[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.

Symptomatic atlantoaxial instability associated with medical and rehabilitative procedures in children with Down syndrome

The Canadian College of Medical Genetics recently questioned the rationale for radiographic screening for atlantoaxial instability in Down syndrome. We report a case series of four children with Down syndrome with symptomatic atlantoaxial instability and followed for more than 5 years. In all cases a medical or rehabilitational procedure was associated with significant apnea, cardiopulmonary compromise, or severe neurological impairments. None of these patients were screened radiographically. The need for protocols to detect atlantoaxial instability in children with Down syndrome undergoing medical and rehabilitational procedures is highlighted by these cases.

A chiropractic perspective on atlantoaxial instability in Down's syndrome

The purpose of this paper is to review the current information on atlantoaxial instability in Down's syndrome. There are potentially fatal consequences to performing adjustive manipulation to the cervical spine of the Down's patient. Atlantoaxial subluxation can cause death. Up to 50% of those suffering from atlantoaxial instability have it due to anomalous axis formation and/or agenesis or laxity of the transverse ligament. Trauma or progressive anterior displacement of atlas may cause serious neurological complications. The standard treatment for atlantoaxial instability is surgical fusion of the upper cervical spine. Conservative chiropractic care is suggested as a possible alternative in some cases. Standards for adjusting patients suffering from Down's syndrome have not been established. However, guidelines reviewed in this paper may indicate when adjusting may be hazardous. Potential protocol for the evaluation and diagnosis of atlantoaxial instability are suggested.

The spectrum of atlantoaxial facet joint involvement in rheumatoid arthritis

Six hundred fifty outpatients with rheumatoid arthritis (RA) were evaluated and followed up during a 7-year period. As part of their routine evaluation or because of neck-shoulder girdle symptoms, 48% of the patients underwent routine cervical spine radiography. Sixty-one RA patients (9% of the total population) had C1-C2 involvement. Compared with the 589 patients with no evidence of C1-C2 involvement, these 61 patients were significantly more likely to be younger, female, and seropositive, and they had significantly more nodules and erosions, as well as a longer disease duration. Based on radiographic evidence of C1-C2 disease severity, 3 groups emerged. Group 1 (28 patients) had lateral mass collapse, group 2 (27 patients) had lateral facet joint sclerosis, erosion, or loss of joint space with no collapse, and group 3 (6 patients) had lateral subluxation with no bone or cartilage changes. Nine patients in group 1 had severe pain, and 25 had a nonreducible rotational tilt of the head. None of the patients in the other 2 groups had either of these signs or symptoms. Moreover, patients in group 1 were more likely to have other C1-C2 or subaxial subluxations and were more likely to have myelopathy. C1-C2 lateral facet joint involvement is common in RA, correlates with disease severity generally and specifically with that in the cervical spine, and, when severe, causes nonreducible rotational tilt of the patient's head.

Atlantoaxial subluxation in systemic lupus erythematosus: further evidence of tendinous alterations

We prospectively determined the frequency of atlantoaxial subluxation in a group of patients with systemic lupus erythematosus (SLE) and analyzed its relationship with tendinous laxity, Jaccoud's syndrome and other features of the disease. Five of 59 patients (8.5%) had atlantoaxial subluxation. No patient presented atlantoaxial subluxation in neutral lateral cervical radiographs but all 5 had anterior atlantoaxial subluxation in full flexion films; one patient also had lateral subluxation. The 5 patients with atlantoaxial subluxation were compared with the remaining 54. Mean SLE disease duration was longer in patients with atlantoaxial subluxation (12 years) than in those without (6.6 years) (p less than 0.01). Jaccoud's syndrome, patellar tendon elongation and articular hypermobility were significantly more frequent in patients with atlantoaxial subluxation. The presence or history of arthritis failed to distinguish patients with and without atlantoaxial subluxation, while chronic renal failure and increased serum parathyroid hormone levels were significantly associated to the presence of atlantoaxial subluxation. We suggest that atlantoaxial subluxation is further evidence of tendinous alterations seen in patients with SLE.

