Cervical spine involvement in patients with chronic arthritis undergoing orthopaedic surgery.
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Involvement of the cervical spine by rheumatoid disease is common, but lateral subluxation at the atlanto-axial level has not been recorded previously. The condition is due to asymmetrical erosion of the lateral atlanto-axial facet joint, and may be complicated by collapse of the lateral mass of the axis. The condition should be suspected in patients with rheumatoid arthritis (RA) who present with occipital, auricular, and/or facial pain.
Radiological abnormalities in the cervical spine were assessed in detail in a group of 62 patients with rheumatoid arthritis of approximately 15 years' duration, of whom 33 had been treated with corticosteroids and 29 had not. The 10 criteria of damage described by Bland (1974), which include subluxation, correlated as a whole with the severity of the disease in general but not with the duration of corticosteroid treatment. Subluxation alone, whether assessed in the cervical spine as a whole or in the atlanto-axial joint alone, was less closely related to disease activity, was on average greater in patients treated with corticosteroids, and tended to increase in relation to the duration of treatment. Corticosteroid treatment thus tends to produce, over the course of years, a degree of subluxation in addition to that caused by the disease itself. Radiological signs of damage to the metacarpophalangeal (MCP) joints and carpal bones correlated with both the degree of damage and the degree of subluxation in the cervical spine as well as with corticosteroid treatment. Mutilans deformity at the MCP joints was associated with subluxation in the neck and with corticosteroid treatment.
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Cervical myelopathy has become commonly recognized as a complication of rheumatoid atlantoaxial subluxation. A small group of patients with atlantoaxial subluxation may have intermittent symptoms associated with change of head position and which are due to vertebral artery compression. Two such cases are reported, one with necropsy findings of infarction in the area supplied by the vertebrobasilar system. The pathogenesis of the symptomatology and infarction is discussed.
The C2 nerve roots and rami were dissected in five cadavers to explore the pathogenesis of Neck-Tongue Syndrome. The most likely cause of the simultaneous occurrence of suboccipital pain and ipsilateral numbness of the tongue is an abnormal subluxation of one lateral atlanto-axial joint with impaction of the C2 ventral ramus against the subluxated articular processes.
Three cases of stable fractures of the atlas and axis in children are presented. All patients presented with pain, spasm of neck musculature and head tilt along with a neurological deficit. All fractures were apparently stable; with conservative treatment all symptoms and signs resolved.
One of the putative causes of headache is osteoarthritis of the C2-3 zygapophysial joint. A technique for blocking the third occipital nerve which innervates this joint was devised and used as a screening procedure for headache mediated by this nerve. Seven out of ten consecutive patients presenting with suspected cervical headache were found to suffer pain mediated by the third occipital nerve and stemming from a C2-3 zygapophysial joint. Because third occipital headache may be indistinguishable clinically from tension or other forms of headache, third occipital nerve blocks are advocated as means of establishing this largely unrecognised diagnosis.
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