Magnetic resonance imaging of the craniovertebral junction in rheumatoid arthritis

Conventional radiography and magnetic resonance imaging (MRI) of the craniovertebral junction were evaluated in 12 patients with longstanding rheumatoid arthritis (RA) and neck pain with or without other neurologic signs or symptoms of cervical myelopathy. MRI demonstrated abnormal soft tissue masses thought to represent pannus in 9 patients. Three patients showed cord or brainstem compression due to pannus or atlantoaxial subluxation. The 3 patients with MRI evidence of cord or brainstem compression had neurologic signs or symptoms of cervical myelopathy, and appropriate therapy was instituted based on these findings. This study indicates that MRI is able to detect abnormal soft tissue masses which probably represent pannus and their relationship to the spinal cord or brainstem, and confirms the utility of the procedure in the management of craniovertebral involvement in RA.     

Magnetic resonance imaging in the evaluation of patients with rheumatoid arthritis and subluxations of the cervical spine

We used magnetic resonance imaging (MRI) to examine 21 patients with rheumatoid arthritis and vertebral subluxations of the cervical spine, in whom neurologic symptoms and signs indicated spinal cord compression. Based on neurologic signs, the patients were assigned to 1 of 3 classes: class I, no objective signs of cervical myelopathy (9 patients); class II, only 1 objective sign of cervical myelopathy (4 patients); or class III, 2 or more objective signs of cervical myelopathy (8 patients). Atlantoaxial subluxation (20 patients) and subluxations below C2 (6 patients) were detected equally well by MRI and radiography. MRI revealed physical distortion of the spinal cord in all class III patients with compressive myelopathy. This distortion was found less frequently in class II and class I patients (3 patients), and the difference was statistically significant (P less than 0.005, class III versus class I and class II). No correlation was found between the vertebral dislocation (measured in millimeters) on plain radiographs and the presence of cord distortion on MRI. Myelography in class III patients showed that passage of contrast medium was blocked at the same level as the cord distortion seen on MRI. These findings suggest that MRI can serve as a useful, noninvasive procedure in the diagnosis and management of rheumatoid arthritis patients in whom compressive cervical myelopathy is suspected.     

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.     

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.     

Cervical myelopathy caused by periodontoid synovial pannus in a patient with psoriatic arthritis: a case report

The atlantoaxial subluxation and the formation of a synovial periodontoid pannus are associated with rheumatoid arthritis causing mechanical compression of the spinal cord and cervical myelopathy. Atlantoaxial subluxation is very rare in psoriatic arthritis (PsA). Even more rare is the formation of a periodontoid synovial pannus associated with PsA and signs of myelopathy. In this report, cervical myelopathy caused by periodontoid synovial pannus in PsA is described.     

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.     

Surgical treatment of cervical cord compression in rheumatoid arthritis.

Cervical myelopathy is a rare but potentially dangerous complication of rheumatoid arthritis and presents considerable therapeutic problems. A conservative approach carries high mortality and surgical intervention is not without serious risks. Reduction of subluxation and posterior fusion is widely practised but may require prolonged bed rest and continuous skull traction, sometimes for many weeks. When anterior decompression has been attempted prolonged immobilisation and external fixation have created problems. In this series 23 rheumatoid patients with cervical myelopathy were investigated over a four-year period. Seventeen underwent anterior decompression of the cervical cord, of whom 14 had a transoral removal of the odontoid peg and pannus and posterior occipitocervical fusion during the same anaesthetic without mortality or serious postoperative complications; all but one have improved. The authors believe that early mobilisation after a combined cord decompression and internal fixation has reduced the mortality and morbidity. Management of cervical myelopathy in rheumatoid arthritis and indications for operation are discussed.     

Low-field MRI in the evaluation of rheumatoid cervical spine. Comparison with neurological findings and routine plain radiography

The usefulness of a low-field magnetic resonance imaging (MRI) instrument in the evaluation of cervical spine abnormalities was studied in 20 patients with rheumatoid arthritis and known anterior atlantoaxial subluxation (AAS) (16 patients) or other cervical spine abnormalities (4 patients). The MRI results were compared with routine plain radiographs and with neurological findings. Three patients had a clinical suspicion of cervical spinal cord compression. This was confirmed by MRI, which additionally detected one more patient with compressive myelopathy. Anterior AAS in MR images was seen in 4 patients, but proper flexion images were not obtained. Atlantoaxial impaction was detected by a recent method of Sakaguchi-Kauppi in 16 patients as compared to 9 patients by the McGregor method and 4 patients by MRI. Most of the clinically important consequences of rheumatoid cervical spine are seen with a low-field MR imager, but detailed bony changes and precise measurements are better evaluated with plain X-rays.     

