A 59-year-old woman with rheumatoid arthritis presented with progressive gait difficulties and electric shock-like pain triggered by neck flexion (Lhermitte sign) for more than 6 months. On examination, she had hyperreflexia in the 4 limbs and brisk deep abdominal reflexes with absent superficial abdominal reflexes (reflex dissociation) (Video 1). MRI showed spinal cord compression resulting from anterior subluxation of the atlas and retrodental pannus (synovial tissue proliferation) (Figure). Superficial abdominal reflexes may be absent in 20% of normal individuals.1 However, the dissociation of abdominal reflexes suggests an upper motor neuron lesion above the T6 spinal segment.2
Video 1
Dissociation of abdominal reflexes. Absent superficial abdominal reflexes with brisk deep abdominal reflexes.Download Supplementary Video 1 via http://dx.doi.org/10.1212/013007_Video_1
T2-weighted sagittal (A) spine MRI showing spinal cord compression and high signal intensity at the level of C1-C2 (dashed arrow) because of anterior subluxation of the atlas (solid arrow) and retrodental pannus (small arrow) in a patient with rheumatoid arthritis. T2-weighted axial (B) image confirms spinal cord compression by atlantoaxial subluxation (arrow, B).
Study Funding
The authors report no targeted funding.
Disclosure
I.V. Brum reports no disclosures relevant to the manuscript; G.D. Silva reports no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Appendix Authors
Footnotes
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Teaching slides links.lww.com/WNL/B633
- © 2021 American Academy of Neurology
References
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