High prevalence of asymptomatic cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopaedic surgery

OBJECTIVE: To study the prevalence of cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopaedic surgery, and symptoms that might be associated with the disorders. METHODS: 194 patients with rheumatoid arthritis were referred for orthopaedic surgery at Jyv?skyl? Central Hospital, 154 (79%) of whom volunteered for the present study including clinical examination, laboratory tests, radiographs of the cervical spine, hands, and feet, and self report questionnaires. Definition of anterior atlantoaxial subluxation (aAAS) was >3 mm and of subaxial subluxation (SAS)>or=3 mm. Atlantoaxial impaction (AAI) was analysed following to the Sakaguchi-Kauppi method. RESULTS: 67 patients (44%) had cervical spine subluxation or previous surgical fusion. The prevalence of aAAS, AAI, SAS, or previous fusion was 27 (18%), 24 (16%), 29 (19%), and 8 (5%), respectively; 69% of patients with cervical spine subluxations (those with fusions excluded) reported neck pain, compared with 65% of patients without subluxations (p=0.71). The prevalence of occipital, temporal, retro-orbital, and radicular pain in upper extremities was similar in patients with or without cervical spine subluxations (54% v 43%; 17% v 31%; 25% v 24%; 47% v 48%, respectively). However, patients with subluxations were older, had longer disease duration, more active disease, poorer function according to the Health Assessment Questionnaire, and had more often erosive disease. CONCLUSIONS: Asymptomatic cervical spine subluxation is common in patients with rheumatoid arthritis waiting for orthopaedic surgery. Regardless of symptoms, the possibility of cervical spine subluxation in patients with severe rheumatoid arthritis should be considered in preoperative evaluation.     

Outcome of cervical spine surgery in patients with rheumatoid arthritis

OBJECTIVES: Cervical spine instability in patients with rheumatoid arthritis (RA) may lead to cervical myelopathy or occipital neuralgia, or both. Morbidity and mortality in patients with RA treated with cervical spine surgery during two years of follow up were evaluated. METHODS: Between 1992 and 1996 55 patients with RA underwent cervical spine surgery because of occipital neuralgia or cervical myelopathy, or both. Patients were classified according to the Ranawat criteria for pain and neurological assessment before operation and three months and two years postoperatively. For occipital neuralgia a successful operation was defined as complete relief of pain and for cervical myelopathy as neurological improvement. RESULTS: Occipital neuralgia was present in 17 patients, cervical myelopathy in 14 patients, and 24 had both. Surgical treatment in the patients with symptoms of occipital neuralgia who were still alive two years after surgery was successful in 18/29 (62%). In the surviving patients with cervical myelopathy neurological improvement of at least one Ranawat class was seen in 16/24 (67%). Postoperative mortality within six weeks was 3/51 (6%). Within two years after the operation 14 /51 (27%) of the patients had died; in most patients the cause of death was not related to surgery. The highest mortality (50%) was found in the group of six patients with quadriparesis and very poor functional capacity (Ranawat IIIB). CONCLUSION: Cervical spine surgery in patients with RA performed because of occipital neuralgia or cervical myelopathy, or both, is successful in most patients who are alive two years after surgery. However, the mortality rate during these two years is relatively high, which seems to be largely related to the severity of the underlying disease and not to the surgery itself.     

Neck pain in the elderly: a management review. Part II

Rheumatoid arthritis and metastatic cancer occur commonly in the elderly, and may cause neck pain. Rheumatoid arthritis may produce cervical radiculopathy and myelopathy resulting from vertebral body subluxation, although radiological manifestations of subluxation are much more common than neurological dysfunction. Cervical spinal cord compression is a neurological emergency and may produce cervical radiculopathy as well as myelopathy. Careful neurological and radiological assessments are required to minimize pain and preserve neurological function in elderly patients suffering from neck pain complicating rheumatoid arthritis or cervical spinal metastasis.     

