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Several studies of patients with chronic cervical pain and chronic whiplash syndrome report a high frequency of oculomotor function derangements pointing towards brainstem involvement and/or default sensory input from neck afferents. In light of these reports, it seems important to investigate other patient groups with similar upper cervical spine disorders. In this study, voluntary eye motor performance was evaluated in 11 rheumatoid patients (RA) with upper cervical dislocation and a clearly noticed joint affection of the cervical spine. The results were compared with 6 RA patients without cervical engagement and normal individuals. Nine of the 11 patients with atlanto-axial dislocation showed pronounced oculomotor disturbances of smooth pursuits compared with only minor changes in the control group. The pattern of oculomotor dysfunction in patients with rheumatoid cervical dislocation indicates brainstem involvement, which may be an early sign of brainstem affection/myelopathy.

In a study of 30 patients with longstanding rheumatoid arthritis the diagnostic usefulness of ultra low field MR equipment was analyzed in assessing lesions of the craniocervical junction. It was found that at 0.04 T all the examinations were diagnostic and that in combination with plain radiography the diagnostic information obtained was valuable in further planning of the treatment strategies. The neurologic findings were related to the degree and severity of atlantoaxial luxation, either horizontal or vertical, and to the periodontoid pannus formation. The correlation between the degree of cord compression shown with MR imaging and the clinical symptoms, especially long tract symptoms, was poor. The only correlating factor was the duration of the disease.

Thresholds for cutaneous perception and pain in 27 rheumatoid patients were investigated by electrical stimulation. Patients with atlanto-axial subluxation showed impaired sensibility over the ophthalmic division of the trigeminal nerve. Patients with vertical atlanto-axial subluxation showed in addition to a pronounced decrease in the sensibility over the ophthalmic and maxillary divisions of the trigeminal nerve, also sensory disturbances over cervical, thoracic and lumbar levels. The mandibular division was never affected. The trigeminal sensibility seems to be affected early in the rheumatoid atlanto-axial subluxation and progresses with the severity of the subluxation, possibly due to bony compression of the trigeminal spinal tract at C 1 level.

CT examination of rheumatoid dislocation in the C1-C2 region was performed in 20 patients with advanced disease. The patients were classified in three grades according to the degree of medullary compression caused by the odontoid process in the extended position of the neck. Five patients showed no dural or medullary compression (grade 1), nine dural compression (grade 2), and six medullary compression (grade 3). CT grading was found to correlate best with long tract symptoms. These were present in 4/6 grade 3 and 0/5 grade 1 patients, while 3/9 grade 2 patients had long tract symptoms. Tissue attenuation values over the anterior atlanto-axial joint indicated interposing firm connective tissue in patients showing no reduction of the subluxation on extension of the neck.

Posterior cervical fusion was performed in 34 patients with advanced rheumatoid atlanto-axial subluxation. Atraumatic surgical technique was used with local anesthesia and without skull traction. Intractable occipital rhizopathy and long-tract signs were the main indications. Anterior atlanto-axial subluxation in 28 patients was operated on with posterior fusion of C1-C2. Superior migration of the odontoid process into the foramen magnum in six patients was treated with posterior fusion of occiput C1-C2. Immediate mobilization in a plastic brace followed surgery. Average follow-up was 3 years. All patients became symptom-free, except for three who had remaining long-tract signs. Bony fusion was achieved in 17 patients; stable fibrous fusion, in 8 patients; and pseudoarthrosis, in 4 patients. There were no major postoperative complications. Five deaths occurred after 1-2 years from unrelated causes.

Somatosensory evoked potentials (SSEPs) were recorded in 34 patients with severe rheumatoid arthritis. Eighteen had atlanto-axial subluxation and 16 had no roentgenological evidence of cervical subluxation. Four patients in the group with cervical subluxation showed pathological SSEP values from both median and tibial nerves indicating conduction block in the upper cervical medulla. In the group with no cervical subluxation, 6 patients had prolonged SSEP latency, 5 of these on recordings from the tibial nerves with normal median nerve latencies and one with only bilaterally prolonged median nerve latencies. The pathological SSEP findings in the former group of patients we attribute to the cervical subluxation, while the findings in the latter group might be related to spinal cord vasculitis or extradural granulation tissue. The SSEP method can be useful in providing objective evidence for spinal cord lesions in patients with rheumatoid cervical subluxation.