Ann Rheum Dis: first published as 10.1136/ard.44.12.809 on 1 December 1985. Downloaded from

Annals of the Rheumatic Diseases, 1985, 44, 809-816

Surgical treatment of cervical cord compression in rheumatoid arthritis

H A CROCKARD,' W K ESSIGMAN,2 J M STEVENS,' J L POZO,1 A 0 RANSFORD,1 B E KENDALL' From 'the National Hospitals for Nervous Diseases and University College Hospital, London WCJ; and the 2Lister Hospital, Stevenage, Herts

SUMMARY Cervical myelopathy is a rare but potentially dangerous complication of rheumatoid arthritis and presents considerable therapeutic problems. A conservative approach carries high mortality and surgical intervention is not without serious risks. Reduction of subluxation and posterior fusion is widely practised but may require prolonged bed rest and continuous skull traction, sometimes for many weeks. When anterior decompression has been attempted prolonged immobilisation and external fixation have created problems. In this series 23 rheumatoid patients with cervical myelopathy were investigated over a four-year period. Seventeen underwent anterior decompression of the cervical cord, of whom 14 had a transoral removal of the odontoid peg and pannus and posterior occipitocervical fusion during the same by copyright. anaesthetic without mortality or serious postoperative complications; all but one have improved. The authors believe that early mobilisation after a combined cord decompression and internal fixation has reduced the mortality and morbidity. Management of cervical myelopathy in rheumatoid arthritis and indications for operation are discussed.

Key words: atlantoaxial subluxation, rheumatoid pannus, cervical myelopathy, transoral , surgery - rheumatoid arthritis. http://ard.bmj.com/ The involvement of the cervical spine in rheumatoid dangerous complication of trauma (1824) and arthritis has become recognised increasingly over syphilitic ulceration of the pharynx (1830) by Sir the last decade. In a recent prospective study of Charles Bell,: but it was not until 1951 that Davis patients with rheumatoid arthritis Windfield et al.' and Markley6 drew attention to it as a cause of have shown that cervical subluxation may develop in medullary compression in rheumatoid arthritis. The association with peripheral erosive disease within subluxation backwards of the odontoid peg resulting two years of its onset, though remaining asymp- in the compression of the craniocervical junction of on September 28, 2021 by guest. Protected tomatic. In those with longstanding disease 25-36% the cord is considered to be the usual cause of have significant radiological changes and 2-5% of neurological abnormalities in this condition. these develop myelopathy.2 3 About half of those The transverse ligament which has such a crucial developing this complication progress rapidly and role in maintaining stability at the atlantoaxial joint succumb within a year despite conservative may be damaged by riding over the eroded surface measures.4 of the odontoid peg or be directly affected by the A review of the literature5 indicates that in the inflammatory changes. The role of pannus formed at cervical spine it is the atlantoaxial joint which is any or all of the synovial joints surrounding the involved most commonly, with the joints below C3 odontoid peg, however, has been less emphasised, being affected evenly to account for the remainder. and the soft tissue mass produced by the inflamma- Atlantoaxial subluxation was recognised as a tory process at the craniocervical junction, though Accepted for publication 23 May 1985. demonstrated at autopsy, has been implicated rarely Correspondence to Mr H A Crockard, The National Hospitals for in pathophysiology of the neurological changes in Nervous Diseases, Queen Square, London WCi. such patients. 809 Ann Rheum Dis: first published as 10.1136/ard.44.12.809 on 1 December 1985. Downloaded from