LYMPHOMATOID GRANULOMATOSIS PRESENTING AS A PROGRESSIVE CERVICAL CORD LESION

A 50-year-old male presented with symptoms of a progressive spinal cord lesion over two and a half months. Investigations, including myelography, CT scan and magnetic resonance imaging (MRI), did not show cord compression although the MRI scan demonstrated thickening of the posterior cervical meninges. CSF examination revealed pleocytosis, increased total protein and cells suggestive of a lymphoproliferative disorder. Open lung biopsy of an asymptomatic toft mid-zone mass was diagnostic of lymphomatoid granulomatosis. We believe this to be a case of lymphomatoid granulomatosis presenting as a progressive cervical myelopathy.     

Intramedullary spinal cord metastasis and leptomeningeal involvement in Hodgkin's disease. Case report and review of the literature

INTRODUCTION: Central nervous system, especially spinal cord involvement, is unusual in Hodgkin's disease. We report the case of a patient with refractory Hodgkin's disease who presented with intramedullary involvement. EXEGESIS: A 36-year-old woman presented with weakness of the right lower extremity and sphincter dysfunction 13 years after initial diagnosis of Hodgkin's disease. Magnetic resonance imaging showed intraspinal tumor with contrast enhancement extending from C7 to D1. Cerebrospinal fluid examination revealed the presence of Reed-Sternberg cells. Specific intramedullary spinal cord metastasis and leptomeningeal involvement were confirmed. Despite intrathecal chemotherapy the neurologic deficit progressed to paraplegia and the patient died 2 months later. CONCLUSION: Intramedullary spinal cord metastases rarely occur in the course of Hodgkin's disease. Except for the initial presentation, their prognosis is poor despite early diagnosis with magnetic resonance imaging. Other causes such as epidural cord compression, paraneoplasic myelopathy, granulomatous angiitis and radiation myelopathy are still delated.     

Syringomyelia in a patient with rheumatoid subluxation of the cervical spine.

A patient with rheumatoid damage of the cervical spine with cervical cord compression, complaining of a typical syringomyelic syndrome is described. Magnetic resonance imaging revealed cord compression due to an upward displacement of the odontoid peg with a mass of pannus behind the dens, and a syrinx cavity extending from C1 to T1. We postulate that this patient's syringomyelia probably represents a complication of cervical rheumatoid arthritis that has not been described.     

Neuropathology of the brainstem and spinal cord in end stage rheumatoid arthritis: implications for treatment.

OBJECTIVE--To study the detailed histopathological changes in the brainstem and spinal cord in nine patients with severe end stage rheumatoid arthritis, all with clinical myelopathy and craniocervical compression. METHODS--At necropsy the sites of bony pathology were related exactly to cord segments and histological changes, and correlated with clinical and radiological findings. RESULTS--Cranial nerve and brainstem pathology was rare. In addition to the obvious craniocervical compression, there were widespread subaxial changes in the spinal cord. Pathology was localised primarily to the dorsal white matter and there was no evidence of vasculitis or ischaemic changes. CONCLUSIONS--Myelopathy in rheumatoid arthritis is probably caused by the effects of compression, stretch, and movement, not ischaemia. The additional subaxial compression may be an important component in the clinical picture, and may explain why craniocervical decompression alone may not alleviate neurological signs.     

Intravenous corticosteroid therapy of cervical cord compression in rheumatoid arthritis.

We describe a case of atlantoaxial joint subluxation and cervical myelopathy in a patient with rheumatoid arthritis. Magnetic resonance imaging (MRI) demonstrated a large periodontoid pannus compressing the upper cervical cord. Neurological function improved rapidly after treatment with intravenous pulse corticosteroids given before surgical fusion of the cervical spine. Post operative MRI showed a significant reduction in size of the pannus.     

Cervical myelopathy due to atraumatic odontoid fracture in patients with rheumatoid arthritis: A case series

To highlight the risk of cervical myelopathy due to occult, atraumatic odontoid fracture in patients with rheumatoid arthritis, we retrospectively reviewed radiographic findings and clinical observations for 7 patients with this disorder. This fracture tends to occur in patients with long-lasting rheumatoid arthritis and to be misdiagnosed as simple atlantoaxial dislocation. Since this fracture causes multidirectional instability between C1 and C2 and is expected to have poor healing potential due to bone erosion and inadequate blood supply, posterior spinal arthrodesis surgery is indicated upon identification of the fracture to prevent myelopathy.     

