Teaching Neuro Images : Rheumatoid pannus of the cervical spine

Abstract

A 71-year-old woman with juvenile-onset rheumatoid arthritis presented with right trigeminal mandibular pain and dysphonia on a background of 6-month oropharyngeal dysphagia and C3-C5 laminectomy in 2010. She had severe deforming polyarthropathy. Neurologic examination revealed bilateral tongue wasting, loss of tongue protrusion, and right vocal cord paresis. Uvula movement and pharyngeal and facial sensation were normal. MRI (figure, A and B) demonstrated a large cervical synovial pannus extending across the skull base. Multiple cranial neuropathies are extremely rare in rheumatoid arthritis1,2 and should raise suspicion of cervical spine pannus. Aggressive disease-modifying medical therapy may obviate need for neurosurgery.1