Clinical course of conservatively managed rheumatoid arthritis patients with myelopathy

The clinical course of rheumatoid arthritis patients with myelopathy who do not undergo surgery was studied.

To establish a more accurate prognosis for rheumatoid arthritis patients who do not undergo surgery.

Cervical myelopathy has been reported in two thirds of rheumatoid arthritis patients with atlantoaxial dislocation. Atlantoaxial fusion, or occipitocervical fusion, is widely performed on these patients. However, several researchers reported serious complications from the surgery, including nonunion, worsening myelopathy, and high mortality. The natural course of disease in rheumatoid arthritis patients with myelopathy should be known before definitive treatments can be outlined.

Twenty-one rheumatoid arthritis patients with myelopathy resulting from atlantoaxial dislocation were studied. Fourteen of the 21 cases were associated with upward migration of the odontoid process. All of these patients were recommended for surgery, but they refused. Patients were reviewed by direct examination yearly. Radiographic changes and clinical course, including the survival rate, were observed.

Atlantodental interval and Redlund-Johnell measurements deteriorated. The patients showed no neural improvement, and deterioration was found in 16 (76%) cases during follow-up. All patients became bedridden within 3 years of the onset of myelopathy. Seven of the 21 patients died suddenly for unknown reasons, 3 died of pneumonia, and 1 died of multiple organ failure. The three sudden-death cases showed progressive upward migration of the odontoid process. The cumulative probability of survival was 0% in the first 7 years after the onset of myelopathy.

The clinical results for rheumatoid arthritis patients with myelopathy treated without surgery are extremely poor. Surgical treatment is recommended for rheumatoid arthritis patients with myelopathy.