Ten patients undergoing long-term renal dialysis for end-stage renal failure developed a destructive, non-infectious spondylarthropathy. All 10 patients had biopsy-proven dialysis-associated spondylarthropathy and subsequent spinal instability secondary to beta 2-microglobulin deposition in the vertebrae, intervertebral disc spaces, and support structures of the spine. Nine patients had cervical spinal instability and one had thoracolumbar spinal instability, with resultant neural compression. In at least one patient, the spinal instability was rapidly progressive. All had received renal dialysis for 34 months or longer (mean 109 months, range 34 to 154 months). Each patient required spinal stabilization (external in seven patients, internal in three). Nine of the 10 patients underwent neural decompression and spinal stabilization and fusion procedures. One patient's neurological condition was worse following surgery due to a postoperative cervical epidural hematoma; in the other nine patients, the presenting symptoms and signs improved. Three of these chronically ill patients did not survive their hospitalization, for a perioperative mortality rate of 30%. Death was due to cardiopulmonary arrest in two patients on Day 5 and 9 postoperatively and to sepsis in the third on Day 14. Of the seven early survivors, two additional patients died: one on Day 59 due to congestive heart failure and the other on Day 273 due to a cerebrovascular accident. Four of five patients who were followed for 8 months or longer (mean 14 months, range 8 to 20 months) had successful neural decompression and spinal stabilization procedures with evidence of stable bone fusion, indicating that these chronically ill, difficult-to-manage patients can be successfully treated. Clinicians who treat patients with renal disease and neurosurgeons who treat spinal disorders should be aware of dialysis-associated spondylarthropathy as a potential cause of degenerative vertebral column instability.