited acceptance of this technique.

The occasional presence of non-contiguous or “skip lesions” in these patients add complexity to surgical management; decompression and fusion at the level of neural compression can lead to deformity, by applying increased stress upon nearby spinal levels where there is bone loss from renal spondyloarthopathy.

In our cases, both patients had signs and symptoms of cervical myelopathy due to spondyloarthropathy and spinal cord compression. Because these lesions were located in front of the spinal cord, we chose to operate through the anterior approach, and proceeded with discectomy or corpectomy and fusion with peek or iliac crest autograft and fixation with dynamic plate. Despite initial improvement, however, both patients sustained hardware failure and symptom recurrence, requiring supplemental craniocervical stabilization or lateral mass screw fixation, respectively, with prompt symtom resolution.

The optimal surgical management of cervical spondyloarthropathy in dialysis-related patients is still unclear [8Yuzawa Y, Kamimura M, Nakagawa H, et al. Surgical treatment with instrumentation for severely destructive spondyloarthropathy of cervical spine J Spinal Disord Tech 2005; 18(1): 23-8.,9Nair S, Vender J, McCormack TM, Black P. Renal osteodystrophy of the cervical spine: Neurosurgical implications Neurosurgery 1993; 33(3): 349-54. Discussion 354-5], and there are no published guidelines or recommendations. However, it seems that patients treated from the beginning with circumferential reconstructive surgery and 360-degree fusion have the best results, with low incidence of symptom recurrence, while avoiding the risks of a second operation [4Abumi K, Ito M, Kaneda K. Surgical treatment of cervical destructive spondyloarthropathy (DSA) Spine 2000; 25(22): 2899-905.]. In our two cases, we chose the anterior approach to surgical reconstruction, due to location of the compression, and also because we wanted to avoid a long circumferential operation. However, because of hardware failure and symptom recurrence, a second operation became necessary in both patients. In retrospect, both of these patients might have benefited from a circumferential (combined anterior and posterior) cervical spine reconstruction as their initial treatment. Based on our limited experience, and also on published relevant experience from other spine surgery centers, we now believe that combined circumferential stabilization and decompression may be the treatment of choice from the beginning in this high risk patient population.

CONCLUSION

Destructive cervical spondyloarthropathy, occasionally involving non-contiguous spinal segments, can cause spinal instability or neurologic deficits in hemodialysis patients. Surgical management is challenging in this patient population, because of diffuse osteoporosis and slow bony healing, leading to a high incidence of hardware failure. In our opinion, because of the high probability of hardware failure, combined anterior and posterior cervical fixation should be the initial procedure of choice in these patients, thereby avoiding the risk and expense of a second operation in this high risk cohort. However, as not all experts agree on this, and there is clearly some controversy in the literature, more data, preferably from large, rigorous prospective studies are required before the controversy settles and guidelines or consensus statements can be formulated.

CONFLICT OF INTEREST STATEMENT

This work was supported solely by Department funds. All authors declare they have no conflict of interest to report.

REFERENCES

[1] Kuntz D, Naveau B, Bardin T, Drueke T, Treves R, Dryll A. Destructive spondylarthropathy in hemodialyzed patients. A new syndrome Arthritis Rheum 1984; 27(4): 369-75.
[2] Danesh F, Ho LT. Dialysis-related amyloidosis: history and clinical manifestations Semin Dial 2001; 14(2): 80-5.
[3] Cuffe MJ, Hadley MN, Herrera GA, Morawetz RB. Dialysisassociated spondylarthropathy. Report of 10 cases J Neurosurg 1994; 80(4): 694-700.
[4] Abumi K, Ito M, Kaneda K. Surgical treatment of cervical destructive spondyloarthropathy (DSA) Spine 2000; 25(22): 2899-905.
[5] Shiota E, Naito M, Tsuchiya K. Surgical therapy for dialysisrelated spondyloarthropathy: Review of 30 cases J Spinal Disord 2001; 14(2): 165-71.
[6] Leone A, Sundaram M, Cerase A, Magnavita N, Tazza L, Marano P. Destructive spondyloarthropathy of the cervical spine in longterm hemodialyzed patients: A five-year clinical radiological prospective study Skeletal Radiol 2001; 30(8): 431-1.
[7] Flipo RM, Cotten A, Chastanet P, et al. Evaluation of destructive spondyloarthropathies in hemodialysis by computerized tomographic scan and magnetic resonance imaging J Rheumatol 1996; 23(5): 869-73.
[8] Yuzawa Y, Kamimura M, Nakagawa H, et al. Surgical treatment with instrumentation for severely destructive spondyloarthropathy of cervical spine J Spinal Disord Tech 2005; 18(1): 23-8.
[9] Nair S, Vender J, McCormack TM, Black P. Renal osteodystrophy of the cervical spine: Neurosurgical implications Neurosurgery 1993; 33(3): 349-54. Discussion 354-5
[10] Kumar A, Leventhal MR, Freedman EL, Coburn J, Delamarter R. Destructive spondyloarthropathy of the cervical spine in patients with chronic renal failure Spine 1997; 22(5): 573-7. Discussion 78
[11] Sudo H, Ito M, Abumi K, et al. Long-term follow up of surgical outcomes in patients with cervical disorders undergoing hemodialysis J Neurosurg Spine 2006; 5(4): 313-9.

Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents




Webmaster Contact: info@benthamopen.net
Copyright © 2019 Bentham Open