Rheumatoid arthritis--atlanto-axial subluxation and its clinical presentation.

The clinical picture, radiological findings and treatment of 22 patients with atlantoaxial subluxation and rheumatoid arthritis are described. This lesion, untreated, may result in damage to the spinal cord, paresis or sudden death. Occipital headache, present in 13 of 22 patients, was often aggravated by working with the head in forward flexion. Paresthesias were present in six patients. The spine of the axis was often prominent. In three patients there was objective evidence of cord compression with sensory and/or pyramidal signs. In eight the lesion was asymptomatic and discovered by routine lateral radiography in flexion, the position of maximum subluxation.Conservative treatment involved the continuous use of a cervical collar to limit neck flexion. This usually relieved subjective symptoms including headaches. Successful surgical fixation was performed in two individuals. Surgical indications included acute or chronic cord compression or severe symptoms unrelieved by a collar.