The surgical treatment of myelopathy secondary to rheumatoid arthritis of the lower cervical spine.

There are few reports in the literature of the surgical treatment of cervical myelopathy secondary to rheumatoid arthritis below the level of the axis. Three cases are presented. All had severe motor and sensory loss in the upper and lower extremities. The cause of myelopathy differed in each case: in the first, the dura mater was infiltrated with rheumatoid material; the second was due to a stenotic spinal canal narrowed by a fixed subluxation of the cervical spine; in the third, traction myelopathy resulted from sub-axial subluxation and posterior angulation combined with cervical instability. Neurological assessment is particularly difficult in patients with rheumatoid arthritis of the cervical spine. Skull or halo traction is useful to gauge neurological improvement, to reduce the dislocation and to immobilise the cervical spine before, during and after surgery. Surgery is considered where conservative treatment is either ineffective or not tolerated, and is indicated if severe myelopathy is evident or progressive. Anterior interbody fusion is the operation of choice for mobile subluxation. Laminectomy is recommended in fixed subluxation where compression of the cord is demonstrated on myelography.