810 Crockard, Essigman, Stevens, Pozo, Ransford, Kendall

Neurological assessment of a patient with paedic operations on one or more of their limb rheumatoid arthritis may be difficult. Increasing joints. difficulty in walking, stiffness of the limbs, clumsi- ness of the hands, muscle weakness, may all be the SYMPTOMS AND SIGNS result of active synovitis, progression of the disease, Neck pain, paraesthesiae, and limb weakness to a or involvement of either the peripheral or central varying degree were the presenting complaints in nervous system, and it may not be easy to assess the 23 patients in this series (Table 1). tendon reflexes in the presence of painful or Nineteen patients had neck pain made worse by ankylosed joints. As the outcome of conservative neck movement and in four it was associated with treatment of progressive cervical myelopathy has occipital neuralgia. Although the systemic disease been uniformly fatal,7 surgical intervention alone was long standing, the neck pain was of relatively may offer hope to these patients. The accurate recent onset (average 10 months) in all but one localisation and knowledge of the character of the patient who had suffered thus for 18 years. It compressive lesion are essential for successful sur- preceded paraesthesia or weakness in nine patients gical planning; conventional and and occurred at the same time in six patients. The myelography have not always been sufficient for this latter group had the most rapid clinical course. purpose. With the advent of the modern computer- Sensory symptoms were common and extremely ised tomography with three dimensional reformat- varied (Table 1). There was no obvious correlation ting and the new non-ionic contrast media assess- with any radiological abnormality. In some there ment of such patients has been greatly simplified was clinical evidence of a peripheral entrapment and can even be carried out on a day patient basis. neuropathy. In two there was a patchy sensory loss. The surgical treatment of cervical cord com- Vibration sense was usually preserved, but joint pression-described in the literature includes anterior position sensation was difficult or impossible to fusion8 with or without decompression9 and pos- assess at deformed or stiff joints. terior fusion as separate operations.I) All require Motor weakness was very difficult to evaluate by copyright. in pre- and postoperative skull traction and prolonged the presence of widespread arthritis, but it was immobilisation in bed or in a 'halo body' jacket. The usually spastic in type. The patients' assessment of recognised complications of such treatment and the their condition in terms of reduction in performance authors' own experience led to the decision to was a more valuable indicator of neurological perform a one stage procedure in which decom- deterioration. For the same reasons reflex changes pression of the cervical cord and internal metal and plantar responses were difficult to assess. In fixation were carried out (unpublished data). Early most cases reflexes were increased, and in all but mobilisation has reduced the incidence of postop- one plantar responses were either doubtful or erative complications. This paper describes the http://ard.bmj.com/ investigation and management of 23 patients over a Table 1 Summary ofsymptoms and signs in the 23 patients four year period. Symptoms and signs No A verage Patients and methods duration (months) PATIENTS Since 1979 we have evaluated 23 patients (14 Neck pain 19 lo* Occipital pain 4 female, nine male) with either classical or definite Numbness and paraesthesia 16 6-6 on September 28, 2021 by guest. Protected rheumatoid arthritis who presented a clinical picture one arm 6 suggesting the involvement of cervical spine in the two arms 3 rheumatoid process. Three patients were less than legs 5 'glove and stocking' 2 31 years of age, one was 45 years, and the remainder Lhermitte's sign 6 were over 50 years (range 22-77 years). Seventeen Weakness 18 41 were seropositive, four seronegative, and in two the one arm 1 serology was not known. All had a longstanding two arms 6 one arm and leg 1 disease, the shortest being five years, the longest 50 two legs 3 years (average 16x9 years), and all of them at some all limbs 7 stage of their illness had been treated with steroids Sphincter disturbance 2 or remission inducing agents, or both. Only one of Brain stem signs 4 had the 20 patients with atlantoaxial subluxation not *Excluding one patient with 18-year history of neck pain. been treated with steroids. Approximately half of Note the rapid progression of the myelopathy despite the long- the patients reported here had already had ortho- standing history of arthritis. Ann Rheum Dis: first published as 10.1136/ard.44.12.809 on 1 December 1985. Downloaded from

