Some patients with severe rheumatoid arthritis (RA) will develop instability in the cervical spine with spinal cord compression. Flexion of the neck during surgery can result in severe morbidity and even mortality. Certain findings can help identify a patient with rheumatoid arthritis who should undergo screening for cervical spine involvement.


Risk factors:

(1) history of rheumatoid arthritis for > 10 years

(2) severe joint deformities

(3) functional Class III or IV


Objective findings:

(4) neck pain, which may radiate to the occiput

(5) paresthesias in the shoulders/or and arms

(6) muscle weakness

(7) loss of sphincter control

(8) hyperreflexia

(9) decreased sensation in the distribution of the first division of the trigeminal nerve (5th cranial nerve, supplying sensory nerves over the nose, eyelids, forehead and anterior scalp)

(10) signs of vertebrobasilar insufficiency

(11) signs of posterior column impairment (gait ataxia, especially when the eyes are closed)


A patient who is suspected of having instability of the cervical spine should undergo imaging studies prior to surgery, preferrably CT scan with the neck in gentle flexion.


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