Reappraisal of cervical spine subluxation in Thai patients with rheumatoid arthritis

Subluxation of the cervical spine is one of a number of devastating complications of rheumatoid arthritis. In spite of this, the features of cervical spine subluxation in Thai patients with rheumatoid arthritis have never previously been studied. We enrolled 134 patients with rheumatoid arthritis who were being followed at the rheumatology clinic, Ramathibodi Hospital, during 1978–2001. Radiological examinations were made in lateral neck flexion, extension and open-mouth views. Symptoms of neck pain and the results of relevant neurological examinations were recorded at the time of imaging. Other data on clinical features and treatments since diagnosis were reviewed retrospectively. The overall prevalence of cervical spine subluxation was 68.7%, which can be categorised into anterior (26.9%), posterior (14.9%), lateral (17.2%), vertical (16.4%) atlantoaxial and subaxial subluxation (28.4%). The percentages of cervical subluxation in patients who had suffered from the disease for 1, 5, 10 or more than 10 years were 77.8%, 64.9%, 70% and 64.7%, respectively. None of the patients had neurological deficits. No correlation between neck pain and cervical spine subluxation was established. The number of patients treated with corticosteroids was significantly higher in the subluxation group than in the non-subluxation group (p=0.04). However, no difference in duration of treatment and cumulative dosages of steroids was displayed between the two groups. It was concluded that the prevalence of cervical spine subluxation in Thai patients with rheumatoid arthritis is much higher than the average, even in the early phase of the disease. Hence, radiological examination of the cervical spine should be included in the initial evaluation of Thai RA patients. Corticosteroid use was associated with cervical subluxation, regardless of dose and duration of treatment. The possible explanations are that steroids may directly cause ligament laxity, osteoporosis and decreasing muscle mass, which leads to accelerated subluxation, or that steroid treatments are used in more severe cases which have a higher tendency towards cervical subluxation.Abbreviations RA Rheumatoid arthritis - AAAS Anterior atlantoaxial subluxation - PAAAS Posterior atlantoaxial subluxation - AAI Atlantoaxial impaction - LAAS Lateral atlantoaxial subluxation - SAS Subaxial subluxation - DMARD Disease-modifying antirheumatic drugs     

RADIOUNUCLIDE IMAGING OF THE NECK IN RHEUMATOID ARTHRITIS

Blind marking was used to assess radionuclide neck images obtainedwith technetium-99m methylene diphosphonate in 28 patients withrheumatoid arthritis and 12 with cervical degenerative jointdisease (spondylosis). Eleven out of the 16 rheumatoid arthritispatients who had neck pain when imaged showed enhanced uptakein the region of the atlantoaxial and temporomandibular joints.In contrast, no patient with cervical spondylosis and only onerheumatoid arthritis patient without neck pain had high uptakein either joint. Changes in uptake in this region on repeatimaging correlated significantly (P<0.01) with changes inpain. Patients with rheumatoid arthritis, with or without neck pain,and with cervical spondylosis showed similar patterns of radiologicalabnormality in the cervical spine. No detailed correlation wasdetected between radionuclide and radiographic findings. Radionuclideabnormalities were seen in the middle and lower cervical spinein both rheumatoid arthritis and cervical spondylosis. An abnormalradionuclide image of the middle or lower neck is thus of littlevalue except when no degenerative change is present on the radiograph.An abnormal radionuclide image of the upper neck may be a usefulindication of inflammation. ^*Present address: Wilsonton Medical Centre, Toowoomba, Queensland,Australia. Present address: Department of Radiology, Prince Henry's Hospital,Melbourne, Australia.     

Mortality associated with cervical spine disorders: a population-based study of 1666 patients with rheumatoid arthritis who died in Finland in 1989

OBJECTIVE: To evaluate the mortality associated with cervical spine deformities in rheumatoid arthritis (RA) based on national data. METHODS: The role of rheumatoid disorders of the cervical spine as a cause of death was studied in 1666 subjects who died in Finland in 1989 and had been entitled under the national sickness insurance scheme to receive reimbursed medication for RA. Death certificates and certificates for drug reimbursement of these 1666 patients and the clinical files of 853 patients were examined for the mention of cervical spine disorders. Thereafter, the cervical spine radiographs and detailed clinical histories of patients with diagnosed cervical spine disorder were evaluated separately. RESULTS: According to the official death certificates, cervical spine disorder was not an underlying, contributory or immediate cause of death in any of these patients. Cervical spine abnormalities had been diagnosed only in 38/853 (4.5%) patients. Cervical spine radiographs from 33 patients were available for examination, and in 17 patients cervical spine deformities were found to be severe enough to be a potential cause of fatal complications. Among these 17 cases, four sudden and four postoperative deaths were recorded (one after cervical spine operation) and three patients were suffering from quadriparesis or paraparesis at the time of death. Among the other 16 patients with cervical spine radiographs, the cervical deformities were less severe and their death histories differed from those of the group with more severe deformities. CONCLUSIONS: Cervical spine disorders in RA should be diagnosed early and treated actively to prevent severe and potentially fatal complications. Deaths caused by these disorders are rare, but they should be remembered when the death certificates are written.     