Surgical treatment of cervical cord compression in rheumatoid arthritis 811 extensor. Three patients were quadriplegic at the In addition to movement in the sagittal plane time of presentation. Two had lost all sphincter there was upward movement of the peg (upward control and one had alteration in her voice and translocation of the dens) through the foramen suffered nasal regurgitation of fluids. magnum in three patients who had the most ad- One of the youngest patients presented with a vanced neurological signs. right sided hemiparesis, loss of gag reflex, and Subluxation below the level of the axis was noted vertical nystagmus. He reported florid nightmares in nine cases and was the only site in three. Two and a terror of going to sleep for the two weeks showed a 'staircase' phenomenon with sequential before his admission (Ondine's curse)-indicating subluxation at all levels. profound depression of the respiratory centre. COMPUTED MYELOTOMOGRAPHY CERVICAL RADIOGRAPHS Twenty-one of the 23 patients had contrast studies, All patients had lateral cervical radiographs in the first by conventional myelography alone. With maximum flexion and extension. In two whose the installation of a high resolution computed presenting symptom was neck pain alone, only tomographic (CT) scan (GE 8800) 20 patients had minimal radiological changes were found and no an intrathecal injection of water soluble contrast further investigations performed (Tables 2 and 3). medium and sequential high resolution axial sec- The commonest site of abnormality was at the tions 1-5 mm in thickness over the affected area. In atlantoaxial level (19 patients) and was the main site the last six patients the studies were repeated with in 13. In six others there was evidence of involve- flexion and extension of the cervical spine. Three ment at other levels. In the 13 patients the maximum dimensional reformatting allowed further visualisa- atlanto-odontoid movement was 5-14 mm. In those tion of the brain stem and cervical cord, the with disease at other sites it was less than 4 mm (six cerebrospinal fluid spaces, and the bony and soft patients). tissue deformations (Fig. 1). Details of the technique are given elsewhere." by copyright. The distribution of the is given in Table 3. There was definite deformity of the medulla caused Table 2 Summary of radiological investigations by odontoid peg and/or soft tissue pannus in three Investigation No and definite distortion at the craniocervical junction in seven cases (Fig. 2). In half of the 10 (three severe, Lateral cervical spine (flexion and extension) 23 seven moderate) it was the soft tissue which was Computed myelotomography ± myelogram 20 responsible for the spinal cord compression. In six Conventional myelogram alone 1 others with little evidence of bony movement, four had associated soft tissue distorting the dural sac in the region. There were five in whom the main site http://ard.bmj.com/ Table 3 Findings on computed myelotomography* of compression was below the axis. No cord com- (a) Bone deformityt pression was noted in four patients. Atlantoaxial Total 19 SURGICAL TECHNIQUE Alone 13 Details of surgical technique are given elsewhere;'2 Subaxial Total 9 a broad outline is provided here.

Alone 3 Transoral craniocervical decompression is carried on September 28, 2021 by guest. Protected No gross bone problem 2 out through a vertical posterior pharyngeal incision (b) Medullary or cord compression, or both over Cl and C2. The anterior arch of Cl and the Medullary (infraolivary) 3 odontoid peg are removed, together with any soft Cord 'craniocervical junction' 16 Degree Due to pannus tissue pannus in the region, and the anterior aspect Severe 3 3 of the dura is decompressed. Exposure has been a Moderate 7 2 major problem. Initially, an elective tracheostomy Mild 6 4 was performed and the soft palate split, but with Cord 'subaxial' 5 4 technical improvements an armoured nasotracheal No compression airway and retraction of the soft palate has been *These are divided into (a) the bony abnormalities and (b) the CT sufficient. Sometimes the temporomandibular joint evidence of brain stem and cervical cord compression. Note that in has been involved in the arthritic process, and in one nine out of 16 patients a significant proportion of the cord compression was not due to bony subluxation but to pannus. case a midline mandibular split was required to tIn five patients multiple levels were seen on computed effect exposure. myelotomography. Posterior occipitoatlantoaxial fusion is performed Ann Rheum Dis: first published as 10.1136/ard.44.12.809 on 1 December 1985. Downloaded from

812 Crockard, Essigman, Stevens, Pozo, Ransford, Kendall

Fig. 1 A sagittal reconstruction of a computed myelotomograph showing the brain stem and cervical cord. There is a pseudofracture ofthe odontoid peg with a soft tissue mass (pannus) in front and between the peg and the body ofC2. The dura is compressed by extensivepannusposteriorly. after the anterior decompression by carefully turn- and allowed out of bed on the third to fifth ing the patient to the prone position. Fixation is postoperative day. effected by interlaminar wiring, fusion by cancellous Anterior decompression at lower cervical levels is bone chips. along conventional neurosurgical lines8 and has The patients are provided with a moulded collar been combined with suitable posterior fusion to prevent angulation at the site of decompression.

