When a patient with rheumatoid arthritis develops cervical instability and/or spinal stenosis with myelopathy, surgical intervention is considered. The goal of surgery is to stabilize the spine and remove the compression from the spinal cord, to improve a patient's pain and level of function, as well as prevent further deterioration of function and worsening pain. A patient with isolated cranial settling and/or atlanto-axial instability without cord compression can be treated with posterior (back of the neck) occipital-cervical fusion with instrumentation. However, patients with severe anterior (front of the neck) cord compression from a pannus at the C1-C2 joint will be indicated for a transoral decompression surgery combined with a posterior occipital-cervical fusion with instrumentation. Patients with subaxial subluxation may have instability or stenosis, or both. Treatment options vary depending on each patient's clinical and radiopgraphic presentation. Patients with subaxial instability may only require a spinal fusion. Patients with stenosis and myelopathy require surgical decompression, and often fusion as well. If the majority of pressure is coming from osteophytes in the front (anterior) of the spine, then an anterior corpectomy with strut graft and fusion may be considered. If the majority of the compression is occurring due to ligamentum flavum hypertrophy in the back part of the spinal cord, then a laminectomy or laminaplasty may be performed. Occasionally, patients with severe, multiple level stenosis and instability will require both front (anterior) and back (posterior) of the neck surgery to adequately decompress and stabilize the spine. Generally, a cervical spinal fusion will always be required and recommended in addition to the decompression component. Spinal instrumentation will typically be utilized to impart immediate stability and increase the fusion (bone healing and mending together) rate. There is a higher rate of improvement for rheumatoid patients with cervical instability and/or neurologic dysfunction treated surgically than those treated nonsurgically. However, careful preoperative evaluation and delicate perioperative and postoperative management is particularly important to ensure success and avoid complications.
Vaughn-Jackson syndrome describes the rupture of the hand digital extensor tendons, which start on the ulnar side of the wrist first and then move radially. This is thought to occur from DRUJ instability, resulting in dorsal prominence of the ulnar head, leading to an attritional rupture of the extensor tendons. Extensor digiti minimi is the extensor tendon commmonly ruptured.
Vaughn-Jackson first described the condition in his case report in JBJS in 1948.
Williamson et al. report on Vaughn-Jackson syndrome, and note that prevention is the best method of treatment of this finding. They note that consideration of the surrounding arthritic changes must be taken into account when treating chronic dorsal tendon attrition.
1) Cranial migration of dens from soft tissue erosion and bone loss between occiput and C1&C2 describes basilar invagination.
2) Rupture of flexor pollicis longus in the carpal tunnel describes Mannerfelt syndrome.
3) Synovitis in the DRUJ leading to supination of the carpal bones away from the head of the ulna describes Caput-ulna syndrome.
5) Synovitis of the MTP joints with eventual hyperextension deformity of the MTP is a common toe deformity seen with RA.