Surgical Treatment of Rheumatoid Lesion at Craniocervical Junction

Authors: P. Vaněk
Authors‘ workplace: 1. LF UK a ÚVN Praha
Published in: Cesk Slov Neurol N 2012; 75/108(3): 273-282
Category: Minimonography


Rheumatoid arthritis is a chronic, systemic inflammatory disorder affecting multiple organ systems. The disorder typically manifests with chronic symetric polyarthritis resulting in destruction of joints and development of joint deformities. The craniocervical junction is the section of the spine most frequently affected by the disease. Increased ligamentous laxity is responsible for a development of craniocervical instability. Anterior atlanto-axial subluxation and cranial settling of dens axis are the most common manifestations of the instability. The instability might be responsible for the development or progression of neurological deficit, including sudden death. Early initiation of aggressive pharmacotherapy may slowdown the disease progression, although surgical treatment is the only meaningful therapeutic moda­lity in patients with radiological progression of the instability or who develop neurological deficit. Surgery may also be indicated for pain associated with the craniocervical instability and unresponsive to conservative treatment. A multidisciplinary approach is the prerequisite for optimal long-term outcome.

Key words:
craniocervical junction – rheumatoid arthritis – instability – surgical treatment


1. Pavelka K. Revmatologie. 2nd ed. Praha: Galén 2010.

2. Wasserman BR, Moskovich R, Razi AE. Rheumatoid arthritis of the cervical spine – clinical consideration. Bull NYU Hosp Jt Dis 2011; 69(2): 136–148.

3. Garrod AE. A treatise on rheumatism and rheumatoid arthritis. London: Grifins Medical Series, Charles Grifin & Co 1890.

4. Davis FW jr, Markley HE. Rheumatoid arthritis with death from medullary compression. Ann Intern Med 1951; 35(2): 451–445.

5. Kornblum D, Clayton ML, Nash HH. Non-traumatic cervical dislocation in rheumatoid spondylitis. J Am Med Assoc 1952; 149(5): 431–435.

6. Bland JH. Rheumatoid arthritis of the cervical spine. Bull Rheum Dis 1967; 18(2): 471–476.

7. Fielding JW, Cochran GB, Lawsing JF jr, Hohl M. Tears of transverse ligament of the atlas. A clinical and biomechanical study. J Bone Joint Surg Am 1974; 56(8): 1683–1691.

8. Štulík J et al. Poranění krční páteře. 1st ed Praha: Galén 2010.

9. Moskovich R, Shott S, Yhang ZH. Does the cervical canal to body ratio predict spinal stenosis? Bull Hosp Jt Dis 1996; 55(2): 61–71.

10. Matthews JA. Atlanto-axial subluxtion in rheumatoid arthritis. A 5-year follow-up study. Ann Rheum Dis 1974; 33(6): 526–531.

11. Crockard HA. Surgical management of cervical rheumatoid problems. Spine 1995; 20(23): 2584–2590.

12. Weissman BN, Aliabadi P, Weinfel MS, Thomas WH, Sosman JL. Prognostic features of atlantoaxial subluxation in rheumatoid arthritis patient. Radiology 1982; 144(4): 745–751.

13. Agarwal AK, Peppelman WC, Kraus DR, Eisenbeis C. The cervical spine in rheumatoid arthritis. BMJ 1993; 306(6879): 79–80.

14. Halla JT, Hardin JG, Vitek J, Alarcón GS. Involvement of cervical spine in rheumatoid arthritis. Arthritis Rheum 1989; 32(5): 652–659.

15. Riise T, Jacobsen BK, Gran JT. High mortality in patients with rheumatoid arthritis and atlantoaxial subluxation. J Rheumatol 2001; 28(11): 2425–2429.

16. Sunahara N, Matsunaga S, Mori T, Ijiri K, Sakou T. Clinical course of conservatively managed rheumatoid arthritis patients with myelopathy. Spine 1997; 22(22): 2603–2607.

17. Yurube T, Sumi M, Nishida K, Takabatake M, Kohyama K, Matsubara T et al. Progression of cervical spine instabilities in rheumatoid arthritis. A prospective cohort study of outpatients over 5 years. Spine 2011; 36(8): 647–653.

18. Mikulowski P, Wollheim FA, Rotmil P, Olsen I. Sudden death in rheumatoid arthritis with atlanto-axila dislocation. Acta Med Scand 1975; 198(6): 445–451.

19. Paus AC, Steen H, Roislien J, Mowinckel P, Teigland J. High mortality rate in rheumatoid arthritis with subluxation of the cervical spine. A cohort study of operated and nonoperated patients. Spine 2008; 33(21): 2278–2283.

20. Boden SD, Dodge LD, Bohlman HH, Rechtine GR. Rheumatoid arthritis of the cervical spine. A long--term analysis with predictor of paralysis and recovery. J Bone Joint Surg Am 1993; 75(9): 1282–1297.

21. Marks JS, Sharp J. Rheumatoid cervical myelopathy. Q J Med 1981; 50(199): 307–319.

22. Rawlins BA, Girardi FP, Boachie-Adjei O. Rheuma­toid arthritis of the cervical spine. Rheum Dis Clin North Am 1998; 24(1): 55–65.