OPERATIVE COMPLICATIONS No patient has died after the transoral procedure. The most serious complication has been bleeding from a displaced vertebral artery during odontoidby copyright. removal. In this patient Cl was rotated as well as subluxed and the vertebral artery 'presented' in the midline anteriorly. Haemostasis was required, but the decompression had to be abandoned, and she has continued to deteriorate. The soft palate has required resuturing in two patients early in the series. Modification of technique has removed the necessity to split the palate. There have been no complications with the posterior pharyngeal wound. Skull traction pre- and postoperatively was usedhttp://ard.bmj.com/ in the first three patients and in all three there were problems associated with prolonged immobilisation; pulmonary emboli in two, and pneumonia in all. No embolic phenomena have been detected since exter- nal splintage has been abandoned.

Histology on September 28, 2021 by guest. Protected At operation the soft tissue mass varied in consist- ency. On several occasions colourless oily fluid emanated from an incision of the anterior longitu- dinal ligament before bone removal. With this, was associated florid soft pink tissue. In two patients the pannus formation was so widespread that the Cl lamina was completely eroded and the muscles in the area infiltrated with the tissue which contained small white 'melon Fig. 2 (a) A computed myelotomograph showing a seeds'. More usually the tissue was firm grey pink transverse section ofthe craniocervicaljunction at the level and showed end-stage chromic inflammation of ofthe base ofthe peg. The cervical cord is severely and ere werovic palamm and compressedfrom thefront by soft tissue. (b) Higher, at the synovial sue.tissue. There were synovial palisades and top ofthe odontoidpeg, the dura is distorted by the bone but patchy inflammatory cell infiltration but no lym- mostly by the soft tissue mass. phoid follicles. There was hyperplasia and prolifera- Ann Rheum Dis: first published as 10.1136/ard.44.12.809 on 1 December 1985. Downloaded from

Surgical treatment of cervical cord compression in rheumatoid arthritis 813 tion of capillaries. Very rarely giant cells have been developed a peptic ulcer. In August 1983 move- seen. ments of the neck became limited and painful, and an x-ray of the cervical spine showed marked atlantoaxial subluxation and forward slip of C4 on Case studies C5. Three months later he began complaining of Our management policy is illustrated by the follow- pain in the neck associated with transient weakness ing three case histories. of the left arm on leaning forward. The weakness gradually increased, he developed tingling and CASE 1 numbness, and became clumsy with his fingers. A female aged 35 had been suffering from classical Computed myelography showed erosions on the seropositive rheumatoid arthritis since the age of 16 odontoid peg and pannus formation above it. In and had intermittent pain in the neck for several addition there was flattening of the cord at the years. Her treatment included steroids and remis- C4-C5 level. Transoral removal of the odontoid peg sion inducing drugs. For five months the neck pain with its associated pannus, anterior decompression had become more severe and neck flexion produced at the C4-C5 level, and posterior occipitocervical pain and paraesthesiae down both arms. Examina- fusion were carried out in one surgical procedure. tion showed brisk but equal reflexes and an equivo- The patient was out of bed in five days and allowed cal extensor plantar response on the left. Cervical home three weeks after the operation. He lost all spine radiography showed atlantoaxial subluxation. neck pain and regained full function of the arm. Her symptoms settled down after four months, with no change in the neurological state. No further Results investigations have been carried out but careful follow up has been arranged. A summary of the management and outcome of the 23 patients is given in Table 4. Two patients with CASE 2 minimal neck pain and paraesthesia were carefully by copyright. A 21 year old female developed chronic seronega- followed up as outpatients and showed no signs for tive juvenile arthritis of rheumatoid type at the age 14 months until there were signs of progressive of six and required treatment with steroids and myelopathy in one case (case 2), for which she had remission inducing agents. When 20 years old she surgery. One patient was unfit for surgery and two underwent synovectomy of the right knee and in her refused despite progressive deterioration. Seven- 21st year of life bilateral hip replacement. Routine teen patients were offered surgery and, apart from x-ray of the cervical spine before the second our first case on whom we performed a conven- operation showed atlantoaxial subluxation (5 mm). tional posterior fusion alone, no patient has died in Four months later she developed pain at the back of the perioperative period; she died of progressive the neck radiating to the right shoulder and made respiratory failure. Two have deteriorated since http://ard.bmj.com/ worse by movements of the neck. On examination surgery, one at three years due to subsequent C6-C7 all reflexes were brisk but equal, with equivocal subluxation, the other within weeks of surgery. In plantar responses but no sensory changes. A com- this latter case profuse bleeding from a displaced puted myelogram showed erosions of the odontoid process, indentation of the dura but no evidence of medullary or spinal compression. She was provided a up. Table 4 Management atnd outcome in the 23 patienits with collar and carefully followed Nine months on September 28, 2021 by guest. Protected later she developed mild weakness of the lower limbs and repeated CT myelography showed the Managemnenit No Oiitcomtie presence of atlantoaxial subluxation with pannus Observation only 2 2. No change formation around the odontoid peg, compressing Unfit for surgery 1 1. No chainge the cord. She underwent transoral excision of 1. Died RefusedRefusedvsurgerysurgerv 2 J 1. Detcrioratcd odontoid and posterior occipitocervical fusion in Posterior fusion alone I 1. Died one procedure without any problems. 0. Died Transoral + posterior fusion 14 2. Deteriorated* 12. CASE 3 Improsedt A male aged 54 with classical seropositive rheuma- Anterior subaxial + posterior fusion 3 { Improsed toid arthritis for 24 years had never been treated *One patient suffered profuse bleeding and the operation wits with steroids or remission inducing agents. abandoned: one patient had subsequent subluxation at C6-C7. Poliomyelitis in his youth left him with weakness of tOne patient died of myocardial infairction at 8/12; one patticnt dicd the left leg and some trunk muscles, and recently he of carcinomatosis at 22/12. Ann Rheum Dis: first published as 10.1136/ard.44.12.809 on 1 December 1985. Downloaded from

