[An unnoticed dislocation of the dens axis in a patient with primary chronic polyarthritis undergoing intensive...

Involvement of the cervical spine is seen in 40%-60% of all patients with rheumatoid arthritis. Consequences are instability of the upper cervical column with pain and neurological deficits, in some cases tetraplegia, and sudden death. From this reason special care has to be taken in the management of those patients, even when they are comatose or anesthetized, to avoid sudden spinal cord compression with irreversible neurological deficits. We report a 49-year-old female with a history of rheumatoid arthritis for more than 10 years. Because of an adhesive ileus complicated by septicemia, she underwent abdominal surgery twice followed by prolonged mechanical ventilation under high doses of sedative drugs. After reduction of the tranquilizer doses tetraplegia with respiratory insufficiency was found. Neurophysiological and X-ray examinations showed spinal cord compression due to dislocation of the odontoid process, a rare but typical complication in patients with rheumatoid arthritis. It was not possible to determine the date of the dislocation, but it might have been caused by intubation or respositioning. Although the patient underwent immobilization and surgical fusion of the upper cervical spine, there was no improvement in the neurological status and she died 5 months later. In patients with advanced rheumatoid arthritis a detailed medical history, clinical examination, and radiography are necessary before general anesthesia or intensive care with intubation is considered. If an unstable cervical spine is suspected, intubation should be performed by fiberoptic technique under light sedation. Regional anesthesia should be preferred over general anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)