23. Rana NA. Natural history of atlanto-axial subluxation in rheumatoid arthritis. Spine 1989; 14(10): 1054–1056.

24. Menezes AH, VanGilder JC, Clark CR, el-Khoury G. Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with cranial settling. J Neurosurg 1985; 63(4): 500–509.

25. Rana NA, Hancock DO, Taylor AR, Hill AG. Upward translocation of the dens in rheumatoid arthritis. J Bone Joint Surg Br 1973: 55(3): 471–477.

26. Ranawat CS, O’Leary P, Pellicci P, Tsairis P, Marchisello P, Dorr L. Cervical spine fusion in rheumatoid arthritis. J Bone Joint Surg Am 1979; 61(7): 1003–1010.

27. Steinbrocker O, Traeger CH, Batterman RC. Therapeutic criteria in rheumatoid arthritis. JAMA 1949; 140(8): 659–662.

28. Kwek TK, Lew TW, Thoo FL. The role of preoperative cervical spine X-rays in rheumatoid arthritis. Anaesth Intensive Care 1998; 26(6): 636–641.

29. Collins DN, Barnes CL, FitzRandolf RL. Cervical spine instability in rheumatoid patients having total hip or knee arthroplasty. Clin Orthop Relat Res 1991; 272: 127–135.

30. Clark CR, Goetz DD, Menezes AH. Arthrodesis of the cervical spine in rheumatoid arthritis. J Bone Joint Surg Am 1989; 71(3): 381–392.

31. Casey AT, Crockard HA, Stevens J. Vertical translocation. Part II. Outcomes after surgical treatment of rheumatoid cervical myelopathy. J Neurosurg 1997; 87(6): 863–869.

32. Casey AT, Crockard HA, Geddes JF, Stevens J. Vertical translocation: the enigma of the disappearing atlantodens interval in patients with myelopathy and rheumatoid arthritis. Part I. Clinical, radiological, and neuropatological features. J Neurosurg 1997; 87(6): 856–862.

33. Boden SD. Rheumatoid arthritis of the cervical spine. Surgical decision making based on predictors of paralysis and recovery. Spine 1994; 19(20): 2275–2280.

34. McGreger M. The significance of certain measurements of the skull in the diagnosis of basilar impression. Br J Radiol 1948; 21(244): 171–181.

35. McRae DL, Barnum AS. Occipitalization of the atlas. Am J Roentgenol Radium Ther Micl Med 1953; 70(1): 23–46.

36. Chamberlain WE. Basilar impression (platybasia): a bizarre development of anomaly of the occipital bone upper cervical spine with striking and misleading neurologic manifestations. Yale J Biol Med 1939; 11(5): 487–496.

37. Redlund-Johnell I, Pettersson H. Radiographic measurements of the cranio-vertebral region. Designed for evaluation of abnormalities in rheumatoid arthritis. Acta Radiol Diagn 1984; 25(1): 23–28.

38. Riew KD, Hillibrand AS, Palumbo MA, Sethi N, Bohlman HH. Diagnosing basilar invagination in the rheumatoid patient. The reliability of radiographic criteria. J Bone Joint Surg Am 2001; 83A(2): 194–200.

39. Einig M, Higer HP, Meairs S, Faus-Tinnefeldt G, Kapp H. Magnetic resonance imaging of the craniocervical junction in rheumatoid arthritis: value, limita­tions, indications. Skeletal Radiol 1990; 19(5): 341–346.

40. Breedveld FC, Algra PR, Vielvoye CJ, Cats A. Magnetic resonance imaging in the evaluation of patients with rheumatoid arthritis and subluxation of the cervical spine. Arthritis Rheum 1987; 30(6): 624–629.

41. Petterson H, Larsson EM, Holtás S, Cronqvist S, Egund N, Zygmunt S et al. MR imaging of the cervical spine in rheumatoid arthritis. AJNR Am J Neuroradiol 1988; 9: 573–577.

42. Bundschuh C, Modic MT, Kerney F, Morris R, Deal C. Rheumatoid arthritis of the cervical spine: surface coil MR imaging. AJR Am J Roentgeol 1988; 151(1): 181–187.

43. Reijnierse M, Breedveld FC, Kroon HM. Are magnetic resonance flexion views useful in evaluating the cervical spine of patients with rheumatoid arthritis? Skeletal radiol 2000; 29(2): 85–89.

44. Bell GR, Stearns KL. Flexion-extension MRI of the upper rheumatoid cervical spine. Orthopedics 1991; 14(9): 969–974.

45. Miyata M, Neo M, Ito H, Yoshida M, Miyaki K, Fujibayashi S et al. Is rheumatoid arthritis a risk factor for a high-riding vertebral artery? Spine 2008; 33(18): 2007–2011.

46. Miyata M, Neo M, Ito H, Yoshida M, Fujibayashi S, Nakamura T. Rheumatoid arthritis as a risk factor for a narrow C-2 pedicle: 3D analysis of the C2 pedicel screw trajectory. J Neurosurg Spine 2008; 9(1): 17–21.