Cervical spine involvement early in the course of rheumatoid arthritis

ObjectivesCervical spine involvement in rheumatoid arthritis (RA) is considered a feature of long-standing disease. We describe two patients who presented with cervical symptoms as early features of RA.MethodsWe report two RA cases with cervical spine involvement as early features and use MEDLINE to review the literature concerning the frequency and disease duration of this manifestation and its imaging with plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI).ResultsAn 80-year-old man with cervical myelopathy from a C1–C2 rheumatoid pannus underwent decompression surgery before development of peripheral synovitis from RA. A 63-year-old woman presented with neck pain and polyarthritis at RA diagnosis, with imaging that confirmed a C1–C2 rheumatoid pannus. Onset of cervical spine involvement in RA is generally after 10 years of disease duration, ranging from 3 months to 45 years after peripheral synovitis among patients with seropositive erosive RA. Occurring in 9–88% of RA patients, cervical spine involvement may result in cervical instability due to either mechanical compression or vascular impairment of the spinal cord. Bone erosions and atlanto-axial subluxation on standard radiographs are two major signs of cervical spine involvement in RA. MRI identifies earlier signs of RA and has a higher sensitivity in detecting bone erosions compared to conventional radiography.ConclusionsCervical spine involvement in RA is not an uncommon condition but is rare at early disease onset. Symptoms of cervical pain and myelopathy should prompt a thorough neurological examination accompanied by imaging.     

Thoracic and lower cervical spine involvement in a case of rheumatoid arthritis

Summary The authors report a case of spine involvement in a severe case of rheumatoid arthritis treated with corticosteroids. First, the patient developed acute back pain, related to costovertebral joints arthritis at levels T9–T10. Then, neck pain and cord involvement yielded to diagnosis of cervical interapophyseal joints arthritis; there was a C5–C6 subluxation which necessitated surgical treatment. The conjunction of these two rheumatoid localizations is an uncommon feature. Study by the CT scan is valuable when rheumatoid arthritis of the spine is suspected. Lower cervical spine subluxation, even severe, may be well tolerated. Surgery is necessary when there is medullary involvement.     

MRI of cervical spine with flexion and extension used in patients with rheumatoid arthritis

Patients with rheumatoid arthritis (RA) often have involvement of the cervical spine. The most common abnormality is atlanto-axial subluxation (AAS). The more serious vertical subluxation (VS) is thought to develop at a later stage. Direct cord compression may occur, but the symptoms may be vague and difficult to interpret. In addition to clinical follow up, RA patients undergo several conventional radiographs of the cervical spine, with addition of flexion and extension images. This, in spite of the fact that the cervical cord and soft tissue do not show. Magnetic resonance imaging (MRI), is the modality of choice to visualize soft tissue and the cervical medulla, but is rarely performed in the follow up of RA patients. Five patients with long-standing RA, episodes of neck pain, and known AAS were asked to volunteer for a MRI study of the cervical spine, consisting of sagittal T2 weighted images of the cervical spine during flexion and extension of the neck. Compared to clinical examinations and cervical radiographs, MRI gave valuable information not otherwise obtained. The importance of MRI with the neck in a flexed and extended position is stressed. This is possible to obtain within a conventional quadrature neck coil in many RA patients.     

Cervical spine involvement early in the course of rheumatoid arthritis

Objectives

Cervical spine involvement in rheumatoid arthritis (RA) is considered a feature of long-standing disease. We describe two patients who presented with cervical symptoms as early features of RA.

Methods

We report two RA cases with cervical spine involvement as early features and use MEDLINE to review the literature concerning the frequency and disease duration of this manifestation and its imaging with plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI).

