A patient with rheumatoid arthritis and neck pain has cervical X-rays to detect instability or upward translocation.
If neither instability nor upward translocation is detected, then the patient has close follow-up and annual routine cervical X-rays.
Instability
If instability is present, then the patient is evaluated for the following:
(1) intractable pain
(2) significant neurologic findings
(3) vertebral artery symptoms (vertigo, transient unconsciousness, cranial nerve deficit).
If these symptoms are present, then the patient has a Brooks' fusion with occipital extension.
If these symptoms are absent, then the patient has close follow-up.
Upwards Translocation
If the arch to pedicle distance is >= 5 mm, then the patient should have close follow-up and annual routine cervical X-rays.
If the arch to pedical distance is < 5 mm, then the patient is evaluated for neurologic deficits.
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Neurologic Deficit Class
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Neurologic Findings
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Management
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Class 1
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none
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close follow-up and annual routine cervical X-rays
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Class 2
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subjective weakness with hyperreflexia and dysesthesia
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consider occipito-cervical fusion with halo post-operatively
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Class 3
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objective weakness and long-track signs
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determine response to halo traction
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If the person with Class 3 neurologic deficit benefits from halo traction, then perform occipito-cervical fusion with halo post-operatively.
If the person with Class 3 neurologic deficit does not benefit from halo traction, then consider posterior decompression or transoral decompression along with occipito-cervical fusion.
