The cervical myelopathy associated with rheumatoid arthritis: analysis of patients, with 2 postmortem cases.

The clinical findings in a group of 32 rheumatoid patients with symptomatic myelopathy are described. The myelopathy appeared in late middle age after many years of rheumatoid disease (average duration, 18 years). The most common radiological abnormality was anterior subluxation of C1. Other patterns occurred in about half the cases. The most common neurological findings were those of a mild to moderate spastic paraplegia, often with atrophy of muscles of the hands and sensory changes in the hands. Symptoms originating above the foramen magnum (nystagmus, diplopia, slurred speech) appeared to have a vascular cause and were sometimes associated with upward as well as posterior movement of the odontoid process. Root pain into the arms was not present, and its absence helped to distinguish these disorders from cervical spondylosis. Root pain into the territory of the C2 root was common. Medical or conservative therapy was not effective, and the preferred approach was use of a halo traction device followed by posterior fusion, with or without laminectomy. Pathologically, in 2 autopsy cases, the maximal change had occurred in the central gray matter and adjacent posterior and lateral columns. We postulate that direct pressure caused intermittent compression and narrowing of distal transverse branches of the anterior spinal artery.