[Significance of the upper neck joints in the etiology of pain in the head and neck area]

The function of the atlantooccipital joints is intimately connected with the function of the spine in total and the temporomandibular joint in special. The present investigation gives report of the frequent combination of headache, facial pain and pain in the temporomandibular joint, which could be found in patients of an orthopedic practice. The role of the atlantooccipital joints is stressed in a special manner and explained with the function of the arthromuscular control loop.

[Evolutive atlanto-axial luxation revealing chronic inflammatory rheumatism in children]

Atlanto-axial luxation in uncommon in chronic arthritis in childhood, especially early in the course of the disease. One case is described in which atlanto-axial luxation occurred early. Computed tomographic myelography showed the cervico-medullary compression which was treated by transoral anterior decompression and posterior occipito-cervical fusion.

Atlantoaxial laxity in rheumatoid arthritis

We found that 14 of 162 rheumatoid arthritis patients with chronic occipitocervical pain had anterior atlantoaxial instability in the absence of any corresponding radiographic changes in the joint cartilage or subchondral bone. Our findings suggest that ligamentous instability is a prerequisite for this type of change. At the time of the detection of the instability, the median duration of disease was 12 (6-28) years. Rheumatoid occipitocervical pain may be initially caused by facet-joint arthritis or inflammation in the ligaments, and at a later stage also by irritation of the C2 nerve roots.

Traumatic lesions of the occipitoatlantoaxial complex

Injuries of the occipitoatlantoaxial complex are relatively rare but form a group of ligamentous and bony lesions that may unnecessarily confuse the clinician. Since fractures of the dens and traumatic spondylolisthesis of the axis have been well described in a number of large series, this article concentrates on the lesions less frequently seen and described. The ligamentous injuries are occipitoatlantal dislocation, rupture of the transverse ligament, and atlantoaxial rotatory fixation. The bony injuries are fractures of the occipital condyles, atlas, and the lateral masses of C2. The incidence, diagnostic criteria, and treatment modalities depend on the nature of localization of the traumatic lesions.

Atlanto-axial rotational limitation secondary to osteoid osteoma of the axis. Case report

An unusual case of atlanto-axial rotational limitation secondary to an osteoid osteoma of the axis is presented. Transoral microsurgical resection followed by physical therapy improved the clinical symptoms. This case illustrates several unique problems within the cervical spine as well as the efficacy of the transoral approach to the axis.

Involvement of the craniocervical junction in Reiter's syndrome

Although Reiter's syndrome uncommonly affects the cervical spine, involvement of the craniocervical articulations does occur and may be manifested as nonreducible rotational head tilt. Computerized axial tomography with reformatted images was helpful in assessing the anatomy of this area in our patient with significant head tilt and abnormal head position.

Cervical spine management in patients with rheumatoid arthritis. Review of the literature

Rheumatoid arthritis of the cervical spine is a well-recognized source of neck pain. Discussion of the potential effects of various treatment interventions on the tissues of patients with rheumatoid arthritis of the cervical spine, however, has been scarce in the physical therapy literature. Physical therapists should understand the implications of this type of inflammatory arthritis when treating patients with rheumatoid arthritis. The end-stage results of the inflammatory process and the mechanical forces on the cervical spine can cause atlantoaxial subluxation, atlantoaxial impaction, and subaxial subluxation. The purpose of this article is to review the literature on several aspects of rheumatoid arthritis of the cervical spine: 1) pathological anatomy, 2) clinical findings, 3) surgical management, 4) management with cervical orthoses, and 5) physical therapy management.

Nontraumatic subluxation of the atlantoaxial joint: Grisel's syndrome

Grisel's syndrome is defined as subluxation of the atlantoaxial joint not associated with trauma or bone disease. Primarily an affliction of children, the disorder may occur in association with any condition that results in hyperemia and pathologic relaxation of the transverse ligament of the atlantoaxial joint, including several common otolaryngic entities. Grisel's syndrome has been noted infrequently in the otolaryngologic literature; this paper reports a case from West Virginia University Hospital of a 6-year-old boy with radiographic evidence of retropharyngeal cellulitis following meningitis progressing to atlantoaxial subluxation. Discussed are the pathophysiologic aspects of Grisel's syndrome with an anatomic explanation recently described to account for the syndrome.

