Atlantoaxial instability and neurologic indicators in rheumatoid arthritis

Atlantoaxial subluxation in rheumatoid arthritis is characterized by pain, disability, and occasionally death. Surgical fusion of the offending vertebrae is the appropriate surgical remedy, but it is a procedure with a high failure and complication rate. Because cord compression and myelopathy are the main complications of this condition, it would be logical to use evidence of early neurologic deficit as an indicator for surgery. A group of 250 patients with rheumatoid arthritis were investigated to evaluate the neurologic status with respect to the degree of instability in the proximal cervical spine. Neurologic isolated signs such as hyperreflexia could not be correlated with the onset of cervical myelopathy or quadraparesis or to the radiographically measured degree of atlantoaxial instability. These signs should not be used as an indication for surgery. The positive indications are intractable pain, cervical myelopathy, and severe atlantoaxial instability.