While there was no focal neurological deficit in this case, the patient was referred for surgical management given the overall severity of symptoms and imaging findings. This case highlights some of the classical imaging features seen in cervical spine involvement with rheumatoid arthritis. Neurological recovery occurs more consistently in patients with lower grades of pre-operative myelopathy. An arthrodesis may also provide adequate pain relief. Primary surgical objectives are to achieve stabilisation of affected segments and relief of neural compression by reduction of subluxation or by direct decompression. Traditional indications for surgery have been intractable pain and the presence of neurologic deficits. Main surgical options include either an anterior or a posterior cervical fusion.

Non-operative management does not alter the natural history of cervical disease. Apophyseal (facet) joint arthropathy +/- fusion: may be present in around 9% of patients and may correlate with the degree of severity of cervical myelopathy. Sub-axial subluxation : can occur to varying degrees and refers to subluxation of joints inferior to the atlanto-axial articulation.ĥ. The presence of cranial settling is considered as one of the most dangerous of cervical manifestations. It is represented by odontoid migration > or =5 mm rostral to McGregor's line (a line drawn from the posterior aspect of the hard palate to the occiput), a sagittal canal diameter <14 mm, or a cervicomedullary angle of <135 degrees. Vertical (cranial) settling / atlanto-axial impaction: thought to affect up to 8% of patients. The presence of atlanto-axial subluxation has been associated with an up to eight-fold increase in mortality. An atlanto-axial subluxation greater than 9mm with vertical settling and a posterior atlanto-odontoid interval less than 14mm are thought to correlate well with the presence of neurologic deficits. Atlanto-axial subluxation: considered one of the commonest manifestations and may be seen in up to 33% of patients. There are some classical changes that can occur in cervical spine involvement with rheumatoid arthritis. Subtle signs of myelopathy may also be present. Typical initial patient symptoms include neck and occipital pain. The upper cervical spine gets primarily affected. It tends to be more common with longstanding disease and in those with multi-articular involvement. Cervical involvement can occur in over 80%. Rheumatoid arthritis involving the cervical spine was first described by Garrod in 1890.

X ray of cervical spine arthritis