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.     

Prevalence of cervical spine inflammatory changes in rheumatoid arthritis patients and the value of neurological examination in their diagnosis

The aim of the study was to evaluate prevalence of cervical spine inflammatory changes, especially atlantoaxial pathology, and their possible relation to subjective and objective neurological symptoms in rheumatoid arthritis patients. 100 patients (88 female and 12 male) aged 23 to 85 (61.4 +/- 12.9), with the mean disease duration of 12.5 +/- 9.5 years were included in the study. According to radiological examination (lateral and antero-posterior X-ray of the cervical spine) supplemented by MR of the cervical spine or CT of the atlanto-axial joint in suspected cases, 26% of patients had only inflammation, next 15% of patients presented with instability of the atlanto-axial joint and 9% developed basilar invagination of the dens of axis. 18% of patients presented subaxial cervical instability. Neurological examitation was performed by independent neurologist in 99 patients, only 14 presented abnormalities suggesting cervical myelopathy. Two of them showed no patology of the cervical spine. Remaining patients presented: C1/C2 inflammation in 4 cases, anterior atlanto-axial subluxation (AAS) in two cases, basilar invagination in 4 cases and instability with medullary compression on lower cervical levels only--in two cases. There were 4 cases of coexisting C1/C2 changes with medullary compression due to discopathy and (in 3 of them) instability on lower cervical levels. In 6 cases surgical stabilisation was proposed (5 patients with basilar invagination and 1 patient with AAS and myelopathy). There was statistically significant correlation between symptoms (like: paraesthesiae, intermittent problems with hearing and seeing), neurological examination and degree of radiological damage of atlanto-axial joint. The authors concluded that careful medical history and neurological examination can be useful in making decision of further radiological diagnostic procedures of the cervical spine in rheumatoid arthritis.     

In vivo segmental motion of the cervical spine in rheumatoid arthritis patients with atlantoaxial subluxation

OBJECTIVE: The dynamic mechanism underlying cervical spine involvement in rheumatoid arthritis (RA) remains unidentified. The purpose of the current study was to determine the in vivo cervical segmental motion in RA patients with atlantoaxial subluxation (AAS) using a patient-based three-dimensional magnetic resonance imaging (MRI) computer model. METHODS: Healthy volunteers and RA patients with AAS (all females, n=10) underwent MRI examination of the cervical spine. Each vertebral body from the occipital bone (Oc) to the first thoracic vertebra (T1) was reconstructed from slices of T2-weighted sagittal MR images in the neutral, flexion, and extension positions. Using volume merge methods, each reconstructed vertebral body was virtually rotated and translated. Rotational segmental and translational segmental motions were obtained in three major planes. RESULTS: Overall, the axial translational motions in the RA group were lower than those in the healthy volunteers; however the axial translational motion at only C1-C2 during flexion was at the same level as that in the healthy volunteers and was greater on the bottom side than that at other intervertebral levels. The frontal rotational motions at C1-C2 during extension were greater in the RA patients than those in the healthy volunteers (p<0.05). CONCLUSION: The atlantoaxial joints in the RA patients with AAS showed great frontal rotational motion during extension and great axial translation on the bottom side during flexion. The current noninvasive MRI-based method could be useful in evaluating the 3-D dynamic mechanism underlying cervical involvement in RA in vivo.     

Cervical Spine Disorders in Patients with Rheumatoid Arthritis and Amyloidosis

The aim of this radiographic study was to ascertain the extent of inflammatory cervical spine disorders in patients with rheumatoid arthritis (RA) complicated by secondary amyloidosis (SA). The study involved 147 patients with RA and SA, whose cervical spine radiographs were available. They were treated at the Rheumatism Foundation Hospital, Heinola, during the period 1989–2000 and had had RA for a mean of 24 years. The inflammatory abnormalities of the cervical spine were studied from radiographs taken at or after the diagnosis of SA during flexion and extension. One-hundred and eleven (76%) patients had subluxations, impaction or apophyseal joint ankylosis. Atlantoaxial impaction (AAI) was seen in 76 (52%) patients and anterior atlantoaxial subluxation (AAS) in 59 (40%). Apophyseal joint ankylosis was the third most frequent finding, seen in 34 (23%) cases. A combination of AAI and apophyseal joint ankylosis was noted in 26 (18%) patients. Eight (5%) patients had undergone surgery on the cervical spine. In conclusion, inflammatory and destructive changes are frequent in the cervical spine of patients with RA and SA. Characteristic changes are AAI and AAS. RA patients with SA have more severe disease than those in epidemiological studies when cervical spine disorders are concerned. Received: 22 March 2001 / Accepted: 17 November 2001     

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.     