Results

An 80-year-old man with cervical myelopathy from a C1–C2 rheumatoid pannus underwent decompression surgery before development of peripheral synovitis from RA. A 63-year-old woman presented with neck pain and polyarthritis at RA diagnosis, with imaging that confirmed a C1–C2 rheumatoid pannus. Onset of cervical spine involvement in RA is generally after 10 years of disease duration, ranging from 3 months to 45 years after peripheral synovitis among patients with seropositive erosive RA. Occurring in 9–88% of RA patients, cervical spine involvement may result in cervical instability due to either mechanical compression or vascular impairment of the spinal cord. Bone erosions and atlanto-axial subluxation on standard radiographs are two major signs of cervical spine involvement in RA. MRI identifies earlier signs of RA and has a higher sensitivity in detecting bone erosions compared to conventional radiography.

Conclusions

Cervical spine involvement in RA is not an uncommon condition but is rare at early disease onset. Symptoms of cervical pain and myelopathy should prompt a thorough neurological examination accompanied by imaging.     

Prospective study of the radiological changes in hands, feet, and cervical spine in adult rheumatoid disease.

Annual radiographs of hands, feet, and cervical spine were taken in 100 patients with rheumatoid arthritis from the first year of disease for a mean follow-up period of 9.5 years. Seventy-six patients developed peripheral erosive disease and 54 developed rheumatoid changes of the cervical spine, of whom 34 (63%) had subluxations. The severity of rheumatoid neck damage correlated strongly with the severity of peripheral erosive disease (p = 0.002). Cervical subluxation was more likely to occur in patients with erosions of the hands and feet which deteriorated progressively with time (p = 0.018). The timing and severity of cervical subluxation coincided with the progression of peripheral erosive disease in 26 of these 34 patients (76.5%). The other 8 patients with cervical subluxation (23.5%) had none or only mild peripheral erosions, but their subluxations did not progress with time. There were 9 patients with marked cervical subluxations which deteriorated relentlessly, and they all also had severe progressive erosive disease of the hands and feet. One of these patients developed a cervical myelopathy, and 2 other patients with normal neurological signs had upper cervical fusions performed for severe occipital headache. This small group of rheumatoid patients who are at risk of developing cervical myelopathy cannot be predicted with certainty, but can be selected out at an early stage by performing regular radiographs of hands, feet, and cervical spine.     

Cervical spine surgery in patients with rheumatoid arthritis: an appraisal.

OBJECTIVES: To review the outcome of surgery undertaken to stabilise the neck in patients with rheumatoid arthritis performed over a five year period, to compare the results with those of previous reports, and to identify factors that may predict surgical outcome. METHODS: Outcome was assessed at time of discharge from hospital after surgery by review of patients' notes, and at follow up by patient interview, clinical examination, anonymous questionnaire, and cervical spine radiograph. The Ranawat classification of neurological impairment and Steinbrocker functional classification were used. RESULTS: Thirty nine patients underwent 44 procedures; 28 patients were available for review after a mean period of 29.8 months (range 12-65 months). Fourteen patients had preoperative neurological impairment and were available for follow up; 13 returned the questionnaire. Four (29%) had improved Ranawat class, nine were unchanged, and one had deteriorated. Nine (69%) reported a subjective improvement in neurological symptoms by questionnaire, even though the Ranawat class was unchanged in five. Twenty five of the patients reviewed had pain before operation; 21 returned the questionnaire. Pain relief was reported by direct questioning and questionnaire in 76% and 67% of patients, respectively. Overall, 67% felt that surgery had been successful. Surgery was more successful in producing symptomatic relief in patients with neck or radicular pain than in those with neurological deficit, but did prevent progression of neurological symptoms. CONCLUSIONS: Our results are similar to those from other centres. Overall patient satisfaction with surgery was good. Surgery was more likely to produce symptomatic relief in patients with neck or radicular pain before operation than in those with neurological deficit. The greater subjective improvement in neurological symptoms as judged by questionnaire probably reflects the relative insensitivity of the Ranawat classification in detecting change in neurological status; previous reports of poor outcome for patients with neurological symptoms who undergo surgery may in part be a reflection of the insensitivity of this method of assessment. No clear factors emerged which allowed prediction of those patients at greatest risk of operative mortality. In particular, an increased risk of neurological compromise appeared to confer no additional risk of immediate perioperative death. Our data support the suggestion that early surgery to correct symptomatic atlantoaxial subluxation may prevent progression of instability.     

