Sudden death from cord compression associated with atlanto-axial instability in rheumatoid arthritis. A case report

We have presented a case of death from AAS in a rheumatoid patient. We believe her cardiac arrest was caused by an acute myocardial infarction (MI) or dysrhythmia. We cannot determine whether the MI/dysrhythmia was itself a lethal event. The damage to her lower medulla and upper cervical cord, which most likely occurred at the time of her intubation, was a lethal injury. The presence of spinal cord ischemic changes and acute inflammatory cells within the cord indicate that the cervical spine injury occurred premortem. This patient had no neck pain, no neurologic symptoms or signs, and had AAS of 8 mm. Weissman suggests that 9 mm of AAS is the critical amount. The 1-mm subluxation difference here is probably not significant, because there is inherent error when measuring radiographs. We took into account her clinical and radiographic data, and decided to manage her C1-C2 articulation nonoperatively. Nevertheless, her atlanto-axial joint consisted of abnormal soft and hard tissue. This joint was satisfactory for her usual activities of daily living. The anteroposterior forces generated during ACLS intubation, which are unlikely to disrupt a normal atlanto-axial joint, were sufficient to subluxate her joint. This case demonstrates that it behooves us to maintain a high level of awareness for potential cervical spine problems in all rheumatoid arthritis patients.