Radiologic findings of the lumbar spine in patients with rheumatoid arthritis, and a review of pathologic mechanisms

Perioperative Management of Comorbidities in Spine Surgery

The number of spinal operations performed in the United States has significantly increased in recent years. Along with these rising numbers, there has been a corresponding increase in the number of patient comorbidities. The focus of this article is to review comorbidities in Spine surgery patients and outline strategies to optimize patients and avoid complications.

Risk of Spine Surgery in Patients with Rheumatoid Arthritis: A Secondary Cohort Analysis of a Nationwide, Population-Based Health Claim Database

Background and Objectives: To study the risk of spine surgery, including cervical and lumbar spine surgeries in patients with rheumatoid arthritis (RA) compared with those without a diagnosis of RA. Materials and Methods: This is a secondary data analysis using population-based health claim data. We identified newly diagnosed adult patients with RA between January 2000 and December 2012, according to the International Classification of Diseases, Ninth revision, clinical modification code 714.0 from Taiwan’s National Health Insurance Research Database. Using data frequency-matched by 10-year age intervals, sex and index year with the RA cohort at a ratio of 5:1, we assembled a comparison cohort. All patients were followed until the study outcomes occurred (overall spine surgery, cervical spine surgery, or lumbar spine surgery) or the end of follow-up. Adjusted incidence rate ratios (aIRR) were calculated using Poisson regression analysis with age group, socioeconomic status, geographical region, and osteoporosis included as potential confounders. Results: We identified 1287 patients with RA and 6435 patients without RA. The incidence of overall spine surgery (aIRR = 2.13, 95% confidence interval (CI) = 1.49–3.04) and lumbar spine surgery (aIRR = 2.14, 95% CI = 1.46–3.15) were all significantly higher in the RA cohort. Moreover, females over 45 years of age were particularly at risk for lumbar spine surgery. In RA patients, older age and the combination with the diagnosis of osteoporosis had an elevated risk for overall and lumbar spine surgery. Conclusion: Patients with RA had an increased risk of receiving spine surgery. Physicians should be vigilant for possible spinal problems in women and older patients with RA.

The Influence of Rheumatoid Arthritis on Higher Reoperation Rates over Time Following Lumbar Spinal Fusion-A Nationwide Cohort Study

This study aimed to compare the rates of reoperation over time following first lumbar fusion in rheumatoid arthritis (RA) patients and non-RA patients. This study was conducted using Korean Health Insurance Review and Assessment (HIRA) data. We identified the RA group as 2239 patients who underwent their first lumbar fusion with RA and the control group as 11,195 patients without RA. This reflects a ratio of 1:5, and the participants were matched by sex, age, and index surgery date. The index dates were between 2012 and 2013. When comparing the rate of patients undergoing reoperation, the adjusted HR was 1.31 (95% CI: 1.10−1.6) in the RA group (p = 0.002). In terms of the three time intervals, the values in the time frames of <3 months and 3 months−1 year were not statistically significant. However, at 1 year post-surgery, there was a higher risk of reoperation in the RA group, as demonstrated by the Kaplan−Meier cumulative event analysis. This higher risk of reoperation continued to increase throughout 5 years of follow-up, after which it was stable until the last follow-up at 7 years. This population-based cohort study showed that the RA patients had a 1.31 times higher risk of reoperation following lumbar fusion than did the controls. This difference was more pronounced at 1 year post-surgery.

Incidence of and risk factors for spondylolisthesis, scoliosis, and vertebral fracture in rheumatoid arthritis

INTRODUCTION

Although lumbar lesions such as spondylolisthesis, scoliosis, and vertebral fracture are not specific to rheumatoid arthritis (RA), the prevalence is high in RA patients. However, no longitudinal study has evaluated lumbar lesions in RA. This study aimed to investigate the incidence of and risk factors for lumbar lesions in RA by a prospective longitudinal cohort study.

MATERIALS AND METHODS

The study cohort comprised 110 patients with RA from the 'analysis of factors for RA spinal disorders (AFFORD)' study who completed the secondary survey at a single orthopaedic outpatient RA clinic. Radiological examination included standing radiographs and magnetic resonance imaging (MRI) of the lumbar spine. New development of spondylolisthesis, scoliosis, and vertebral fracture were assessed between baseline and secondary survey.

RESULTS

The incidences of spondylolisthesis, scoliosis, and vertebral fracture were 42%, 16%, and 12%, respectively, during a mean follow-up of 7 years. The independent risk factor for de novo scoliosis was poor control of RA (adjusted odds ratio [aOR] 4.81, p = 0.011), while the independent risk factors for new vertebral fracture was use of glucocorticoid at secondary survey (aOR 14.87, p = 0.012). Patients with de novo scoliosis exhibited more severe low back pain and lower quality of life than those without.