814 Crockard, Essigman, Stevens, Pozo, Ransford, Kendall vertebral artery during a transoral procedure forced patient; (b) paraesthesiae or numbness in the trunk us to abandon the decompression; neurologically or limbs or 'electric shocks' produced by movements she continued to deteriorate and is now quadri- of the neck, such as reading, lifting the head off the paretic. pillow, or leaning forward (Lhermitte's sign); and All the other patients who had transoral surgery (c) the patient's own account of his diminished or anterior subaxial surgery reported cessation of motor ability or a documented change since the last their neck pain, and 15 out of the 17 patients outpatient visit. improved. The quadriparetic patients walked out of Any synovial joint in the cervical spine may be hospital with recovered sphincter function. Those involved in rheumatoid arthritis, but in a review of with paraesthesia noted an improvement, and the 325 cases assembled from the literature Boyle found Lhermitte's sign disappeared in all cases in which it an incidence of 47% involvement at the C1-C2 was present before the operation. level.5 The role of atlantoaxial subluxation was There were no perioperative deaths in those emphasised by Davis and Markley in 19516 and led subjected to transoral surgery, but as might be to an increased awareness of the condition. Stevens expected in this age group some succumbed for et al. reported2 that 36% of the patients in their other reasons. Two of the patients aged 68 and 72 series had this complication and estimated that two died eight months and 22 months after surgery of thirds of such patients eventually developed cervical myocardial infarction and carcinomatosis respec- myelopathy. They also recorded that 16% of their tively. cases with no gross bony subluxation had cervical myelopathy and emphasised that the bony subluxa- tion in itself may not necessarily be the whole Discussion problem. pannus in the produc- The neurological assessment of a patient with The role of the rheumatoid