47. Toolanen G, Knibestol M, Larsson SE, Landman K. Somatosensory evoked potentials (SSEPs) in rheumatoid cervical subluxation. Scand J Rheumatol 1987; 16(1): 17–25.

48. Dvorák J, Herdmann J, Janssen B. Motor-evoked potentials in patients with cervical spine disorders. Spine 1990; 15(10): 1013–1016.

49. Borenstein D. Inflammatory arthritides of the spine. Surgical versus nonsurgical treatment. Clin Orthop Rel Research 2006; 443: 208–221.

50. Kaito T, Hosono N, Ohshima S, Ohwaki H, Takenaka S, Fujiwara H, Makino T, Yonenobu K. Effect of Biological Agents on Cervical Spine Lesions in Rheumatoid Arthritis. Spine. In press 2012.

51. Pellicci PM, Ranawat CS, Tsairis P, Bryan WJ. A prospective study of the progression of rheumatoid arthritis of the cervical spine. J Bone Joint Surg Am 1981; 63(3): 342–350.

52. Suchomel P, Choutka O. Reconstruction of Upper Cervical Spine and Craniovertebral Junction. 1st ed. Berlin: Springer Verlag 2011.

53. Gallie WE. Fracture and dislocations of the cervical spine. Amer J Surg 1939; 46: 495–499.

54. Brooks AL, Jenkins EW. Atlanto-axial arthrodesis by the wedge compression method. J Bone Joint Surg 1975; 57: 879–887.

55. Lögters T, Hoppe S, Linhart W, Habermann C, Windlof J, Rueger J et al. On the problem of halo vest treatment in the elderly. Results of a retrospective analysis. Unfallchirurg 2006; 109(4): 306–312.

56. Magerl F, Seemann PS. Stable posterior fusion of gthe atlas and axis by transarticular screw fixation. In: Kehr P, Weidner A (eds). Cervical spine. Wien: Springer 1987: 322–327.

57. Gluf WM, Schmidt MH, Apfelbaum RI. Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications and lessons learned in 191 adult patients. J Neurosurg Spine 2005; 2(2): 155–163.

58. Harms J, Melcher PR. Posterior C1–2 fusion with polyaxial screw and rod fiaxation. Spine 2002; 26(22): 2467–2471.

59. Yoshida M, Neo M, Fujibayashi S, Nakamura T. Comparison of the anatomical risk for vertebral artery injury associated with the C2-pedicle screw and atlantoaxial transarticular screw. Spine 2006; 31(15): 513–517.

60. Johnston RA, Kelly IG. Surgery of the rheumatoid cervical spine. Ann Rheumatic Dis 1990; 49 (Suppl 2): 845–850.

51. Mouchaty H, Perrini P, Conti R, Di Lorenzo N. Craniovertebral juction lesions: our experience with transoral surgical approach. Eur Spine J 2009; 18 (Suppl 1): 13–19.

62. Grob D, Würsch R, Grauer W, Sturzenegger J, Dvorak J. Atlantoaxial fusion and retrodental pannus in rheumatoid arthritis. Spine 1997; 22(14): 1580–1583.

63. Sugimoto Y, Tanaka M, Nakanishi K, Misawa H, Takigawa T, Ozaki T. Assessing the range of cervical rotation in patients with rheumatoid arthritis after atlantoaxial screw fixation using axial CT. Spine 2007; 32(21): 2318–2321.

64. Kraus DR, Peppelman WC, Agarwal AK, DeLeeuw HW, Donaldson WF jr. Incidence of subaxial sbluxation in patients with generalized rheumatoid arthritis who have had previous occipital cervical fusions. Spine 1991; 16 (Suppl 10): S486–S489.

65. Meijers KA, Cats A, Kremer HP, Luyendijk W, Onvlee GJ, Thomeer RT. Cervical myelopathy in rheumatoid arthritis. Clin Exp Rheumatol 1984; 2(3): 239–245.

66. Stulik J, Vyskocil T, Sebesta P, Kryl J. Atlantoaxial fixation using the polyaxial screw-rod system. Eur Spine J 2007; 16(4): 479–484.

67. Suchomel P, Stulík J, Klézl Z, Chrobok J, Lukás R, Krbec M et al. Transarticular fixation of C1–C2: a multicenter retrospective study. Acta Chir Orthop Traumatol Cech 2004; 71(1): 6–12.

68. Krauss WE, Bledsoe JM, Clarke MJ, Nottmeier EW, Pichelmann MA. Rheumatoid Arthritis of the Craniovertebral Junction. Neurosurgery 2010; 66 (Suppl 3): 83–95.

69. Casey AT, Crockard HA, Bland JM, Stevens J, Moskovich R, Ransford AO. Surgery on the rheumatoid cervical spine for the non-ambulant myelopatic patient-too much, too late? Lancet 1996; 347(9007): 1004–1007.

70. Peppelman WC, Kraus DR, Donaldson WF, Argawal A. Cervical spine surgery in rheumatoid arthritis: improvement of neurologic deficit after cervical spine fusion. Spine 1993; 18(16): 2375–2379.

Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 3

2012 Issue 3

Most read in this issue

This topic is also in:

Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account