Upper cervical instability in rheumatoid arthritis

Upper cervical instability remains a significant problem for the patient with rheumatoid arthritis. Seventeen patients treated by upper cervical fusions for instability, were followed to determine the efficacy of our current treatment protocol. Improvement in neurologic status was observed in ten of 11 patients presenting with neurologic symptoms. In all patients with preoperative pain, improvement occurred at least one grade. However, complete amelioration of pain was noted in only five patients. A pseudarthrosis rate of 25% reflects the difficulty in achieving a solid arthrodesis in the patient with rheumatoid disease. Modification of the wedge compression technique may help ensure arthrodesis in rheumatoid patients.     

Laryngeal involvement in rheumatoid arthritis

Patient with rheumatoid arthritis should be screened prior to surgery for any laryngeal manifestation. A thorough history and physical examination coupled with indirect or direct laryngoscopy are mandatory. Nonspecific laryngeal symptoms in patients with rheumatoid arthritis should raise suspicion of laryngeal involvement. Phonatory disturbances or airway difficulties may reflect advanced stages of the disease. Their presence is usually coupled with high resolution computerized tomography findings. Aggressive therapy should be started and corticosteroid injection should be contemplated in cases of failure of conventional treatment. The anesthesiologist should handle with extreme care the inflamed laryngeal structures and be least aggressive in securing the airway.     

Renal involvement in patients with rheumatoid arthritis

In rheumatoid arthritis (RA) kidney is commonly affected organ with clinical presentation characterised by proteinuria (often nephrotic range) and microhematuria followed by chronic renal failure. This condition is well recognized as a rheumatoid nephropathy (rheumatoid glomerulonephritis), which is mediated by an immunological inflammation and by nephrotoxic effects of numerous drugs usually used in rheumatoid arthiritis treatment, such as NSAID, DMARD. In the patohistological examination various kinds of associated renal lesions could be seen. The most often are amyloidosis, glomerulonephritis, interstitial nephritis. In this study, we presented 15 patients, 10 women and 5 men, mean age of 60.2 with average rheumatoid arthritis duration of 19.4 years and signs of rheumatoid nephropathy. In all patients renal biopsy was performed with frequency of histopathological findings as follows: amyloidosis in 5 patients, IgA nephropathy in 3 patients, FSGS in 3 patients, mesangial proliferative glomerulonephritis in 3 patients, minimal change disease, pauci-immune glomerulonephritis and thin membrane disease in 1 patient. In all patients (except patient with thin membrane nephropathy) we started immunossuppresive therapy with glucocorticoids in combination with cyclophosphamide or cyclosporin or azatioprine. In conclusion, in all patients with rheumatoid arthritis, parameters of renal function should be monitored and in the case of patologic results, renal biopsy should be be performed. In the treatment of RA patients with related renal disorder, suspected causal drug should be removed from the treatment and specific immunosuppressive therapy initiated.     

Hip involvement in juvenile rheumatoid arthritis.

We followed 386 children who met the criteria for juvenile rheumatoid arthritis (JRA) an average of 89 months. Hip involvement in JRA results in poor functional capacity. The prognosis for the pauciarticular group is good, but patients with onset at age greater than 6 years appear to do worse than those aged less than 6 years. In the polyarticular group, age of onset did not change the prognosis, whereas the systemic-onset group aged less than 6 years had a worse prognosis and more frequent radiographic changes than the older group.     

Hypoglossal nerve palsy secondary to cervical spine involvement in rheumatoid arthritis: Clinical and radiological features

Isolated hypoglossal nerve (HN) palsy has been reported in a variety of disorders involving the cervical spine and/or skull base, however, unilateral HN palsy caused by rheumatoid arthritis (RA) has rarely been reported. We report herein an uncommon case of isolated HN palsy secondary to RA cervical spine involvement: pannus formation at the C1–C2 articulation, atlanto-axial subluxation, as well as, erosion of the right occipital condyle, lateral mass and anterior arch of C1. Pulse therapy with methylprednisolone followed by maintenance therapy with prednisone resulted in dramatic improvement. We also present the variety of diagnostic modalities helpful for the diagnosis and follow-up.     

Posterior upper cervical fusion in rheumatoid arthritis.

The purpose of this study was to determine fusion rates in patients who underwent posterior cervical fusion for instability of the upper cervical spine secondary to rheumatoid arthritis. A retrospective review of clinical and radiographic data was conducted. Nineteen patients underwent posterior cervical fusions limited to the upper cervical spine. There were 11 C1-C2 fusions and 8 occiput-C2 fusions. Instability with pain or neurologic deficits were the main indications. A uniform technique was used in all cases. Preoperative reduction in halo vest or cast was followed by a Gallie type fusion using autogenous iliac bone graft and wire, and postoperative halo vest or cast immobilization for 3 months. A fusion rate of 94% was achieved. The average follow-up was 5 years. Complete or partial relief of pain was obtained in all patients; 30% of those with preoperative deficits improved after surgery. A high fusion rate may be achieved with C1-C2 and occiput-C2 fusions in rheumatoid arthritis, with relief of pain and prevention of neurologic deterioration.     