CONCLUSION

The incidence of scoliosis was related in patients with poor control of RA, while new vertebral fracture was more common in patients with use of glucocorticoid. Control of disease activity might be important in preventing radiological lumbar disorders in RA.

Risk Factors for Low Back Pain Increase in Rheumatoid Arthritis: Analysis of a 7-year Follow-up Study

OBJECTIVE

Several studies have demonstrated that low back pain (LBP) is related to disease activity in patients with rheumatoid arthritis (RA). However, there is no longitudinal research. This study aimed to determine the impacts and risk factors for LBP increase in RA in a longitudinal cohort study.

METHODS

The study evaluated 113 patients with RA who completed the secondary survey. LBP increase was defined as ≥1 standard deviation of mean change in visual analog scale (VAS) between the baseline and secondary surveys. The impacts of LBP increase on quality of life (QOL) and psychological status were evaluated. Risk factors were assessed among patient demographic characteristics, radiological changes.

RESULTS

Mean change in VAS for LBP was -0.8±30.4 mm during a mean 7-year follow-up. LBP increase was defined as ≥30-mm increase in VAS for LBP. Patients with LBP increase had significantly lower QOL and worse mental status than patients without. Poor control of RA was identified as an independent risk factor for LBP increase (odds ratio, 9.82, p=0.001).

CONCLUSION

Patients with poor control of RA were likely to experience LBP increase in the long-term. Control of RA disease activity is important for control of LBP, QOL, and mental status.

The radiological outcome in lumbar interbody fusion among rheumatoid arthritis patients: a 20-year retrospective study

BACKGROUND

Clinical outcomes amongst Rheumatoid Arthritis (RA) patients have shown satisfactory results being reported after lumbar surgery. The increased adoption of the interbody fusion technique has been due to a high fusion rate and less invasive procedures. However, the radiographic outcome for RA patients after receiving interbody fusion has scarcely been addressed in the available literature.

METHODS

Patients receiving interbody fusion including ALIF, OLIF, and TLIF were examined for implant cage motion and fusion status at two-year follow-up. Parameters for the index correction level including ADH, PDH, WI, SL, FW, and FH were measured and compared at pre-OP, post-OP, and two-year follow-up.

RESULTS

We enrolled 64 RA patients at 104 levels (mean 64.0 years old, 85.9% female) received lumbar interbody fusion. There were substantial improvement in ADH, PDH, WI, SL, FW, and FH after surgery, with both ADH and PDH having significantly dropped at two-year follow up. The OLIF group suffered from a higher subsidence rate with no significant difference in fusion rate when compared to TLIF. The fusion rate and subsidence rate for all RA patients was 90.4 and 28.8%, respectively.

CONCLUSIONS

We revealed the radiographic outcomes of lumbar interbody fusions towards symptomatic lumbar disease in RA patients with good fusion outcome despite the relative high subsidence rate amongst the OLIF group. Those responsible for intra-operative endplate management should be more cautious to avoid post-OP cage subsidence.

Long-Term Results of Anterior-Only Lumbar Interbody Fusions in Rheumatoid Arthritis Patients: Comparative Retrospective Cohort Study

OBJECTIVE

Rheumatoid arthritis (RA) is a risk factor of lumbar spine surgical failure. The interest of anterior lumbar fusion in this context remains unknown. This retrospective study aimed to compare the outcome of anterior-only fusions between RA patients and non-RA (NRA) patients to treat lumbar spine degenerative disorders.

METHODS

NRA and RA groups including anterior-only fusion were compared. Clinical data (Visual Analog Scale score axial back pain scale, the Oswestry Disability Index, and a questionnaire of satisfaction regarding the surgical result); radiologic data (bone fusion, sagittal balance analysis); and adverse events were assessed using repeated measure 1-way analysis of variance.

RESULTS

The mean follow-up was 9.5 years (95% confidence interval [7.1-12.2]) for the RA group (n = 13) and 9.4 years (95% confidence interval [8.7-10.3]) for the NRA group (n = 36). Anterior fusion improved clinical outcome without any effect of RA (Visual Analog Scale score axial back pain scale; P < 0.001/Oswestry Disability Index; P = 0.01). The presence of RA influenced neither the satisfaction as the regards the surgical result nor spine balance nor bone fusion. Context of RA increased the surgical revision rate (10 patients [76.9%] for RA group vs. 3 patients [8.8%] for the NRA group; P = 0.001) because of the occurrence of an adjacent segment disease needing surgical revision (P = 0.028), especially the occurrence of intervertebral frontal dislocation (P = 0.02).

CONCLUSIONS

As noticed for posterior-only fusion, the anterior lumbar approach in RA patients does not seem to avoid the occurrence of an adjacent segment disease.

