The consequent instability contributes to intervertebral disk destruction, which causes further loss of spinal integrity. Clinical manifestations caused by arthritic changes and neural element compression include neck pain, radiculopathy, and myelopathy. As in upper cervical spine instability, cervical traction is used initially in an attempt to establish normal spinal alignment. Reducible lesions are then stabilized posteriorly, using posterolateral fusion with lateral mass plate fixation. Postoperatively the patient is immobilized in a Philadelphia collar and followed with serial radiographs.
Immobilization is maintained until fusion is seen radiographically.
In patients with rheumatoid arthritis, compression of the neural elements may result from bony impingement caused by spinal deformity or from pressure exerted by inflammatory pannus formation. Atlantoaxial subluxation is often associated with both causes of compression and may be further exacerbated by the development of cranial settling. Radiographic evidence of neural element compression is best demonstrated by magnetic resonance imaging because of its excellent soft tissue contrast. The establishment of normal spinal alignment by cervical traction may, by itself, achieve adequate decompression. However, in some cases, such as those involving an irreducible lesion, a transoral approach may be needed.