✓ Cervical spine involvement by rheumatoid arthritis is common; brain-stem compression secondary to vertical subluxation of the odontoid in patients with rheumatoid arthritis is rare. Vertical subluxation results from 1) destruction of the transverse atlantal, apical, and alar ligaments of the atlas and odontoid, and 2) bone resorption in the occipital condyles, lateral masses of the atlas, and basilar processes of the skull. Neurological symptoms result from direct compression of the brain stem or from ischemia secondary to compression of vertebral arteries, anterior spinal arteries, or small perforating arteries of the brain stem and spinal cord. A case is reported in which a slowly progressive neurological deficit developed in a woman with rheumatoid arthritis following a fall from a stretcher. Neurological symptoms represented direct compression of the medulla by the dens, a mechanism confirmed at operation and autopsy.
Recognition of progressive neurological deficit is often difficult in patients with rheumatoid arthritis because of their inactivity and their atrophic and immobile joints, but is essential if appropriate decompressive or stabilizing procedures are to be done. In patients with vertical subluxation of the dens, the transoral approach with removal of the odontoid is recommended. Decompression should be extensive, including the fibrous capsule around the odontoid and overlying synovial tissue as well as the odontoid itself.
DavisFWJrMarkleyHE: Rheumatoid arthritis with death from medullary compression.Ann Intern Med35:451–4541951Davis FW Jr Markley HE: Rheumatoid arthritis with death from medullary compression. Ann Intern Med 35:451–454 1951
GreenbergADScovilleWBDaveyLM: Transoral decompression of atlanto-axial dislocation due to odontoid hypoplasia. Report of two cases.J Neurosurg28:266–2691968Greenberg AD Scoville WB Davey LM: Transoral decompression of atlanto-axial dislocation due to odontoid hypoplasia. Report of two cases. J Neurosurg 28:266–269 1968
NakanoKKSchoeneWCBakerRAet al: The cervical myelopathy associated with rheumatoid arthritis: analysis of 32 patients, with 2 postmortem cases.Ann Neurol3:144–1511978Nakano KK Schoene WC Baker RA et al: The cervical myelopathy associated with rheumatoid arthritis: analysis of 32 patients with 2 postmortem cases. Ann Neurol 3:144–151 1978