Smith H P, Challa V R, Alexander E
J Neurosurg. 1980 Dec;53(6):841-5. doi: 10.3171/jns.1980.53.6.0841.
Cervical spine involvement by rheumatoid arthritis is common; brain-stem compression secondary to vertical subluxation of the odontoid in patients with rheumatoid arthritis is rare. Vertical subluxation results from 1) destruction of the transverse atlantal, apical, and alar ligaments of the atlas and odontoid, and 2) bone resorption in the occipital condyles, lateral masses of the atlas, and basilar processes of the skull. Neurological symptoms result from direct compression of the brain stem or from ischemia secondary to compression of vertebral arteries, anterior spinal arteries, or small perforating arteries of the brain stem and spinal cord. A case is reported in which a slowly progressive neurological deficit developed in a woman with rheumatoid arthritis following a fall from a stretcher. Neruological symptoms represented direct compression of the medulla by the dens, a mechanism confirmed at operation and autopsy. Recognition of progressive neurological deficit is often difficult in patients with rheumatoid arthritis because of their inactivity and their atrophic and immobile joints, but is essential if appropriate decompressive or stabilizing procedures are to be done. In patients with vertical subluxation of the dens, the transoral approach with removal of the odontoid is recommended. Decompression should be extensive, including the fibrous capsule around the odontoid and overlying synovial tissue as well as the odontoid itself.
类风湿关节炎累及颈椎很常见；类风湿关节炎患者因齿状突垂直半脱位继发脑干受压则很罕见。垂直半脱位是由以下原因导致的：1）寰椎和齿状突的寰椎横韧带、尖韧带和翼状韧带遭到破坏；2）枕髁、寰椎侧块和颅骨基底突出现骨质吸收。神经症状是由脑干直接受压或椎动脉、脊髓前动脉或脑干和脊髓的小穿支动脉受压继发缺血所致。本文报告一例类风湿关节炎女性患者从担架上跌落之后出现缓慢进展的神经功能缺损的病例。神经症状表现为齿突对延髓的直接压迫，这一机制在手术和尸检中得到证实。由于类风湿关节炎患者活动少且关节萎缩、活动受限，因此往往难以识别其进展性神经功能缺损，但如果要进行适当的减压或稳定手术，识别这一点至关重要。对于齿状突垂直半脱位的患者，建议采用经口入路切除齿突。减压应广泛进行，包括齿突周围的纤维囊、覆盖其上的滑膜组织以及齿突本身。