Arthrodesis of the cervical spine in rheumatoid arthritis

Forty-one patients who had rheumatoid arthritis were treated with a cervical arthrodesis and were followed for a minimum of twenty-three months. Twenty patients had had an isolated atlanto-axial subluxation; five, isolated cranial settling; and four, subaxial subluxation alone. Twenty patients had an atlanto-axial arthrodesis; sixteen, an occipitocervical arthrodesis; and five, a posterior arthrodesis of the subaxial spine. In addition, two patients had a transoral odontoidectomy and one, an anterior cervical vertebrectomy. At the latest follow-up, thirty-six (88 per cent) of the patients had osseous union, two had fibrous union but were stable, and three had a non-union. All of the problems with union occurred in the patients who had had an isolated atlanto-axial arthrodesis. Clinically, twenty-seven (66 per cent) of the patients had improved, fourteen were unchanged, and none were worse. The preoperative neurological status remained the same postoperatively in thirty patients (73 per cent) and it improved in eleven (27 per cent). Twenty-one of the twenty-three patients who had had marked pain preoperatively had little or no pain at the latest follow-up. Complications included a transient hemiparesis in one patient, a superficial wound infection in two, displacement of an anterior graft in one, a broken wire in three, and erosion of methylmethacrylate into the outer part of the occipital cortex in one. Four patients died, but not as a result of the operation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cervical spine involvement in rheumatoid arthritis. A review

Cervical spine involvement occurs in over half of patients with rheumatoid arthritis (RA). The most common abnormality is atlantoaxial dislocation, followed by atlantooccipital arthritis with cranial settling and by lesions of the lower cervical spine. Cervical spine involvement usually occurs in patients with severe RA. Pain and evidence of spinal cord injury are the main symptoms. The presence of symptoms is not correlated with the severity of radiological abnormalities. Computed tomography and magnetic resonance imaging provide detailed images of the bone and spinal cord lesions. Because the course is unpredictable, conservatively treated patients usually require regular follow-up. Surgery is in order in patients with pain unresponsive to major narcotics or with progressive neurological impairment. The choice between the anterior and the posterior route depends on the experience of the surgical team. It is reasonable to stabilize the spine before the development of cranial settling or major neurological loss (Ranawat's stage III). The good functional results of spinal surgery are frequently overshadowed by major impairments related to severe peripheral joint disease. Safety is acceptable when somatosensory evoked responses are monitored intraoperatively. Surgery can provide substantial improvements in symptoms, particularly pain.     

Changes in the cervical spine in juvenile rheumatoid arthritis

One hundred and twenty-one patients with juvenile rheumatoid arthritis were studied clinically and roentgenographically for evidence of disease of the cervical spine. None of the fifty-seven patients with pauciarticular-onset juvenile rheumatoid arthritis had cervical symptoms or signs, and only one had minor roentgenographic changes of disease in the cervical spine. In contrast, clinical stiffness and roentgenographic changes in the cervical spine occurred commonly in the fifty-one patients with polyarticular-onset disease and in the thirteen patients with systemic-onset disease. Despite extensive roentgenographic involvement of the cervical spine, however, pain in the neck was not a common complaint. Neither severe pain in the neck nor torticollis, occurring either separately or concomitantly, is frequently found in patients with juvenile rheumatoid arthritis, and its presence may suggest an intercurrent problem such as a fracture or infection. As patients with juvenile rheumatoid arthritis rarely have disease in the cervical spine alone, the patient should be carefully examined for involvement of multiple joints.     

The cervical spine involvement in patients with psoriatic arthritis

Psoriatic arthritis (PsA) is a systemic disease and cervical spine can be affected. The data regarding cervical spondylitis are very rare and diverse in literarture. The aim of study was to assess the prevalence of cervical spine involvement in patients with PsA. Between totally 41 patients with PsA we confirmed the incidence of 68% (29 patients) with symptomatic cervical spine disease and 29% (12 patients) with radiological evidence of inflammatory involvement. The most frequent radiological findings were apophyseal joint changes, rarely ligamentous calcification and syndesmophytes. Only one patient had subaxial subluxation. The most common type of PsA was axial disease with or without peripheral arthritis (46%) and the least common was oligoarthritis (22%). There was no statistically significant difference between any type of PsA and cervical involvement. CONCLUSION: inflammatory cervical spine changes are not common radiographic finding in patients with PsA and apophyseal joint affection is the most common radiologic sign.     

