Rheumatoid disease of the spine

Rheumatoid disease of the spine is a morbid consequence of untreated longstanding severe cervical spinal rheumatoid arthritis (RA)–an inflammatory autoimmune disease that attacks the ligaments, joints, and bones of the neck. Although the anterior subluxation of the atlantoaxial joint is the most common manifestation of the disorder, subluxation can also occur with posterior or vertical movement, and subaxial (below C2) joints can also be involved.[1][2]

Rheumatoid disease of the spine
Other namesAtlantoaxial joint disease in rheumatoid arthritis, atlantoaxial instability of rheumatoid arthritis, cervical subluxation in rheumatoid arthritis
SpecialtyRheumatology

Signs and symptoms

Atlantoaxial instability is a common asymptomatic finding in rheumatoid arthritis patients.[3] However, it can lead to cervical myelopathy.[4] Patients with atlantoaxial instability can experience neck pain and headaches in the back of the head (occipital headaches). Myelopathic symptoms include: weakness, gait disturbance, paresthesias, and loss of dexterity (e.g. difficulty buttoning clothing).[5]

Causes

The inflammatory mediators of RA including cytokines, growth factors, metalloproteinases destroy articular cartilage, subchondral bone, tendons and ligaments. Destructive synovitis leads to bone erosion and causes the ligaments of the spine to become too laxed (loose), eventually resulting in cervical spinal instability (loose neck bones).[6]

Diagnosis

Physical exam

On palpation, the examiner may find crepitus at the neck joint and unstable movement including a positive "clunk test" (palpable subluxation). Lhermitte's sign may be elicited with head flexion.

Imaging

As many as 50% of people with radiographic instability are actually asymptomatic.[2] Initial radiography should include flexion and extension lateral X-rays in addition to static anterior/posterior and lateral views. These views are often repeated every 2–3 years, especially in patients with new symptoms or possibly requiring future intubation.[2] Progression of disease is measured via anterior atlantodental interval (AADI), and posterior atlantodental interval (PADI). Other techniques include the Ranawat Index, MacGregor Line, the Clark stations, and the Redlund-Johnell measurement.

Management

Up to 10% of patients with rheumatoid arthritis are at risk of sudden death due to unrecognized cord compression.[2] Thus surgical intervention is a reasonable choice in the presence of a neurologic deficit as a result of instability. In fact, early surgery for atlantoaxial subluxation may actually delay the debilitating progress of myelopathy.[7][8]

References
  1. Paimela, L.; Laasonen, L.; Kankaanpää, E.; Leirisalo-Repo, M. (July 1997). "Progression of cervical spine changes in patients with early rheumatoid arthritis". The Journal of Rheumatology. 24 (7): 1280–1284. ISSN 0315-162X. PMID 9228125.
  2. Vu Nguyen, Hoan; Ludwig, Steven C; Silber, Jeffery; Gelb, Daniel E; Anderson, Paul A; Frank, Lawrence; Vaccaro, Alexander R (2004-05-01). "Rheumatoid arthritis of the cervical spine". The Spine Journal. 4 (3): 329–334. doi:10.1016/j.spinee.2003.10.006. PMID 15125859.
  3. Current diagnosis & treatment. Rheumatology. Imboden, John B., 1951-, Hellmann, David B., Stone, John H. (Third ed.). New York. ISBN 9780071638050. OCLC 851645602.{{cite book}}: CS1 maint: others (link)
  4. Marjani, Abdoljalal; Moghasemi, Sedigheh (2012). "The Metabolic Syndrome among Postmenopausal Women in Gorgan". International Journal of Endocrinology. 2012: 953627. doi:10.1155/2012/953627. ISSN 1687-8337. PMC 3296160. PMID 22518135.
  5. Reiter, Mitchell F.; Boden, Scott D. (1998-12-15). "Inflammatory Disorders of the Cervical Spine". Spine. 23 (24): 2755–2766. doi:10.1097/00007632-199812150-00017. ISSN 0362-2436. PMID 9879101.
  6. Wasserman, Bradley R.; Moskovich, Ronald; Razi, Afshin E. (2011). "Rheumatoid arthritis of the cervical spine--clinical considerations". Bulletin of the NYU Hospital for Joint Diseases. 69 (2): 136–148. ISSN 1936-9727. PMID 22035393.
  7. Wolfs, Jasper F. C.; Kloppenburg, Margreet; Fehlings, Michael G.; van Tulder, Maurits W.; Boers, Maarten; Peul, Wilco C. (2009-12-15). "Neurologic outcome of surgical and conservative treatment of rheumatoid cervical spine subluxation: a systematic review". Arthritis and Rheumatism. 61 (12): 1743–1752. doi:10.1002/art.25011. ISSN 0004-3591. PMID 19950322. S2CID 17956993.
  8. Schmitt-Sody, M.; Kirchhoff, C.; Buhmann, S.; Metz, P.; Birkenmaier, C.; Troullier, H.; Jansson, V.; Veihelmann, A. (August 2008). "Timing of cervical spine stabilisation and outcome in patients with rheumatoid arthritis". International Orthopaedics. 32 (4): 511–516. doi:10.1007/s00264-007-0349-2. ISSN 0341-2695. PMC 2532281. PMID 17372732.
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