单侧开门外侧块螺钉固定植骨治疗颈脊髓压迫症

目的 探讨单侧开门外侧块螺钉固定植骨术治疗颈脊髓压迫症的临床疗效.方法 自2004-02～2008-06采用单侧开门外侧块螺钉固定植骨术治疗颈脊髓压迫症26例,男18例,女8例;年龄51～67岁,平均58岁.26例中有22例为多节段脊髓型颈椎病(3个或3个节段以上),其中10例合并发育性椎管狭窄症(6例合并动力性椎管狭窄症,3例合并后纵韧带骨化症,1例为外伤性);4例为颈椎管内肿瘤.随访9个月～2年2个月,平均1年8个月.结果 疗效评定标准参照日本整形外科协会(JOA)评分标准,优8例,良15例,可2例,差1例,优良率为88.5%.无一例出现血管损伤或内固定物断裂并发症,1例脊膜瘤因肿物过大术后出现脊髓再灌注损伤表现,经积极治疗好转,生活可自理.结论 该法适用于需要从后方入路进行减压的颈脊髓压迫症,疗效肯定.其优点是手术相对安全,在彻底减压的同时进行坚强的内固定,尤其适用于伴有节段性不稳的脊髓型颈椎病.     

Three cases of rheumatoid arthritis with laryngeal stridor

The purpose of this is case-based review is to report a series of patients with rheumatoid arthritis who developed stridor and highlight this potentially life-threatening manifestation of the disease. We report three cases from the Rheumatology Department of University College Hospital, London and review the literature on the prevalence, clinical presentation, histopathological features and treatment of laryngeal involvement in rheumatoid arthritis. In two patients, emergency tracheostomy was necessary to maintain a patent airway. One patient improved with systemic corticosteroids without the need for surgical intervention. All patients were seropositive with anti-CCP antibodies and had long-standing erosive disease. Stridor in patients with rheumatoid arthritis is typically due to arthritis of the cricoarytenoid joints leading to fixation of the vocal cords in a midline position. Cricoarytenoid joint arthritis may be acute, chronic, or acute-on-chronic. Emergency tracheostomy may be life-saving in cases of acute stridor. Cricoarytenoid inflammation and airway compromise may respond to local or systemic corticosteroid therapy. Other causes of vocal cord paresis in rheumatoid arthritis include ischaemic neuropathy of the recurrent laryngeal and vagus nerves due to vasculitis or cervicomedullary compression due to rheumatoid involvement of the cervical spine.     

Is transcranial magnetic stimulation a helpful method in diagnosis of cervical myelopathy in patients with chronic polyarthritis?

Fifty-seven patients with rheumatoid arthritis were examined clinically, radiologically, and by means of transcranial magnetic brain stimulation. With this method central motor conduction times of the corticospinal pathways can be measured. The aim of the study was to compare the different methods to detect a cervical myelopathy and to correlate them. In 90% of patients clinical signs of cervical myelopathy could be detected, although in two-thirds of these, the neurological deficit was minimal. Radiologically, over 50% of patients had an atlanto-axid dislocation (AAD) of more than 5 mm. The central motor latencies measured in the upper extremities were prolonged in 47% of cases. These results show the usefulness of transcranial magnetic brain stimulation as an additional noninvasive investigation for detecting compression of the cervical myelon. This is an additional useful criterion for determining the need for operative intervention.     

Compression of the spinal cord revealing a seronegative rheumatoid arthritis

INTRODUCTION: Craniocervical junction damages may result in a compression of the spinal cord. They may be caused by infectious, tumoral or inflammatory processes. Rheumatoid arthritis is probably among rheumatic diseases the most frequent cause of atlantoaxial arthritis. Nevertheless involvement of the craniocervical junction as the presenting symptom of rheumatoid arthritis is a very rare feature. EXEGESIS: We report the case of a 61 years old woman who presented with atlantoaxial involvement and spinal cord compression one year before the diagnosis of a seronegative rheumatoid arthritis. CONCLUSION: Symptomatic craniocervical junction damages may appear. Patients with damages of the craniocervical junction and negative investigations should be followed long-term; an underlying inflammatory disease may become evident after significant delay.     

Symptomatic noncompressive motoromyelopathy presents as early manifestation in ankylosing spondylitis

Ankylosing spondylitis (AS) is an autoimmune spondyloarthropathy involving principally the sacroiliac joint and axial skeleton. Spinal cord involvement is an infrequent and late complication. It mostly results from compressive myelopathy due to skeletal osteopathy and usually presents with radiculomyelopathic sensory and motor deficits. To report three patients who suffered a progressive paraparesis/tetraparesis compatible with motor myelopathy without typical skeletal symptom. Myelopathy of unknown origin was initially interpreted in these patients. Radiography did not show typical change at sacroiliac joint or vertebrate. Spinal magnetic resonance image revealed cord atrophy at cervical and thoracic segment. A positivity of B27 antigen was found afterward. Their spondyloarthropathic symptoms developed within six months later with radiographic sacroiliitis. Seropositive AS with noncompressive myelopathy was finally established. Patients showed a reverse of motor impairment when their pain was well undercontrolled. Motor myelopathy may be neglected or underestimated in AS, in especially when typical skeletal symptom is absent or minimal. It may progress surreptitiously to harm spinal function or superimpose to crippling disability in compressive spinal cord injury. Therefore, a careful evaluation and monitor of spinal cord function is important for AS patient despite spinal deformity is not observed.