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.     

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.     

Magnetic resonance imaging for the study of cervical myelopathy in rheumatoid arthritis

Cervical myelopathy is found fairly often with rheumatoid arthritis. It is one of the worst complications of the disease and can lead to tetraplegia or even to sudden death. However, when we consider the high incidence of involvement of the cervical spine in rheumatoid arthritis, the number of cases of cervical myelopathy, even of slight degree, is not very high. We have used magnetic resonance to identify the condition of the cervical structures, especially the nerve structures, in 15 patients with rheumatoid arthritis, with involvement of the cervical articulations but without neurological symptoms. We found anterior compression of the spinal cord caused by the odontoid process of the epistropheus in 13 cases. One case had lateral deviation of the spinal cord and another had compression of a vertebral artery. In another the lumen of the nasopharynx was decreased and one had posterior compression of the spinal cord by the posterior arch of the atlas. Magnetic resonance also makes it possible to detect a rheumatoid pannus on the affected articulations. We conclude that magnetic resonance is at present a useful instrument for evaluation of the presence of cervical myelopathy in rheumatoid arthritis patients, to prevent more serious complications.     

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.     

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.     

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

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.     

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.     

Risk of cervical myelopathy in rheumatoid arthritis patients with neck pain

BackgroundCervical spine (CS) evaluation in rheumatoid arthritis (RA) is challenging since subtle neurological insult is usually masked by the severe peripheral joint affection or muscle atrophy. Neglected CS lesions could end up with cervical myelopathy. Magnetic resonance imaging (MRI) has been the modality of choice in assessing CS in RA.Aim of the workTo evaluate CS in RA using MRI and detect the risk factors for its involvement.Patients and methodsForty RA patients with neck pain were assessed using disease activity score (DAS28), Ranawat classification of rheumatoid myelopathy, simple erosion narrowing score (SENS), bilateral hand and wrist musculoskeletal ultrasound (MSKUS) for early erosion detection and CS MRI.ResultsThe mean age of patients was 44.3 ± 10.1 years, disease duration 7.9 ± 6.6 years and the DAS28 was 4.8 ± 1.6. 70% of patients were in Ranawat class I, 30% in class II, and none in class III. 70% of patients had CS lesions where synovitis occurred in 67.5% of patients, odontoid erosions in 15%, atlanto-axial marrow edema in 5%, atlanto-occipital marrow edema in 5% and none had atlanto-axial subluxation (AAS), subaxial subluxation (SAS), spinal cord/brain stem compression. CS involvement was significantly related to peripheral joint erosion, high SENS and positive RF (p = 0.01, p < 0.0001, p < 0.0001 respectively).ConclusionCS involvement is remarkable in RA especially in those with peripheral joint erosions, high SENS and positive RF. RA patients with persistent neck pain, even in absence of objective neurological deficit should be evaluated early for detection and management of CS lesions before irreversible neurological damage takes place.     

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.     

Early diagnosis of spinal epidural metastases

Early signs of spinal cord injury on neurologic examination have been the primary indication to proceed with myelography in patients with possible spinal epidural metastases. With this approach, loss of ambulation occurs in more than one half of the patients. In an attempt to diagnose epidural metastases before the onset of myelopathy, we designed a prospective study based on the development of back pain, a precursor of spinal cord injury in nearly all cancer patients. Eighty-seven patients were studied. A high incidence of epidural metastases was found in patients with myelopathy (78 percent). In addition, patients with radiculopathy alone frequently had epidural tumor (61 percent). In 36 percent of the patients who presented with back pain but who had normal neurologic findings, there was evidence of epidural metastases on myelography; all of those patients had vertebral metastases on plain roentgenogram. Over-all, the plain roentgenogram of the spine correctly predicted the presence or absence of epidural tumor in 83 percent of the patients. Whereas 93 percent of the patients with myelopathy had more than 75 percent myelographic block, this occurred in 53 percent of those with radiculopathy and in only 33 percent of those with back pain and normal neurologic findings. In most cancer patients, spinal epidural metastases are both detectable and significantly less extensive before the onset of spinal cord injury.     

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.     

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.     

Spinal cord compression by epidural lipomatosis in juvenile rheumatoid arthritis

Two cases of spinal cord compression secondary to steroid-induced epidural lipomatosis in systemic juvenile rheumatoid arthritis (JRA) patients are reported. This complication of prolonged corticosteroid therapy has not been described previously in children with JRA. Epidural lipomatosis should be considered in the differential diagnosis of JRA patients receiving high-dose and/or prolonged corticosteroid therapy who present with neurologic signs and symptoms referable to the spinal cord.     

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.     

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.     

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.     

Somatosensory evoked potentials (SSEPs) in rheumatoid cervical subluxation

Somatosensory evoked potentials (SSEPs) were recorded in 34 patients with severe rheumatoid arthritis. Eighteen had atlanto-axial subluxation and 16 had no roentgenological evidence of cervical subluxation. Four patients in the group with cervical subluxation showed pathological SSEP values from both median and tibial nerves indicating conduction block in the upper cervical medulla. In the group with no cervical subluxation, 6 patients had prolonged SSEP latency, 5 of these on recordings from the tibial nerves with normal median nerve latencies and one with only bilaterally prolonged median nerve latencies. The pathological SSEP findings in the former group of patients we attribute to the cervical subluxation, while the findings in the latter group might be related to spinal cord vasculitis or extradural granulation tissue. The SSEP method can be useful in providing objective evidence for spinal cord lesions in patients with rheumatoid cervical subluxation.