has not been given itsby copyright. arthritis, particularly in its more severe tion of cervical myelopathy rheumatoid though its description has been form, may be difficult. Failure to establish an early due importance, diagnosis of cervical myelopathy, therefore, is not found in pathology texts. More severe grades of may be shown with conventional unusual and there are reports of a six months' delay compression the neurological deterioration, myelography, but the advent of computed in appreciating with facility to reformat in any plane which in some patients may lead to, or coincide myelography the more precise evaluation of the a In Marks and Sharp's series3 has allowed with, fatal outcome. roles by the bony element and soft of 31 patients died due to a myelopathy, 15 of relative played 19 tissue, and the detection of milder grades of them within six months of onset, and Meijers et Some advocate recently that of nine patients with compression of the cervical cord. al.13 reported tomography without intrathecal contrast http://ard.bmj.com/ cervical myelopathy who were not operated upon, computed for these 4 but in our opinion cord com- died within a year. patients, four may not be apparent in some cases. Cord compression in rheumatoid arthritis was first pression described by Garrett in 1890,3 and a recent estima- The results of different forms of treatment have tion of the incidence of this complication in a long- been evaluated by Marks and Sharp,3 though there standing disease is between 2 and 5%.5 There is a was considerable difficulty in establishing compar- small proportion of patients who improve spon- able groups. In their untreated group there was a taneously, whereas in others myelopathy is static for 100% mortality, while 50% of patients treated with on September 28, 2021 by guest. Protected All to skull years. However, any progression of an established a cervical collar also died. subjected in the neurological traction alone died. In a recent communication myelopathy and deterioration 'nine be taken as evidence of an unfavour- Meijers et al.13 reported that in their series status should not able outcome if left untreated. patients with cervical myelopathy who were has operated upon all died within a year, four of them The clinical picture of cervical myelopathy Reduc- been well described, and our patients were due to consequence of cord compression'. already most similar to those of other series. There was no tion and fixation by posterior fusion was the out of in obvious correlation with sensory symptoms and the successful procedure, though two eight distribution of radiological abnormalities. There was Boyle's series5 died in the immediate postoperative and CT period from respiratory failure. A recent report has some relationship between motor signs this evidence of cord compression. We have found the again shown the respiratory hazards of following particularly useful in alerting the clinician approach.'5 These procedures have- aimed at the to the possibility of myelopathy: (a) neck pain or correction of subluxation and have not taken into occipital neuralgia of recent onset in a rheumatoid account the compressive effect of pannus, which Ann Rheum Dis: first published as 10.1136/ard.44.12.809 on 1 December 1985. Downloaded from

Surgical treatment of cervical cord compression in rheumatoid arthritis 815 may increase when the bones have been realigned. ity and thus allows early mobilisation of these All the published accounts describe immediate patients without prolonged bed rest in skull traction. respiratory failure or further cord compression in a It is still very early to assess the overall outcome proportion of their operated cases. One has gone as of the patients treated by this technique but, given far as saying that sudden death was an unfortunate the poor prognosis for patients with myelopathy, but inevitable consequence in some cases. 16 It is our our experience is encouraging. All the patients on opinion that attention to the compressive element whom the combined operation was carried out anteriorly before posterior fixation is an essential showed subjective and objective improvement clini- part of the treatment for patients with pannus. cally and there have been no operative deaths or Meijers et al. 13 treated their 25 patients with immediate postoperative complications. We do not, cervical myelopathy by posterior fusion, preceded however, underestimate all the potential dangers of for three days to 10 weeks (mean three weeks), and this operation and must emphasise that in our view followed for a period of 2½/2-3 months by continuous the only definite indications, for it are: clinical skull traction and nursing on a circoelectric bed. evidence of an established cervical myelopathy or Three of their patients died from the complications progressing neurological deficit indicating cord com- of immobilisation, e.g., pulmonary embolism. pression. The anterior route is particularly necessary There have been other reports of a two stage if there is compression by rheumatoid pannus. procedure'7 with transoral decompression initially Conventional radiological abnormality alone, and occipitocervical fusion at a later date, but the even when extensive, is not a criterion on which patients required continuous skull traction between such an operation should be advised. the two operations. None of the authors digress In conclusion, it is necessary to emphasise the from purely technical and academic assessment of importance of early recognition of cervical myelo- their results to describe their experience in terms of pathy in patients with rheumatoid arthritis. The investigation by human suffering of the patients exposed to a computed myelotomography is less by copyright. prolonged bed rest on continuous skull traction. traumatic for the patient and provides the clinician Because of this and the increased incidence of with more information. A one stage anterior decom- complications associated with immobilisation for a pression and posterior internal fixation is well long period of time, we decided to perform anterior tolerated, produces clinical improvement, and has decompression and posterior fusion as a one stage been much less hazardous for the patients than surgical procedure. We have been surprised to conventional forms of treatment. discover how well the patients have tolerated surgery of this magnitude. They have been out of bed within five days, starting on an active mobilisa- References tion programme, and discharged from the hospital 1 Windfield J, Cook D, Brook A S, Corbett M. A progressive http://ard.bmj.com/ a be study of the radiological changes in the cervical spine in early after fortnight to followed up from both the rheumatoid disease. Ann Rheum Dis 1981; 40: 109-14. neurosurgical and rheumatological outpatient de- 2 Stevens J C, Cartledge N E F, Saunders M, Appleby A, Hall M, partments. Their only inconvenience was a stiff Shaw D A. Atlanto-axial subluxation and cervical myelopathy collar, which they have had to wear for about three in rheumatoid arthritis. Q J Med 1971; 159: 391-408. 3 Marks J S, Sharp J. Rheumatoid cervical myelopathy. Q J Med months. 1981; 199: 307-19. Obviously the cord may be compressed subaxially 4 Nakano K K. Neurologic complications of rheumatoid arthritis.