[Peripheral vestibular vertigo and functional disorders of the craniovertebral joint]

Some vertiginous lesions producing nystagmus (e.g. acute vestibulopathy, benign paroxysmal postural vertigo and Ménière's disease) are well-defined diseases of purely labyrinthine origin. The possible place of a functional disorder of the vertebral joints on their etiology and pathogenesis, has been discussed, but is purely hypothetical. Since the lesion almost always reaches with reduced function of the vestibular apparatus, the course of the disease depends crucially on central compensation of the peripheral disorder of vestibular function. Investigations of the effect of a functional disorder of the vertebral joints on the central compensation of vestibular functional disorders have not been described previously. Our own observations show that a functional disorder of the vertebral joints can crucially impair central compensation of peripheral vestibular vertigo. The pathological mechanism of the impaired compensation is discussed, and diagnostic and therapeutic consequences explained.

Pitfalls in the CT diagnosis of atlantoaxial rotary subluxation

CT was used to examine six patients with clinically evident atlantoaxial rotary fixation, two patients with torticollis, and six normal subjects who had turned their heads to the side as far as voluntarily possible. The CT appearances of the atlantoaxial complex were identical in all three groups. To differentiate these groups, we propose a functional scan through C1-C2 in which patients are scanned initially as they present, with their heads fixed in lateral rotation. Subsequent scans are obtained with their heads turned to the maximum contralateral rotation. CT scans in patients with atlantoaxial rotary fixation demonstrate no motion at C1-C2 during this maneuver, while those in patients with transient torticollis show a reduction or reversal of the rotation of C1 on C2.

[Simultaneous rotation and lateral inclination of the head. A clinical sign of restricted motion in segment C1/2]

The clinical diagnosis of a restricted motion at the atlanto-axial level is not always easy. Especially in the presence of a painful restricted neck motion, our clinical tests are unreliable. During a clinical controlled study of patients with dorsal fusions C1-2, we noted a constant and very obvious combined motion of the head: The rotation of the head was not only markedly limited, but it was constantly associated with an ipsilateral tilt of the head. This combined motion of the head can be used as a diagnostic sign of a restricted motion at the atlanto-axial level. Clinical pictures and pathomechanism of this phenomenon are explained.

Somatosensory-evoked potentials in the evaluation of the unstable rheumatoid cervical spine. A preliminary report

Median nerve somatosensory-evoked potential (SEP) examinations were performed in 24 consecutive patients with rheumatoid arthritis who had symptomatic cervical spine instability. Eighteen patients had C1-C2 instability: in ten, the subluxation was completely reducible, and in eight, the subluxation was irreducible, with or without superior migration of the odontoid process. Four patients had superior migration alone, and two had subaxial subluxation alone. Abnormal SEPs were found in seven patients overall. However, 58% of those patients with irreducible atlanto-axial subluxation and/or superior migration of the dens demonstrated abnormal cervical cord conduction latencies. Patients with these radiographic findings may be at a higher risk for the development of overt myelopathy.

Combined occipitoatlantoaxial hypermobility with anterior and posterior arch defects of the atlas in Pierre-Robin syndrome

Combined occipitoatlantoaxial instability of the cervical spine occurred in a 8-year-3-month old boy with Pierre-Robin syndrome. He also had failure of ossification of both the anterior and posterior arches of the atlas. An in situ fusion from the occiput to C2 restored cervical spine stability. This case is discussed in relation to other hypermobility and instability syndromes of the cervical spine.

Atlanto-axial subluxation in rheumatoid arthritis. A study of 104 hospital patients

Arthritic affection of the upper cervical spine is relatively common in rheumatoid arthritis (RA). Atlanto-axial subluxations are also reported to occur frequently, but it seems that neurological symptoms due to the subluxations seldom occur. We have studied 104 consecutive in-patients. In a group of 50 non-arthritics we have measured the distance from dens to the anterior arch of the atlas, and from dens to the foramen magnum line. By means of percentile-estimate we have defined values at risk for having pathological values for the measured distances. In 104 rheumatoid arthritis patients we found that 45% of the patients had values at risk, but only one of the patients had medullary neurological signs. A planned follow-up study will show if oncoming neurological symptoms due to subluxations will occur in the risk-group or in the group now defined as having normal values.