Radiological and clinical comparisons of the patients with rheumatoid arthritis operated with rigid and dynamic instrumentation systems due to lumbar degenerative spinal diseases

BACKGROUND

It is extremely difficult to treat spine disorders with stabilization in patients with rheumatoid arthritis. Because revision rates are significantly higher in rigid stabilization. To date, there is no data about patients with rheumatoid arthritis treated with dynamic stabilization. Our aim was to compare the radiological and clinical results of patients with rheumatoid arthritis who underwent lumbar rigid stabilization or dynamic stabilization with Polyetheretherketone rod (PEEK).

METHODS

Patients with degenerative lumbar spine disease with rheumatoid arthritis who underwent dynamic stabilization between 2013 and 2015 and rigid stabilization between 2010 and 2012 were evaluated radiologically for adjacent segment disease, proximal junctional kyphosis, system problem (nonunion, screw loosening, instrumentation failure, pull out). It was also compared according to both the revision rates and the Visual Analog Scale and Oswestry Disability Index scores at the 12th month and 24th month.

RESULTS

The difference of decrease in Visual Analog Scale and Oswestry Disability Index scores from preoperative to 12th month between patients who underwent dynamic stabilization and rigid stabilization was statistically insignificant. However, there was a significant difference of increase in Visual Analog Scale and Oswestry Disability Index scores between the 12th month and 24th month of patients who underwent rigid stabilization, compared with patients with dynamic stabilization. In patients with dynamic stabilization, the problems of instrumentation were seen less frequently. Revision rates were high in patients with rigid stabilization when compared the patients with dynamic stabilization.

CONCLUSION

Radiological and clinical outcomes in patients with rheumatoid arthritis operated with dynamic stabilization are more significant when compared to rigid stabilization. These patients have lower pain and disability scores in their follow up periods. Revision rates are lower in patients with dynamic stabilization.

Rheumatoid Arthritis Increases Risk of Medical Complications Following Posterior Lumbar Fusion

BACKGROUND

Rheumatoid arthritis (RA) is a systemic disease with prominent musculoskeletal manifestations that is associated with increased morbidity and mortality in patients undergoing cervical spine surgery; however, few studies have specifically examined postoperative outcomes in patients with RA following lumbar surgery. The aim of this study was to evaluate whether patients with RA who underwent posterior lumbar fusion experienced increased postoperative complications and economic burden compared with patients without RA.

METHODS

Patients <85 years old who underwent elective 1- or 2-level instrumented posterior lumbar fusion for degenerative lumbar pathology between 2006 and 2012 were identified in the Medicare insurance claims database. Same-day revisions and cases for spinal infection, malignancy, and trauma were excluded. The resulting cohort was divided into patients with RA before fusion and patients without RA (controls). All outcomes of interest were compared using multivariate regression. Reoperation-free survival at 1- and 2-year follow-up was analyzed used log-rank test. Significance was defined as P < 0.05.

RESULTS

RA patients had significantly higher risk of 90-day readmission (odds ratio [OR] = 1.27, P < 0.001), thromboembolic events (OR = 1.39, P = 0.010), sepsis (OR = 2.32, P < 0.001), pneumonia (OR = 1.57, P = 0.001), and wound complications (OR = 1.41, P < 0.001). Reoperation-free survival was significantly lower in RA patients at 2-year follow-up (90.4% vs. 92.4%, P < 0.001). Following adjusted regression, RA independently contributed to a $1491 increase in additional 90-day costs (P < 0.001).

CONCLUSIONS

Preexisting RA may increase risk for short-term postoperative medical complications following posterior lumbar fusion, specifically infectious events. In addition, patients with RA have higher rates of subsequent reoperation following index surgery. Patients with RA be should counseled regarding these risks.

Do rheumatoid arthritis patients have low back pain or radiological lumbar lesions more frequently than the healthy population? - Cross-sectional analysis in a cohort study with age and sex-matched healthy volunteers

BACKGROUND CONTEXT

Rheumatoid arthritis (RA) can affect the spine; however, the epidemiology of lumbar lesions and/or low back pain (LBP) in RA patients has not been well-studied.

PURPOSE

The purpose of this study was to compare the prevalence of lumbar lesions and LBP in RA patients with that in healthy volunteers, and to elucidate the influence of RA on lumbar disease.

STUDY DESIGN

Cross-sectional analysis in a cohort study with age- and sex-matched healthy volunteers.

PATIENT SAMPLE

This study included 185 patients with RA and 188 gender/age-matched healthy volunteers without RA.

OUTCOME MEASURES

Lumbar spondylolisthesis and prevalent vertebral fractures were evaluated using plain lateral X-ray images. Thoraco-lumbar scoliosis was evaluated using dual-energy X-ray absorptiometric images. LBP was assessed using the visual analogue scale (VAS) and Rolland-Morris disability questionnaire (RDQ).