Sensitivity of lateral view cervical spine radiographs taken in the neutral position in atlantoaxial subluxation in rheumatic diseases

The value of lateral view cervical spine radiography in various positions of the neck was assessed in patients with rheumatoid atlantoaxial subluxation (AAS). We wanted to find out how much information is lost if only neutral position radiographs are used. The series consisted of 65 rheumatoid patients with unstable AAS. Lateral view cervical spine radiographs were taken in the neutral position and during flexion and extension. Neutral position radiographs would have failed to confirm the diagnosis of AAS in 31 cases (48%) and would have failed to record its true severity in 43 cases (66%); their diagnostic sensitivity was 52%. The sensitivity of the neutral radiographs in showing the reversibility of AAS was 48%. Routine cervical spine radiography of rheumatoid patients should include lateral view radiographs taken during flexion and extension. The result may be applied to magnetic resonance imaging, which is usually performed in the neutral position.     

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.     

Craniocervical junction involvement in rheumatoid arthritis: a clinical and radiological study

OBJECTIVE: To make a comparative evaluation of different imaging techniques for studying the craniocervical junction involvement in patients with rheumatoid arthritis (RA). Upper cervical spine involvement was compared with clinical and immunological data. METHODS: Patients (n = 47) underwent plain radiographs and computerized tomography (CT) and magnetic resonance (MR) study of the craniocervical junction. Neurological examination following clinical signs of possible atlantoaxial involvement was performed in all patients following the Ranawat classification. RESULTS: Radiographic and MR images showed craniocervical involvement in 41.3% and 61% of the patients, respectively. Immunological data were not correlated with imaging findings, whereas Ranawat class II and III of neurological involvement seem to be predictive of atlantoaxial alteration. CONCLUSION: Conventional radiography allowed us to detect 41.3% of patients with craniocervical involvement, but only in advanced stages of the disease. MR imaging had the unique potential of direct and detailed synovial visualization, especially in the gadolinium enhanced axial images, resulting in the early diagnosis of craniocervical RA.     

Recurrence of cervical spine instability in rheumatoid arthritis following previous fusion: can disease progression be prevented by early surgery?

In a retrospective study, 110 patients with rheumatoid arthritis who had cervical spine fusion were evaluated for recurrence of cervical spine instability and resultant need for further surgery. Recurrence of cervical instability was correlated with initial radiographic abnormality, primary surgical procedure and interval between the 2 surgeries. There were 55 patients who had atlantoaxial subluxation (AAS) and required C1-C2 fusion as primary surgery. Three of these patients (5.5%) developed subaxial subluxation (SAS) and had a second procedure after a mean interval of 9 years. Twenty-two patients had AAS with superior migration of the odontoid (AAS-SMO) and had initial surgery of occiput-C3 fusion. Eight of these patients (36%) developed SAS and had a second surgery after a mean interval of 2.6 years. Of the 19 patients with primary radiographic deformity of SAS, one required further surgery for subluxation of an adjacent superior vertebra after a period of 6 years. Fourteen patients had combined deformity of AAS-SMO-SAS, and one required further surgery for SAS after an interval of 22 months. Recurrence of cervical instability following a previous fusion occurred in 15% of these 110 patients. It was seen in 5.5% of patients with initial deformity of AAS vs 36% of patients with AAS-SMO. No patients with C1-C2 fusion for AAS progressed to develop superior migration of the odontoid. We conclude that early C1-C2 fusion for AAS before development of SMO decreases the risk of further progression of cervical spine instability. The pattern of progression of cervical spine involvement, as discussed in the literature, is reviewed.     

High mortality in patients with rheumatoid arthritis and atlantoaxial subluxation.

OBJECTIVE: To study relationships between atlantoaxial subluxation (AAS) and total mortality in patients with rheumatoid arthritis (RA). METHODS: Radiological reports and clinical files of patients with RA were reviewed for the presence of cervical spine involvement verified by cervical radiographs. RESULTS: Among 241 patients with cervical radiographs, anterior AAS > or = 4 mm was found in 5% [95% confidence interval (CI) 2-8] of patients. Vertical and posterior subluxations were found in 1.4 and 0.5%, respectively. The mean observation time from RA diagnosis to AAS was 3.9 years. Patients with AAS had 8 times higher mortality than patients without AAS (95% CI 3-25). According to the death certificate, the patients died from cancer, stroke, and myocardial infarction. Cervical spine disorder was not mentioned on the death certificate. However, an autopsy was not performed. CONCLUSION: We found high mortality in RA patients with AAS. AAS in the cervical spine developed relatively early in the course of the disease. Analyses adjusted for seropositivity, erosiveness, and glucocorticosteroids did not reduce the mortality rate ratio. Our results underline the need for careful evaluation of patients with RA with respect to development of AAS.     