Cervical spine surgery in patients with rheumatoid arthritis: longterm mortality and its determinants

OBJECTIVE: Atlantoaxial subluxation (AAS) is a frequent manifestation of rheumatoid arthritis (RA). The instability of the craniocervical junction caused by AAS is a potentially fatal condition and may require surgical treatment. Systemic manifestations associated with RA may increase the risk of perioperative complications. We evaluated the longterm mortality and its determinants in RA patients with AAS after cervical spine surgery. METHODS: A retrospective study of consecutive patients treated at Kuopio University Hospital between 1994 and 1998. Preoperative risk factors, neurological impairment using the Ranawat classification, perioperative course, functional outcome, and survival status were evaluated. RESULTS: During the study period 86 rheumatoid patients with AAS underwent cervical spine surgery. The mean followup time was 7.5 years (range 5.0-9.8). During the followup, 32 patients (37%) died. The mean survival time after surgery was 7.2 years (95% CI 6.7-8.0). Seven patients experienced postoperative complications. Age, AAS other than horizontal, and occurrence of complications were independent predictors of mortality. In two-thirds of the patients there was relief or decrease of pain, and the functional capacity improved. Neurological deficits subsided in 53% of cases. CONCLUSION: Patients with RA should be actively studied for AAS or other cervical instability, even when cervical symptoms are minor. Attention should be paid to perioperative management of these patients. Surgical treatment may not decrease the mortality of patients with RA, but it may result in more symptom-free life-years.     

Bony ankylosis of the facet joint of the cervical spine in rheumatoid arthritis: Its characteristics and relationship to the clinical findings

Objectives: The purpose of this study was to clarify the characteristics of bony ankylosis of the facet joint of the cervical spine in rheumatoid arthritis (RA) patients who required cervical spine surgery, and its relationship to the clinical findings.

Methods: Eighty consecutive RA patients with cervical spine disorder who received initial surgery were reviewed. The occurrence of bony ankylosis of the facet joint of the cervical spine was investigated using computed tomography (CT) before surgery. We also evaluated the severity of neurological symptoms and the plain wrist radiographs taken before surgery; furthermore, we evaluated each patient’s medical history for total knee arthroplasty (TKA) or hip arthroplasty (THA).

Results: The preoperative CT imaging demonstrated bony ankylosis of the facet joint of the cervical spine in 45 facet levels of 19 cases (BA?+?group). In all patients, responsible instability or stenosis was demonstrated just caudal or on the cranial side of those bony ankylosis. Before surgery, the BA?+?group included significantly more patients showing severe cervical myelopathy (p?p?p Conclusions: Bony ankylosis of the facet joint of the cervical spine may be a risk factor of instability or stenosis at the adjacent disc level and severe cervical myelopathy. Furthermore, its ankylosis was demonstrated in RA patients with severe destroyed joints.     

The cervical spine in patients with psoriatic arthritis

OBJECTIVE: To establish the incidence of clinically important inflammatory cervical spine abnormalities in radiographs of patients with psoriatic arthritis (PsA). METHODS: Patients were selected from a rheumatological outpatient clinic and one ward of the Rheumatism Foundation Hospital, Heinola, Finland, by examining 160 consecutive PsA cases. A total of 65 patients (38 women, 27 men) with PsA were identified who had cervical spine radiographs available. These were evaluated for inflammatory changes, and patient records studied for disease characteristics, laboratory and clinical findings. RESULTS: In 12 cases (18%) inflammatory cervical spine changes were seen in the cervical spine radiographs. The most frequently detected was apophysial joint ankylosis, seen in seven patients (11%). Anterior atlantoaxial subluxation (aAAS) was seen in five (8%) and atlantoaxial impaction in three (5%). In 20 of the 40 patients who had the rotational range of neck motion measured the measurement was < or =45 degrees either to the left or the right side. CONCLUSION: Inflammatory cervical spine changes were not commonly seen in radiographs of patients with PsA. Apophysial joint ankylosis and aAAS were detected most often. PsA may decrease the rotational range of neck motion significantly.     

