Treatment of the cervical spine in rheumatoid arthritis

Of thirty-four selected patients who had rheumatoid arthritis and subluxations of the atlanto-axial and other joints of the cervical spine, eighteen were treated operatively and sixteen were treated non-operatively. Of the subluxations of the atlanto-axial joint, nineteen were anterior; four, posterior; and eleven, vertical. Additionally, subaxial subluxations were seen in three patients. At the time of treatment, the mean duration of the rheumatoid disease was 19.4 years and the mean duration of the disorders of the cervical spine was 4.5 years. After treatment the patients were followed for an average of 2.2 years (range, six months to six years). Of the thirty-four patients, two (both of whom were treated non-operatively) died of causes unrelated to the lesions of the cervical spine and were excluded from this study. Of the remaining thirty-two patients, eighteen were treated operatively and fourteen, non-operatively. The two groups were roughly comparable with respect to the lesions of the cervical spine, but more of the patients who were treated surgically showed evidence of compression of the cord as demonstrated by computed tomography and myelography. The thirty-two patients were not randomized in the two groups; therefore, comparison of the findings in these groups is not completely valid. Surgical treatment of the eighteen patients included an atlanto-axial fusion in thirteen and an occipitocervical fusion in five. In addition, two patients who had an occipitocervical fusion also had a subaxial laminectomy and posterior fusion. There was a superficial wound infection, which was treated successfully with short-term antibiotic therapy, in two patients. No patient died postoperatively. Occipital pain was relieved in twelve of the fifteen operatively treated patients who had pain, whereas pain was relieved in only one of the eight conservatively treated patients who had pain. At follow-up, neurological function was unchanged or improved in the operatively treated group but was slightly worse in the conservatively treated group. We concluded that fusion of an unstable rheumatoid cervical spine relieves pain and prevents progression of existing neural lessons without undue risk for the patient.