Case history

A 55 year old woman had a 10 year history of erosive, seropositive rheumatoid arthritis (RA), when referred for assessment of intractable neck pain. From its onset in 1985 the disease deteriorated quickly and neither gold salts, nor sulphasalazine, methotrexate, cyclophosphamide, or cyclosporin A, with or without combination of non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroids, prevented major joint deformities. Joint replacement surgery of the right hip and both knees, as well as corrective surgery of hands and feet, were performed in 1992 and 1993 using regional anaesthetic blocks. Neck pain was first reported in 1992 and became intractable later on.

On admission in March 1995 the patient particularly complained about pain localised to the neck and she expressed difficulties in swallowing large pieces of food. Drug treatment included NSAIDs, low dose corticosteroids, paracetamol, a tricyclic antidepressant, and calcium. Physical examination showed widespread joint swelling and secondary osteoarthritis of most peripheral joints including both temporomandibular joints (TMJ) resulting in limited oral aperture capability. Mobility …