Bow hunter syndrome in rheumatoid arthritis: illustrative case

Brian P. Curry*, Vijay M. Ravindra, Jason H. Boulter, Chris J. Neal, Daniel S. Ikeda

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


BACKGROUND Rheumatoid arthritis (RA) frequently features degeneration and instability of the cervical spine. Rarely, this degeneration manifests as symptoms of bow hunter syndrome (BHS), a dynamic cause of vertebrobasilar insufficiency. OBSERVATIONS The authors reviewed the literature for cases of RA associated with BHS and present a case of a man with erosive RA with intermittent syncopal episodes attributable to BHS as a result of severe extrinsic left atlantooccipital vertebral artery compression from RA-associated cranial settling. A 72-year-old man with RA-associated cervical spine disease who experienced gradual, progressive functional decline was referred to a neurosurgery clinic for evaluation. He also experienced intermittent syncopal events and vertiginous symptoms with position changes and head turning. Vascular imaging demonstrated severe left vertebral artery compression between the posterior arch of C1 and the occiput as a result of RA-associated cranial settling. He underwent left C1 hemilaminectomy and C1–4 posterior cervical fusion with subsequent resolution of his syncope and vertiginous symptoms. LESSONS This is an unusual case of BHS caused by cranial settling as a result of RA. RA-associated cervical spine disease may rarely present as symptoms of vascular insufficiency. Clinicians should consider the possibility, though rare, of cervical spine involvement in patients with RA experiencing symptoms consistent with vertebral basilar insufficiency.

Original languageEnglish
Article numberCASE21298
JournalJournal of Neurosurgery: Case Lessons
Issue number3
StatePublished - 2021
Externally publishedYes


  • atlantoaxial instability
  • bow hunter syndrome
  • cervical spine
  • positional vertebrobasilar insufficiency
  • rheumatoid arthritis
  • vertebral artery


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