Atlanto-Axial Subluxation in Rheumatoid Arthritis

Abstract

With greater awareness of the complications and with improvement in radiographic techniques, atlanto-axial subluxation is being diagnosed more frequently. Its recorded incidence varies with the selection of patients and the radiographic techniques used

Nonreducible rotational head tilt and lateral mass collapse. a prospective study of frequency, radiographic findings, and clinical features in patients with rheumatoid arthritis

“…Of their 17 patients with neck pain, about half had radiographic evidence of anterior atlantoaxial subluxation. Many reports (4,5,8,10,(36)(37)(38)(39) have addressed the frequency of neck pain in RA patients with known atlantoaxial subluxation, and this frequency ranges from 3 1-100% depending on the population studied. Data from our study suggest that neck pain is common in RA patients regardless of the cervical spine radiographic findings.…”

Atlantoaxial immobilization in rheumatoid arthritis: a prophylactic procedure?

“…Therefore, nonoperative management of C1/2 instability in RA is known to have a considerable failure rate, with figures of up to 50% for the mortality rate once myelopathy is present [21,22,24,35]. These fatal outcomes have been attributed to persistent repetitive trauma by both retrodental pannus and the dislocation and subsequent upward migration of the odontoid [9,17,21,27,28,29]. This has led to acceptance of surgical stabilization of the atlantoaxial instability.…”

“…aiming to avoid unnecessary surgery, this speculative approach may lead to late interventions, which have proved to worsen the outcome [1,5,29,30]. Once upward migration has occurred, the mortality rate [32] increases drastically, even after adequate surgery with decompression and stabilization.…”

Surgical Considerations of Rheumatoid Disease Involving the Craniocervical Junction and Atlantoaxial Vertebrae

“…Some authors have noted spontaneous radiological fusion occurring on serial follow up, but a significant proportion of these "auto-fused" patients will progress to displaying neurological deterioration. Though the timing of, and indications for, surgical intervention in such individuals remain controversial, many authors advocate decompression and arthrodesis, on the basis that the degree of neurological compromise often does not correlate with the degree of radiological subluxation (Rana et al 1973, Bland 1990, Oostveen et al 1999. Further, arthrodesis with the appropriate technique has been shown to prevent progression, particularly in relation to C1/C2 subluxation progressing to basilar invagination.…”

“…Identification of asymptomatic patients likely to progress to neurological deterioration without arthrodesis relies on the experienced spine surgeon liaising with his rheumatology colleagues, and facilitating quick decompression and stabilisation should signs of early myelopathy become apparent. An atlantoaxial dental interval of greater than 10mm is certainly an indication for surgical intervention (Rana et al 1973), though intervals between the 5mm and 10mm need to be considered in the setting for the potential for progression to neurological dysfunction. Conventional trauma-based measurements cannot be extrapolated to rheumatoid patients, given that 5mm AADI is often seen in rheumatoid spines, as opposed to the 3mm limit of normal in unaffected adult individuals (Oda et al 1991, Shen et al 2004.…”