Operations for the unstable cervical spine in rheumatoid arthritis

Sixteen patients with seropositive rheumatoid arthritis were operated on for subaxial subluxations. Four of the patients had slight, but progressive, tetraparesis, and 5 had severe or total tetraparesis; they were operated on 1-4 months after the first signs. Seven patients were treated for severe neck and shoulder pain. Nine patients had subluxation at the C3-4 level, the most common site, and 3 patients also had an atlantoaxial subluxation. Patients with cord compression were treated with posterior laminectomies and fusions that relieved the tetraparesis. Two patients died during the early postoperative period: 1 of a cardiac infarction and the other of pneumonia. During 4 (1.5-9) years' follow-up, 3 patients had new subluxations at other levels.     

Stage-related surgery for cervical spine instability in rheumatoid arthritis

Thirty-six consecutive patients with cervical spine instability due to rheumatoid arthritis (RA) were treated surgically according to a stage-related therapeutic concept. The aim of this study was to investigate the clinical results of these procedures. The initial change in RA of the cervical spine is atlanto-axial instability (AAI) due to incompetence of the cranio-cervical junction ligaments, followed by development of a peridontoid mass of granulation tissue. This results in inflammatory involvement of, and excessive dynamic forces on, the lateral masses of C1 and C2, leading to irreducible atlanto-axial kyphosis (AAK). Finally, cranial settling (CS) accompanied by subaxial subluxation (SAS) occurs. According to these three separate pathological and radiological lesions, the patients were divided into three therapeutic groups. Group I comprised 14 patients with isolated anterior AAI, who were treated by posterior wire fusion. Group II comprised 15 patients with irreducible AAK, who were treated by transoral odontoid resection. The fixation was done using anterior plating according to Harms in combination with posterior wire fusion according to Brooks. Group III comprised seven patients with CS and additional SAS, who were treated with occipito-cervical fusion. Pre- and postoperatively, evaluation was performed using the parameters pain (visual analog scale), range of motion (ROM), subjective improvement and Health Assessment Questionnaire (HAQ). The neurologic deficit was defined according to the classification proposed by Ranawat. Radiographs including lateral flexion and extension views, and MRI scans were obtained. The average clinical and radiographic follow-up of all patients was 50.7 ± 19.3 months (range 21–96 months). No perioperative fatality occurred. Postoperative pain was significantly relieved in all groups (P < 0.001). In group II a slight improvement in the HAQ was obtained. In groups I and II the ROM of all patients increased significantly (average gain of motion in group I: 11.3°± 7.8° for rotation; 7.8°± 5.6° for bending; average gain of motion in group II: 21.5°± 14.0° for rotation; 17.2°± 5.5° for bending), while it decreased significantly in group III (10.7°± 18.1° for rotation; 6.7°± 18.5° for bending). Preoperatively 27 patients had a manifest neurologic deficit. At follow-up four patients remained unchanged, all others improved by at least one Ranawat class. All patients, except one, showed solid bony fusion. According to the significantly improved postoperative subjective self-assessment and the clinical and radiological parameters, transoral plate fixation combined with posterior wire fixation after transoral odontoid resection represents an effective reliable and safe procedure for the treatment of irreducible AAK in rheumatoid arthritis. Received: 4 March 1999 Accepted: 19 May 1999     

上颈椎类风湿性关节炎的研究进展

<正>类风湿性关节炎(rheumatoid arthritis,RA)是一种以全身多关节滑膜炎为主要病理特征的自身免疫性疾病,人群患病率为0.5%～1.0%^[1]。RA常累及手足等外周关节,其次是颈椎,寰枢及寰枕关节、齿状突及维持上颈椎稳定性的重要韧带受侵蚀破坏后,可致寰枢椎脱位、颅底凹陷,脊髓神经受压时可表现为相应的神经损害症状^[2、3]。若不积极治疗,神经功能进一步损害,将影响生活质量甚至死亡。因     