Cervical spine surgery in ankylosing spondylitis: Is the outcome good?

Summary Objective. To assess retrospectively, the outcome of cervical spine surgery in patients with ankylosing spondylitis (AS).Methods. A cross-sectional study of 3464 patients with identified AS, 19 patients of whom had cervical spine surgery. A self-administered questionnaire (including the use of 10 cm visual analogue scales, 0=none, 10=worst) assessing the complications of the surgery, patients' neck symptoms and post-surgery functional ability was sent to the 19 patients. Available casenotes and radiographs were reviewed. Results. The mean duration of follow-up was 10 years. One patient had two separate cervical spine operations. The types of surgery performed included cervical fusion (n=7), osteotomy (n=7) and laminectomy (n=6). Six patients had minor complications as a result of surgery. The majority of patients (93%) felt that their surgery had been successful. Most patients (81%) had a reduction in neck pain (mean pain score=3.1, SD 2.8) but increased neck stiffness (mean stiffness score=8.0, SD 2.9). Postoperative radiographs of 7 patients showed complete ankylosis of the cervical spine. Generally, few patients reported difficulty with reading/watching television (6%), sleep (19%) or driving (36%). A third of the patients were still in full time employment.Conclusions. About 1 in 200 patients with AS undergo cervical spine surgery. The surgery is often successful and complications are usually minor. Neck pain is often better after surgery and any remaining neck symptoms do not significantly affect the patient's sleep or functional activities. In this retrospective study, the long term outcome of cervical spine surgery in patients with AS appears to be good.The Arthritis and Rheumatism Council, the National Ankylosing Spondylitis Society, the Pilkington Trust and the Coates Trust. Dr Koh is supported by the Singapore government.     

Prevalence of radiological changes in the cervical spine--a cross sectional study after 20 years from presentation of rheumatoid arthritis

OBJECTIVE: To evaluate the prevalence of cervical spine changes in patients with rheumatoid factor (RF) positive rheumatoid arthritis (RA) followed prospectively for 20 years. METHODS: An inception cohort of 103 patients with RF positive RA have been followed at the Rheumatism Foundation Hospital, Heinola. A total of 68 patients attended for the 20 year followup. An additional 28 patients died and 7 were not able to attend due to severe disease or old age. The plain cervical spine radiographs of 69 patients (68 and one received from another hospital) taken after 20 years of RA were evaluated. RESULTS: Anterior atlantoaxial subluxation was found in 16 cases (23%), while 18 patients (26%) had atlantoaxial impaction as judged by the Sakaguchi-Kauppi method. Subaxial subluxations and lateral atlantoaxial subluxations were found in 13 cases (19%) and 3/52 cases (6%), respectively, while 45 patients (65%) had subaxial disc space narrowing. CONCLUSION: Cervical spine changes are common in patients with long lasting RA. They should be diagnosed and treated early to avoid complications. In our patient group no cervical spine surgery was performed, but at least 7 patients (10%) required further evaluation for possible surgery.     

Lateral subluxation of the atlanto-axial joint in rheumatoid arthritis.

Involvement of the cervical spine by rheumatoid disease is common, but lateral subluxation at the atlanto-axial level has not been recorded previously. The condition is due to asymmetrical erosion of the lateral atlanto-axial facet joint, and may be complicated by collapse of the lateral mass of the axis. The condition should be suspected in patients with rheumatoid arthritis (RA) who present with occipital, auricular, and/or facial pain.     

Pain and the cervical spine.

Persistent neck symptoms following flexion-extension type injuries are common and may respond to early mobilization. Cervical degenerative disc and joint disease probably account for most chronic neck-related problems. Most often symptoms result from compression of neural structures, especially nerve roots. The cervical spine is commonly affected by rheumatoid arthritis, ankylosing spondylitis, and other inflammatory arthropathies. Potentially serious complications usually result from subluxations at C1-C2, usually in chronic rheumatoid arthritis. Most problems causing neck pain without neurologic signs or symptoms can be managed conservatively with physical therapy maneuvers, especially interrupted traction.