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.     

Factors predictive of subsequent deterioration in rheumatoid cervical myelopathy

OBJECTIVE: To identify the features of rheumatoid cervical spine disease associated with deterioration resulting in the need for surgical intervention or death. PATIENTS AND METHODS: Patients with rheumatoid cervical myelopathy who underwent cervical spine magnetic resonance imaging (MRI) between 1991 and 1996 were identified. Patients requiring immediate surgical intervention were excluded. The remainder were divided into two groups. Deterioration group: patients requiring surgical intervention during the follow-up period and deaths resulting from cervical myelopathy. Conservative group: all other patients. Relevant clinical features and radiology reports were extracted retrospectively from the casesheet. RESULTS: The deterioration group comprised 11 patients (12%), median time to deterioration 15 months (range 4-84 months). The conservative group included 82 patients. Initial clinical features did not differ significantly between the two groups. Sixty per cent of those patients with compression or impingement at the atlanto-axial level on first MRI deteriorated over a median of 12 months (range 4-36 months). CONCLUSION: Deterioration is likely if there is evidence of cord compromise at the atlanto-axial level on MRI regardless of initial clinical and plain X-ray features.     

Correlation between severity of rheumatoid arthritis and manner and extent of cervical lesion

To determine the proper management of treatment for rheumatoid cervical lesions, we investigated the clinical course of the cervical spine in rheumatoid arthritis (RA). The severity of RA was classified into three groups according to the disease subsets advocated by Ochi et al.: the less erosive subset (LES), the more erosive subset (MES), and mutilating disease (MUD). Then the following radiographic assessments were performed on cervical roentogenograms: atlantoaxial subluxation (AAS), vertical subluxation (VS), and subaxial subluxation (SAS). One hundred and seventy-four patients were available for this study. The mean age of the patients was 60.9 years (19–85 years). The average duration from the onset of RA was 19.1 years (10–40 years). Eighty-seven patients were classified as LES, 69 were MES, and 18 were MUD. We found that few patients in the LES group had required an operation on the cervical spine. AAS was seen in about 60% of the MES patients, but few cases had VS or SAS, and most operations were atlantoaxial fusion. All patients in the MUD group had some cervical instabilities. Not only VS but also SAS were seen in more than half of these patients, and many patients had required occipitothoracic fusion.     

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.     

Improved medical and surgical management of cervical spine disease in patients with rheumatoid arthritis over 10 years

OBJECTIVES: (1) To compare clinical outcome and symptomatology of rheumatoid cervical myelopathy between patients managed conservatively and surgically. (2) To determine if surgical outcome has improved since the series published from this unit in 1987. (3) To examine the role of magnetic resonance imaging (MRI) in the diagnosis of cervical myelopathy. METHODS: Patients undergoing MRI of the cervical spine between 1991 and 1996 were identified. Case records were reviewed retrospectively. RESULTS: 111 patients with RA underwent 124 MRI scans. The median age at onset of cervical spine symptoms was 58 years (range 16-87) with median disease duration of 16 years (range 1-59). 18 (16%) required surgery immediately after MRI. 93 (84%) were managed conservatively, 9 of whom (10%) later required surgery. 2/7 deaths in the conservative group were directly related to cervical myelopathy. Patients requiring surgery were more likely to report paraesthesia, weakness, unsteadiness and to exhibit extensor plantar reflexes, gait disturbance, and reduced power. MRI findings did not correlate with clinical features. When compared with the 1974-82 cohort, fewer patients had severe myelopathy (Ranawat grade IIIB) before surgery (34% versus 7%). Early postoperative mortality improved from 9% to 0% and surgical complication rate fell from 50% to 22%. 89% of patients in the 1991-96 cohort reported subjective improvement in overall function. CONCLUSION: In this series surgical outcome has improved. The major factor in this more favourable outcome is probably that patients presenting with rheumatoid cervical myelopathy are now referred for surgery at an earlier stage of disease. Clinical findings correlate poorly with MRI findings, therefore clinical history should remain the key to determining the need for MRI.     

