REVIEW Cervical spine involvement in rheumatoid arthritis. A review Agnès Bouchaud-Chabot, Frédéric Lioté* Fédération de Rhumatologie, Centre Viggo-Petersen, Hôpital Lariboisière, (Assistance Publique-Hôpitaux de Paris), 2, rue Ambroise Paré, 75475 Paris cedex 10, France (Submitted for publication June 13, 2000; accepted in revised form July 12, 2001) Summary – Cervical spine involvement occurs in over half of patients with rheumatoid arthritis (RA). The most common abnormality is atlantoaxial dislocation, followed by atlantooccipital arthritis with cranial settlingandbylesionsofthelowercervicalspine.Cervicalspineinvolvementusuallyoccursinpatientswith severe RA. Pain and evidence of spinal cord injury are the main symptoms. The presence of symptoms is not correlated with the severity of radiological abnormalities. Computed tomography and magnetic resonance imaging provide detailed images of the bone and spinal cord lesions. Because the course is unpredictable, conservatively treated patients usually require regular follow-up. Surgery is in order in patientswithpainunresponsivetomajornarcoticsorwithprogressiveneurologicalimpairment.Thechoice betweentheanteriorandtheposteriorroutedependsontheexperienceofthesurgicalteam.Itisreasonable tostabilizethespinebeforethedevelopmentofcranialsettlingormajorneurologicalloss(Ranawat’sstage III).Thegoodfunctionalresultsofspinalsurgeryarefrequentlyovershadowedbymajorimpairmentsrelated to severe peripheral joint disease. Safety is acceptable when somatosensory evoked responses are monitored intraoperatively. Surgery can provide substantial improvements in symptoms, particularly pain. Joint Bone Spine 2002 ; 69 : 141-54. © 2002 Éditions scientifiques et médicales Elsevier SAS cervical spine surgery / imaging studies / rheumatoid arthritis / spine INTRODUCTION Involvement of the cervical spine by rheumatoid arthri- tis (RA) was first described in 1890 by Garrod [1]. The first case with fatal spinal cord compression was reported in 1951 [2]. Since then, the clinical, radiological, and therapeutic aspects of cervical spine RA have been described in detail. Atlantoaxial dislocation (AAD) occurs in 25% of RA patients [3-5], either alone or in combination with atlantooccipital involvement respon- sible for vertical translocation of the dens, which is also known as cranial settling. Involvement of the lover cervical spine is less common, occurs later in the course of the disease, and manifests as multilevel anterior dislocation. The prevalence of cervical spine lesions of any kind among RA patients has been estimated at 43–86% [3, 6-14]. The broad variety of clinical mani- festations and absence of correlation between these manifestations and the roentgenographic changes present in 19–88% [15] of RA patients raise major therapeutic challenges. Furthermore, surgical treatment is difficult. Until recently, the adverse event and mor * Correspondence and reprints. E-mail address: frederic.liote@lrb.ap-hop-paris.fr (F. Lioté). Joint Bone Spine 2002 ; 69 : 141-54 © 2002 Éditions scientifiques et médicales Elsevier SAS. All rights reserved S1297319X02003615/REV