| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | |
| IMAGE QUIZ ARCHIVE | ||||||
| Image Quiz | ||
| Vertigo, Faintness, Blurred Vision, and Weakness in a Woman with Rheumatoid Arthritis1 (continued) | ||
| Answer: 1. Vertical subluxation; atlantoaxial subluxation 2. Basilar invagination; mild spinal cord compression; no brain-stem compression 3. Left vertebrobasilar insufficiency |
||
 Fig. 1 |
Fig. 1. Lateral radiograph of the cervical spine, made in June 2000, showing
vertical subluxation in addition to atlantoaxial subluxation. For larger view, click on image |
|
 Fig. 2 |
Figs. 2-A and 2-B. Magnetic resonance images, made in June 2000, showing granulation tissue surrounding the odontoid process of the axis as well as basilar invagination, but the degree of spinal cord compression is mild and no brain-stem compression is noted. Fig. 2-A (left) Sagittal view. Fig. 2-B (right) Axial view of the atlantoaxial line. For larger view, click on image |
|
 Fig. 3 |
Figs. 3-A and 3-B. Angiograms of the left vertebral artery, made in July 2000. Fig. 3-A There is no constriction with the neck in a neutral position. Fig. 3-B There is complete constriction at the cranial edge of the transverse foramen of the axis when the neck is extended by the attending physician. For larger view, click on image |
|
| Discussion | ||
| Patients with rheumatoid arthritis often have involvement of the cervical spine, which may lead not only to impairment of activities of daily living but also to sudden death. Cervical instability secondary to rheumatoid arthritis is associated with compression myelopathy in many patients and with vertebrobasilar insufficiency in some patients. | ||
| The syndrome of vertebrobasilar insufficiency is due to a decrease of blood flow in the vertebrobasilar artery. It has been suggested that the syndrome is reversible. However, if the syndrome occurs repeatedly, it may lead to brain-stem infarction or death. | ||
| The symptoms, such as vertigo, faintness, blurred vision, and weakness, may be transient and are likely to be misinterpreted as an undefined clinical syndrome or as a psychological problem. It is also difficult to identify the syndrome with physical examination. Special care should be taken to consider this condition in patients in whom cervical instability is likely to develop, such as those with rheumatoid arthritis. | ||
| Cervical instability often develops in patients with chronic rheumatoid arthritis, and it is an important factor for determining the prognosis in these patients. Advanced cervical instability may result in a compression myelopathy, which is relatively easy to diagnose as it can be identified on radiographs and magnetic resonance imaging. Vertebrobasilar insufficiency has been observed in these patients, but it is not common. | ||
| Patients without compression myelopathy who have symptoms on extension of the cervical spine, as our patient did, may have no abnormalities on routine neurological examination. The diagnosis is confirmed by angiography performed with the neck in the extended position. To keep patients in this provocative position for hours has been shown to be dangerous because it is likely to aggravate symptoms or cause unconsciousness. If the vertebral artery is constricted continuously, such as by synovitis surrounding the odontoid process, decompression of the artery may be necessary. | ||
| We believe that this condition should be diagnosed early and that appropriate treatment should be instituted before the condition becomes irreversible. | ||
| Reference | ||
1. Maekawa T, Sasai K, Iida H, Yamashita K, and Sakaida M. Atlantoaxial arthrodesis for vertebrobasilar insufficiency due to rheumatoid arthritis. A case report. J. Bone and Joint Surg. 2003;85:711-4. |
||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |