Objective: To reassess whether the Ranawat IIIB (quadriparetic, non-ambulant) rheumatoid arthritis (RA) with cervical myelopathy patients should be surgically treated.

Study Design: Retrospective study

Subjects: Over a 12-year period (1988–1999), 51 patients [15 M: 36F; mean age 64 years] in Ranawat IIIB with RA were diagnosed to have cervical myelopathy. These included 47 patients with atlantoaxial subluxation (AAS) [15 with AAS alone, 10 with basilar invagination (BI), 18 with associated subaxial subluxation (SAS) and four patients with BI and SAS] and four patients with SAS alone.

Results: Thirty-two patients considered fit for surgery successfully underwent operative treatment (Group 1). All underwent posterior instrumented fixation with or without transoral odontoid peg excision. Postoperatively 22/27 patients were pain free and 21/32 patients initially non-ambulant were able to walk. 3/26 patients died within six months of surgery. 13/19 patients managed conservatively (Group 2) because of medical complications died within six months of presentation.

Conclusions: Even in advanced stages of cervical myelopathy in RA, surgical intervention is beneficial with significantly higher morbidity/mortality in conservatively managed patients.