Principles of surgical treatment of the cervical spine in rheumatoid arthritis

About 20% of patients with rheumatoid arthritis complain about neck problems based on instability and deformity. As a consequence, pain, myelopathy, and severe neurological deficit may occur. Results reported in the literature were not encouraging as regards surgical decompression and stabilization. However, new surgical techniques allow a more aggressive strategy towards the complex problem of the instable cervical spine in rheumatoid arthritis. The most frequent instability of C1/2 can be stabilized by a posterior atlantoaxial screw fixation, a three-dimensional multidirectional construct with few complications. For the inclusion of the occiput into the fusion and the extension of the fusion down to the lower cervical spine, a titanium Y-plate is presented as a successful implant. While through a posterior approach, stability may be achieved, decompression is preferably done by anterior diskectomy or vertebrectomy. Encouraging results with a significant recovery of neurological deficits justify an early intervention in cases of instability of the cervical spine in rheumatoid arthritis.