18, 28 Additionally, all cases of AAS can also be classified as reducible, partially reducible, or fixed, according to the response to traction or dynamic radiological studies. Posterior subluxation is associated the highest rate of neurological deficits of all forms of AAS. 6 Posterior AAS generally occurs in the setting of an odontoid base erosion or fracture. 4, 38 Considering atlantoaxial instability, anterior AAS is the most common form, followed by lateral AAS, which represents about 20% of cases, and posterior AAS, which represents about 7% of all cases of AAS in association with RA. Stroke and sudden death have been reported in patients with RA involvement of the upper cervical spine due to vertebrobasilar insufficiency. 15, 18 Clinically, cervical pain can be secondary to instability or C-2 nerve root compression. As a natural tendency, the head drops forward, resulting most commonly in anterior atlantoaxial subluxation (AAS) craniocervical kyphosis, decreasing the craniocervical angle. This inflammatory process results in laxity of the ligamentous complex and loss of ligamentous restriction, leading to atlantoaxial instability. 4, 42, 43 There is an important predilection for chronic inflammatory infiltration and pannus formation at the C1–2 joints that precedes bone destruction. The most common site of involvement is the atlantoaxial region. 18, 22, 27, 33, 38, 44 Cervical involvement is probably a consequence of the intense chronic synovitis that occurs in the joints, progressing to bone erosion and consequent ligamentous laxity and finally clinical and radiological instability. The cervical spine is involved in up to 86% of patients with RA, especially in those with inadequate treatment or more severe forms of the disease. 17 Although this autoimmune condition involves mainly bone, joints, and ligaments, extra-articular involvement has been described in nearly every organ, including the lungs, eyes, skin, and vessels. R heumatoid arthritis (RA) is a systemic inflammatory disease that predominantly affects adult women (2 to 4 times as frequently as men).
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