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Rheumatoid arthritis affects 0.5–1% of the Caucasian population; however, the incidence around the world varies considerably with some North American Indians having an incidence of 5–7% and the disease being almost unheard of in South Africa and Nigeria [1]. It has not always been seen in Europe; there is little evidence of its prevalence before Renoir’s self portrait and Garrod’s descriptions about 120 yrs ago [2, 3]. The polyarthropathy of rheumatoid arthritis affects the joints of the spine, and particularly the upper cervical spine. A rare but devastating complication is the development of progressive neurological disability leading ultimately to paralysis and a lingering death. In the early days, this complication was under-diagnosed and disability was blamed on peripheral neuropathy due to drugs and nerve compression by diseased peripheral joints. Sudden unexplained deaths were attributed to strokes or heart attacks until Redlund-Johnell [4] reviewed the coroners post mortems in Southern Sweden and found that over half of the ‘sudden deaths’ in rheumatoid arthritis were actually associated with instability of the cervical spine and cord compression. The increasing availability of CT, and then MRI scans, revealed that the brain stem and upper cervical cord compression of rheumatoid arthritis was more common than previously realized. Henderson et al. [5] clearly demonstrated that it was the mechanical problem of spinal cord compression and not vasculitis that caused disability in these patients, and through the databases collected by Corbett et al. [6] and Kauppi et al. [7], the natural history of this complication was determined. Cervical myelopathy rarely appeared in the first decade from the onset of disease because the aetiology was probably repeated minor cord injuries over time [8]. Two or three previous large-joint operations usually preceded the development of myelopathy [9]. Once established, however, neurological deterioration could be rapid with half of those who developed myelopathy dying within a year and most patients dying within 7 yrs [9]. In the ’80s, it became apparent that patients and clinicians had to be made more aware of the problems of rheumatoid cervical instability. More emphasis was now placed on the importance of treatment before irreversible neurological damage had occurred [10]. The timing and extent of surgery, however, were issues which remained for debate. It was clear that surgery for the bed-bound quadriparetic patient was not only dangerous, with a mortality of up to 30%, but also did not improve the disability often; it was ‘too much and too late’ [10], whilst others with atlantoaxial subluxation might remain asymptomatic for many years without evidence of neurological deterioration. Therefore, if a proposed operation had a significant mortality, then the risks of surgery out-weighed the dangers of atlantoaxial subluxation. The true danger of atlantoaxial subluxation could not be assessed with flexion and extension X-rays alone; once the movement exceeded 3mm, it did not really matter how much subluxation there was. Only with the advent of MRI scans could the true extent of subluxation and cord compression be appreciated, allowing rational decisions to be made regarding surgery. MR imaging for example reveals compression by rheumatoid pannus and vertical translocation, which can occur with only small increases in anterior atlantodental intervals on cervical X-rays. Casey and Crockard [11] calculated that there might be more than 62 000 people in the United Kingdom at risk of neurological compression from rheumatoid cervical instability, and extrapolating to the United States, a figure of a quarter of a million [11]. This was calculated from records going back to the ’60s and ’70s when the patients first developed their disease. In a more recent study at the turn of this century, Hamilton et al. [12] showed that the incidence is actually 14 times lower. There has been a step-like change in the disease prevalence. During the same time period, the numbers of large-joint replacements have also dramatically fallen. Ward [13] in California and de Silva et al. [14] in Minnesota revealed a clear decrease in the numbers of knee and hip arthroplasties performed in patients with rheumatoid arthritis. These changes have coincided with the introduction of new disease modifying antirheumatic drugs (DMARDs) and the decreased use of steroids in rheumatoid arthritis. Many of the bony and ligamentous changes seen in the rheumatoid spine resemble those of long-term steroid usage. Indeed, it might be argued that some of the problems associated with rheumatoid changes in the neck might be attributed to the long-term use of steroids rather than the disease itself. Over the last 20 yrs, five factors have emerged, changing the way we treat cervical rheumatoid disease:

Neck problems in rheumatoid arthritis--changing disease patterns, surgical treatments and patients' expectations