High mortality in patients with rheumatoid arthritis and atlantoaxial subluxation

Objective. To study relationships between atlantoaxial subluxation (AAS) an d total mortality in patients with rheumatoid arthritis (RA). Methods. Radiological reports and clinical files of patients with RA were r eviewed for the presence of cervical spine involvement verified by cervical radiographs. Results. Among 241 patients with cervical radiographs, anterior AAS greater than or equal to 4 mm was found in 5% [95% confidence interval (CI) 2-8] o f patients. Vertical and posterior subluxations were found in 1.4 and 0.5%, respectively. The mean observation time from RA diagnosis to AAS was 3.9 y ears. Patients with AAS had 8 times higher mortality than patients without AAS (95% CI 3-25). According to the death certificate, the patients died fr om cancer, stroke, and myocardial infarction. Cervical spine disorder was n ot mentioned on the death certificate. However, an autopsy was not performe d. Conclusion. We found high mortality in RA patients with AAS. AAS in the cer vical spine developed relatively early in the course of the disease. Analys es adjusted for seropositivity, erosiveness, and glucocorticosteroids did n ot reduce the mortality rate ratio. Our results underline the need for care ful evaluation of patients with RA with respect to development of AAS.