Surgical treatment of multiple level cervical spine subluxation due to rheumatoid arthritis

The authors report a patient with extensive rheumatic cervical spine involving atlantoaxial subluxation with spinal cord compression, and subaxial subluxation from the level of C2 to C7. The patient was admitted with neck pain and myelopathy and was treated with pre-operative skeletal traction and a two stage surgery: first, transoral decompression; and second suboccipital decompression involving C1 laminectomy with posterior fusion of the occiput-C1 to C7 levels. Cervical MRI was performed between the two stages of surgery revealing an inadequate decompression with the transoral approach alone. Although adequate spinal cord decompression and spinal fixation can be obtained by posterior approach alone in most of the condition, combined anterior and posterior decompression with posterior fixation was necessary for treatment of the extensive multiple cervical spine subluxation in certain conditions as in this case. Cervical MRI imaging between the two stages of surgery is recommended to evaluate whether the decompression in the first stage surgery was complete or not.