and the usual finding is a forward displacement of Orthop Clin North Am 1975; 6: 861-81. on September 28, 2021 by guest. Protected 5 Boyle A C. The rheumatoid neck. Proc R Soc Med 1971; 64: the upper on the lower vertebral body. In six of our 1161-5. patients with an atlantoaxial problem there was 6 Davis F W, Markley H E. Rheumatoid arthritis with death from evidence of subaxial involvement. The surgical medullary compression. Ann Intern Med 1951; 35: 451-61. decision in such patients was to approach the site of 7 Mathews J A. Atlanto-axial subluxation in rheumatoid arthritis: maximum compression as on a five year follow-up. Ann Rheum Dis 1974; 33: 526-31. judged computed 8 Cloward R B. The anterior approach for removal of ruptured myelotomography and follow up the patient care- cervical discs. J Neurosurg 1958; 15: 602-17. fully postoperatively. For subaxial compression we 9 Sukoff M H, Kadin M M, Moran T. Transoral decompression have been disappointed for myelopathy caused by rheumatoid arthritis of the spine. J with a conventional anterior Ncurosurg 1972; 37: 492-7. decompression and fusion (Cloward procedure), 10 Newman P, Sweetman D R. Posterior fusion for atlanto-axial because of angulation at the operative site within a subluxation in rheumatoid arthritis. J Bone Joint Surg 1969; few months. The approach which we have adopted 51B: 423-8. is a simultaneous anterior decompression and pos- 11 Stevens J M, Kendall B E, Crockard H A. The spinal cord in the cervical myelopathy of rheumatoid arthritis: a correlated terior interlaminar fixation to an 0 ring. This compbuted myelographic study. Neurol Neurosurg Psychiatr (in produces good decompression with complete stabil- press). Ann Rheum Dis: first published as 10.1136/ard.44.12.809 on 1 December 1985. Downloaded from

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12 Crockard H A. The transoral approach to the base of the brain 15 Christophidis N, Huskisson E C. Misleading symptoms and and upper cervical cord. Ann R Col Surg Engl 1985; 67: 321-5. signs of cervical spine subluxation in rheumatoid arthritis. Br 13 Meijers K A E, Cats A, Kremer H P H, Lugendij K W, Med J 1982; 285: 364-5. Onrlec G J, Thomeer R T W M. Cervical myclopathy in 16 Hamblen D L. Postgraduate text book, of clinical orthopaedics. rheumatoid arthritis. Clin Exp Rheumatol 1984; 2: 239-45. Bristol, London, Boston: Wright, 1983: 487-97. 14 Braunstcin E M, Weissman B N, Seltzer S E, et al. Computcd tomography and conventional radiographs of the cranio- 17 O'Laoire S A, Thomas D G T. Transoral approach to the vertebral regions in rheumatoid arthritis: a comparison. cervical spine: report of four cascs. J Neurol Neurosurg Arthritis Rheum 1984; 27: 26-31. 1982: 45: 6(1-3. by copyright. http://ard.bmj.com/ on September 28, 2021 by guest. Protected