Magnetic resonance imaging in rheumatic disorders of the spine and sacroiliac joints

OBJECTIVE: To review the value of magnetic resonance imaging (MRI) in diagnosis and evaluation of rheumatic diseases of the spine and sacroiliac joints. METHODS: A review of the literature on MRI of the spine and sacroiliac joints in rheumatoid arthritis (RA), ankylosing spondylitis (AS), infectious spondylodiscitis, infection of the sacroiliac joint (SIJ), gout, calcium pyrophosphate deposition disease, nontraumatic vertebral compression fractures, insufficiency fracture of the sacrum, avascular necrosis of the vertebral body, sarcoidosis, and Paget's disease was performed. The reports were obtained from a Medline search. RESULTS: In RA, AS, and crystal deposition disease, synovial tissue, atlantoaxial and subaxial subluxations, crystal deposition, and neurologic compromise can be adequately diagnosed with MRI of the cervical spine. Studies on MRI of SIJs in AS indicate that MRI enables early diagnosis of sacroiliitis. In most cases of infectious spondylodiscitis, avascular necrosis of the vertebral body, nontraumatic vertebral compression fractures, and insufficiency fractures of the sacrum characteristic findings on MRI suggest the correct diagnosis. Moreover, soft tissue abnormalities and neurologic compromise can be visualized. In infection of the SIJ, MRI shows findings suggesting an inflammatory process. In Paget's disease, MRI does not provide additional information as compared with plain radiography (PR) or computed tomography (CT). CONCLUSION: In evaluation of spinal and SIJ abnormalities in many rheumatic diseases, MRI, in addition to PR, can replace conventional tomography, CT, and myelography. Moreover, MRI can visualize soft tissue abnormalities and neurologic compromise without use of intrathecal contrast.     

Bone resorption of the facet joint in rheumatoid arthritis as a predictor of lower cervical myelopathy

The purpose of the present study was to identify the risk factors to predict instability of the subaxial cervical spine and cervical myelopathy based on plain radiographs. The study was performed on 99 patients with mutilating rheumatoid arthritis (RA). From plain lateral radiographs of the cervical spine over time, rheumatoid cervical spine lesions were investigated and evaluation was made on the possibility to develop cervical myelopathy. The incidence of subaxial cervical spine lesions in the patients with mutilating RA was as high as 98%. In particular, resorption of the superior facet suggests high risk to develop cervical myelopathy. The presence of spinous process erosion is also likely to reveal such a possibility. There was no statistically significant difference in the anteroposterior diameter of cervical spinal canal between the cases with cervical myelopathy and those without it. Resorption of the superior facet is the most important factor for the development of cervical myelopathy. In the cases with rheumatoid cervical spine lesions, it is necessary to take special notice of the superior facet.     

Bone resorption of the facet joint in rheumatoid arthritis as a predictor of lower cervical myelopathy

Abstract

The purpose of the present study was to identify the risk factors to predict instability of the subaxial cervical spine and cervical myelopathy based on plain radiographs. The study was performed on 99 patients with mutilating rheumatoid arthritis (RA). From plain lateral radiographs of the cervical spine over time, rheumatoid cervical spine lesions were investigated and evaluation was made on the possibility to develop cervical myelopathy. The incidence of subaxial cervical spine lesions in the patients with mutilating RA was as high as 98%. In particular, resorption of the superior facet suggests high risk to develop cervical myelopathy. The presence of spinous process erosion is also likely to reveal such a possibility. There was no statistically significant difference in the anteroposterior diameter of cervical spinal canal between the cases with cervical myelopathy and those without it. Resorption of the superior facet is the most important factor for the development of cervical myelopathy. In the cases with rheumatoid cervical spine lesions, it is necessary to take special notice of the superior facet.     

Bile duct disease: prospective comparison of ERCP, CT, and fat suppression MRI.

The authors compared computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP), techniques commonly used to study the biliary tree, with pre- and post-Gd-DTPA breath-hold fast low angle shot (FLASH) and fat suppressed spin-echo in 28 consecutive patients with bile duct abnormalities detected on ERCP, including 11 patients with malignant disease and 17 patients with benign disease. ERCP, CT, and magnetic resonance (MR) images were prospectively interpreted in a blinded fashion and reviewed by consensus. ERCP characterized all cases of malignant disease by the presence of a narrowed bile duct lumen with irregular margins. CT and MRI detected all cases of malignant disease and characterized nine of 11 as malignant. In seven of these cases, CT and MRI showed thickening of extrahepatic bile duct walls greater than 5 mm. MRI images showed intrahepatic-enhancing periportal tissue in four cases, which was not seen on CT images, and which was biopsy-proven tumor extension. Benign disease was characterized on ERCP images by the demonstration of smooth tapered narrowings in 16 cases, whereas on CT and MR images it was characterized by mild to moderate dilatation of the intrahepatic bile ducts and wall thickness less than 5 mm in 13 cases. Overall ERCP correctly characterized 27 cases as benign or malignant and CT and MRI both characterized 25. The results of this study show a trend that ERCP is superior to CT and MRI for characterizing bile duct disease.