Computer-assisted screw insertion for cervical disorders in rheumatoid arthritis

To reconstruct highly destructed unstable rheumatoid arthritis (RA) cervical lesions, the authors have been using C1/2 transarticular and cervical pedicle screw fixations. Pedicle screw fixation and C1/2 transarticular screw fixation are biomechanically superior to other fixation techniques for RA patients. However, due to severe spinal deformity and small anatomical size of the vertebra, including the lateral mass and pedicle, in the most RA cervical lesions, these screw fixation procedures are technically demanding and pose the potential risk of neurovascular injuries. The purpose of this study was to evaluate the accuracy and safety of cervical pedicle screw insertion to the deformed, fragile, and small RA spine lesions using computer-assisted image-guidance systems. A frameless, stereotactic image-guidance system that is CT-based, and optoelectronic was used for correct screw placement. A total of 21 patients (16 females, 5 males) with cervical disorders due to RA were surgically treated using the image-guidance system. Postoperative computerized tomography and plane X-ray was used to determine the accuracy of the screw placement. Neural and vascular complications associated with screw insertion and postoperative neural recovery were evaluated. Postoperative radiological evaluations revealed that only 1 (2.1%; C4) of 48 screws inserted into the cervical pedicle had perforated the vertebral artery canal more than 25% (critical breach). However, no neurovascular complications were observed. According to Ranawat's classification, 9 patients remained the same, and 12 patients showed improvement. Instrumentation failure, loss of reduction, or nonunion was not observed at the final follow-up (average 49.5 months; range 24-96 months). In this study, the authors demonstrated that image-guidance systems could be applied safely to the cervical lesions caused by RA. Image-guidance systems are useful tools in preoperative planning and in transarticular or transpedicular screw placement in the cervical spine of RA patients.     

Surgical aspects of the cervical spine in rheumatoid arthritis

Approximately 20% percent of the patients with rheumatoid arthritis show pathology in the cervical spine. The translational instability between axis and atlas might be painful and leads in the long term to myelopathic changes due to chronic traumatization of the myelon. Ongoing osseous resorption of the lateral masses of the atlas cause upward migration of the dens into the foramen magnum. In the subaxial cervical spine, the inflammatory process causes instability and deformity. Neck pain is the most common indication for surgery, but neurological symptoms with myelopathy or radicular deficits might be the primary cause for surgery. Neurophysiological investigation is suitable to obtain objective results. Stabilization of the atlantoaxial segment is the most common procedure for treatment of atlantoaxial instability. It is performed by screw fixation technique from a posterior approach. In case of severe occipitocervical dislocation, the fixation has to be extended to the occiput. Persistent dislocation or compression by the dislocated dens has to be treated by transoral decompression. In the subaxial spine, instabilities may be treated by posterior plate fixation with lateral mass screws or pedicle screws. Concomitant nar-rowing of the spinal canal should be approached by anterior decompression with corpectomy and/or posterior laminectomy. The timing of surgery in rheumatoid patients is crucial to obtain satisfactory clinical results.     

超声心动图评估类风湿性关节炎累及心脏

类风湿性关节炎（RA）是以侵袭性、对称性多关节炎为主要临床表现的慢性、异质性、系统性自身免疫疾病,确切发病机制不明;其关节外病变可导致多器官损害,尤以心血管系统为重。超声心动图具有无创、实时、动态、便捷、可重复性好等优点,是评估RA累及心脏的首选影像学检查方法。本文对超声心动图评估RA累及心血管系统进展进行综述。     

A long-term follow-up study of cervical lesions in rheumatoid arthritis

To determine the natural history of cervical lesions in rheumatoid arthritis, 161 patients who had been followed for a minimum of 5 years were enrolled in this study. The average follow-up period was 10.2 years (range, 5 to 20 years). The severity of the rheumatoid arthritis was classified into three types based on the multiplicity of peripheral joint rheumatoid involvement: a least erosive subset, a more erosive subset, and a mutilating disease subset. Ninety-two patients (57%) had upper cervical involvement, which progressed in the order of anterior atlantoaxial subluxation, anterior atlantoaxial subluxation combined with vertical subluxation, and vertical subluxation alone. Subaxial subluxation was found in 18 patients (11%). In 17 of these 18 patients, upper cervical lesions were also noted. The incidence of cervical involvement in each disease subset was 39% in the least erosive group, 83% in the more erosive group, and 100% in the mutilating disease group. Fifty percent of the patients with cervical involvement had neck pain, and the remaining patients were asymptomatic. Neural involvement occurred in 10 patients. In 7 of these 10 patients, vertical subluxation of the atlas was responsible for the neural deficit. Six patients required surgical intervention because of progressive myelopathy.     

Magnetic resonance imaging of upper cervical disorders in rheumatoid arthritis

Upper cervical spine was examined with magnetic resonance imaging (MRI) and conventional roentgenograms in 55 patients with rheumatoid arthritis. The MRI findings were compared with various values determined in roentgenograms: the atlanto-dental interval (ADI), the space available for the spinal cord (SAC), and the Ranawat and Redlund-Johnell values. In patients with vertical settling (VS), MRI showed medullary compression in all those with abnormal Redlund-Johnell values and Ranawat values of 7 mm or less. In patients with anterior atlanto-axial subluxation, compression of the upper cervical cord was observed in all patients with SAC of 13 mm or less and many of those with ADI of 8 mm or greater. This study indicated that medullary compression can be estimated by these values determined in roentgenograms of the cervical spine.