Of thirty-four selected patients who had rheumatoid arthritis and
subluxations of the atlanto-axial and other joints of the cervical spine,
eighteen were treated operatively and sixteen were treated non-operatively.
Of the subluxations of the atlanto-axial joint, nineteen were anterior;
four, posterior; and eleven, vertical. Additionally, subaxial subluxations
were seen in three patients. At the time of treatment, the mean duration of
the rheumatoid disease was 19.4 years and the mean duration of the
disorders of the cervical spine was 4.5 years. After treatment the patients
were followed for an average of 2.2 years (range, six months to six years).
Of the thirty-four patients, two (both of whom were treated
non-operatively) died of causes unrelated to the lesions of the cervical
spine and were excluded from this study. Of the remaining thirty-two
patients, eighteen were treated operatively and fourteen, non-operatively.
The two groups were roughly comparable with respect to the lesions of the
cervical spine, but more of the patients who were treated surgically showed
evidence of compression of the cord as demonstrated by computed tomography
and myelography. The thirty-two patients were not randomized in the two
groups; therefore, comparison of the findings in these groups is not
completely valid. Surgical treatment of the eighteen patients included an
atlanto-axial fusion in thirteen and an occipitocervical fusion in five. In
addition, two patients who had an occipitocervical fusion also had a
subaxial laminectomy and posterior fusion. There was a superficial wound
infection, which was treated successfully with short-term antibiotic
therapy, in two patients. No patient died postoperatively. Occipital pain
was relieved in twelve of the fifteen operatively treated patients who had
pain, whereas pain was relieved in only one of the eight conservatively
treated patients who had pain. At follow-up, neurological function was
unchanged or improved in the operatively treated group but was slightly
worse in the conservatively treated group. We concluded that fusion of an
unstable rheumatoid cervical spine relieves pain and prevents progression
of existing neural lessons without undue risk for the patient.