Figure 912

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Lateral plain film of the cervical spine showing subaxial instability from C2-C3 through C4-C5 (arrows).

seen on sagittal images in CT as well as in MRI studies. The latter can disclose cord compression and show signal changes within the cord substance.


The challenges posed by the cervical spine in rheumatoid patients are complex and require vast knowledge and expertise. In the last two decades the medical management of RA has changed with the rather early administration of disease-modifying agents. Early utilization of drugs such as sulfasalazine, methotrexate, or leflunomide is expected to suppress synovial pathology and postpone or reduce irreversible bony structural changes. It is hoped that earlier administration of these agents will eventually result in decreased cervical spine involvement in RA patients.

Nonmyelopathic patients can benefit from conservative care: education (cervical anatomy, pathophysiology), activity modification (staying away from contact sports, avoiding activities that require acute neck flexion), isometric neck exercises (emphasizing strengthening of upper cervical extensors), and custom-made cervical collars can all help patients with atlanto-axial instability at least in the early stages of the disease.

There is still, however, no well-accepted approach to the neurolog-ically intact rheumatoid patient who has radiologically proven atlanto-axial instability. Because the natural history of the disease has not been completely elucidated, the timing of surgical intervention remains controversial. Should the surgeon wait for the development of long tract signs, or should the patients be operated on prophylactically?

Recent research suggests that prophylactic posterior fusion may be superior to conservative care, and can decrease the morbidity and the mortality and improve the quality of life of patients with RA.

Patients with C1-C2 instability and a PADI of less than 14 mm, cervico-medullary angle smaller than 135 degrees (normal angle is between 135 and 175 degrees), and atlanto-axial impaction where the dens has migrated more than 5 mm above the McGregor line should be referred for neurosurgical consultation without delay.


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