Brain stem compression and atlantoaxial instability secondary to chronic rheumatoid arthritis in a 67-year-old female

Abstract

Objective: This case study describes a patient with long-standing rheumatoid arthritis of the cervical spine who presented with significant bone destruction, gross joint derangement, and a potentially life-threatening complication, basilar invagination with brain stem compression. The pathophysiology, clinical presentation, imaging, and surgical management are discussed.

Clinical features: A 67-year-old female presented to a chiropractic clinic with chronic neck pain of 30 years of duration complicated by rheumatoid arthritis. Her neck pain had recently exacerbated and was radiating into her trapezius muscle and shoulders. She also reported a recent onset of mild dysphagia. The patient was referred to a neurosurgeon for consultation and management.

Intervention and outcome: Computed tomography and magnetic resonance imaging of the cervical spine demonstrated significant bone destruction, gross joint derangement, and basilar invagination. There was moderate stenosis of the foramen magnum secondary to basilar invagination with significant brain stem compression. The patient underwent surgical stabilization fusion from the occiput to T2 using a posterior approach. Her pain severity was lessened after surgery, and the dysphagia had not progressed suggesting stabilization of brain stem compression.

Conclusion: Patients with long-standing rheumatoid arthritis of the cervical spine often present with chronic neck pain. Cervical spine instability may arise from rheumatoid osteolysis and is also secondary to horizontal or vertical subluxation of the atlantoaxial and occipitoatlantal regions, respectively. High-velocity, low-amplitude manipulation of the upper cervical spine is an absolute contraindication in cases of atlantoaxial instability. A timely diagnosis and favorable surgical outcome provided relief from a potentially life-threatening disorder. This case exemplifies the clinical caution necessary for managing patients with chronic cervical spine pain complicated by rheumatoid arthritis.