Functional evaluation of the spinal cord by magnetic resonance imaging in patients with rheumatoid arthritis and instability of upper cervical spine

Thirty-four patients with atlanto-axial instability due to rheumatoid arthritis were examined with plain x-ray views and functional magnetic resonance imaging (MR), and were neurologically evaluated. Transcranial brain stimulation was performed in 25 patients. In 22 cases, the authors observed inflammatory tissue thicker than 3 mm behind the odontoid peg. The spinal canal diameter was significantly decreased in the flexed position. Nine patients showed signs of cranial migration of the axis. The diameter of the spinal cord was measured to be 7.4 mm in the neutral position, and 6.5 mm in flexion. The difference between the diameter of the neutral and flexed positions was highly significant. Twelve of the 34 patients displayed clinical signs of cervical myelopathy, and 13 showed a significant delay of central motor latency, as calculated from the motor evoked potentials. Surgical intervention, either by a posterior approach only or combined with a transoral dens and inflammatory tissue resection, is recommended in patients with progressive atlanto-axial instability, pathologic clinical and neurophysiologic findings, and a spinal cord diameter of less than 6 mm in flexion. Severe pain and cranial migration of the axis, as measured by the MRI, also justify a surgical intervention.