Risk factors:
(1) history of rheumatoid arthritis for > 10 years
(2) severe joint deformities
(3) functional Class III or IV
Objective findings:
(4) neck pain, which may radiate to the occiput
(5) paresthesias in the shoulders/or and arms
(6) muscle weakness
(7) loss of sphincter control
(8) hyperreflexia
(9) decreased sensation in the distribution of the first division of the trigeminal nerve (5th cranial nerve, supplying sensory nerves over the nose, eyelids, forehead and anterior scalp)
(10) signs of vertebrobasilar insufficiency
(11) signs of posterior column impairment (gait ataxia, especially when the eyes are closed)
A patient who is suspected of having instability of the cervical spine should undergo imaging studies prior to surgery, preferrably CT scan with the neck in gentle flexion.