METHODS

The prevalence of radiological lumbar lesion and LBP was compared between the RA and control groups. In the RA group, factors associated with lumbar lesion and LBP were analyzed using a multiple logistic regression model.

RESULTS

The prevalence rates of spondylolisthesis and prevalent vertebral fracture were significantly higher in the RA group than in the control group; the prevalence of thoraco-lumbar scoliosis tended to be higher in the RA group. There was no significant difference in the average LBP-VAS between the groups. However, the percentage of analgesic drug use was significantly higher, and RDQ scores tended to be worse in the RA group than the control group. Multivariate analysis revealed that age and disease activity score were both related to LBP in the RA group.

CONCLUSIONS

RA patients are more likely to have radiological lumbar lesions. LBP in RA patients is well controlled, similar to the level in the healthy population; however, disease activity was related to LBP in RA patients. These results suggest that disease control is important for lumbar care in RA patients.

The necessity and risk factors of subsequent fusion after decompression alone for lumbar spinal stenosis with lumbar spondylolisthesis: 5 years follow-up in two different large populations

BACKGROUND/CONTEXT

Although decompression without fusion is a reasonable surgical treatment option for some patients with lumbar spinal stenosis (LSS) secondary to spondylolisthesis, some of these patients will require secondary surgery for subsequent fusion. Long-term outcome and need for subsequent fusion in patients treated with decompression alone in the setting of lumbar spondylolisthesis remains controversial.

PURPOSE

The aim of this study was to examine the rate, timing, and risk factors of subsequent fusion for patients after decompression alone for LSS with spondylolisthesis.

STUDY DESIGN/SETTING

A retrospective cohort study.

PATIENT SAMPLE

Patients who had LSS with spondylolisthesis and underwent decompression alone at 1 or 2 levels as a primary lumbar surgery with more than 5 year follow-up.

OUTCOME MEASURES

The rate, timing, and risk factors for subsequent fusion.

METHODS

Subjects were extracted from both public and private insurance resources in a nationwide insurer database. Risk factors for subsequent fusion were evaluated by multivariate cox proportion-hazard regression controlling for age, gender, comorbidities and the presence or absence of claudication.

RESULTS

Five thousand eight hundred and seventy-five patients in the public insurance population (PI population) and 1,456 patients in the private insurance population (PrI population) were included in this study. The rates of patients who needed subsequent fusion were 1.9% at 1 year, 3.5% at 2 years, and 6.7% at 5 years in the PI population, whereas they were 4.3% at 1 year, 8.9% at 2 years, 14.6% at 5 years in the PrI population. The time to subsequent fusion was 730 (365-1234) days in the PI population and 588 (300-998) days in the PrI population. Age less than 70 years, presence of neurogenic claudication and rheumatoid arthritis (RA)/collagen vascular diseases (CVD) were independent risk factors for subsequent fusion in both populations.

CONCLUSIONS

Decompression surgery alone can demonstrate good outcomes in some patients with LSS with spondylolisthesis. It is important for surgeons to recognize, however, that patient age less than 70 years, symptomatic neurogenic claudication, and presence of RA and/or CVD are significant independent factors associated with greater likelihood of needing secondary fusion surgery.

Does Rheumatoid Arthritis Affect the Infection and Complications Rates of Spinal Surgery? A Systematic Review and Meta-Analysis

BACKGROUND

Rheumatoid arthritis (RA) is a chronic autoimmune disease that produces synovial membrane inflammation and causes progressive articular damage with function loss. Some controversy exists regarding whether RA is associated with infection and complications after spinal surgery. The present study aimed to determine the effect of RA on spinal surgery infection and complications.

METHODS

A systematic literature search was performed in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. All studies that had compared patients who had undergone spinal surgery with and without RA were included in the analysis.

RESULTS

We found significantly greater rates statistically of complications (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.20-1.70; P < 0.05) and infections (OR, 1.69; 95% CI, 1.46-1.95, P < 0.05) in those with RA than in those without RA after spinal surgery. When registry data were excluded, the results suggested that the incidence of complications (OR, 2.24; 95% CI, 0.92-5.44; P = 0.08) and infections (OR, 1.76; 95% CI, 1.50-2.07; P < 0.05) was still greater for the RA group than for the non-RA group.

CONCLUSION

When undergoing spinal surgery, patients with RA have a greater risk of operative complications and infection. Surgeons should be aware of these risks and appropriately plan spinal operation for patients with RA to reduce the risk of complications.

Surgical Management of the Lumbar Spine in Rheumatoid Arthritis

STUDY DESIGN

Narrative review.

OBJECTIVE

To provide an overview on the diagnosis and surgical management of rheumatoid involvement of the lumbar spine. Rheumatoid arthritis (RA) is a chronic inflammatory disease of synovial joints, most commonly appendicular followed by axial. Although cervical spine involvement of RA is well documented, data on lumbar spine involvement and surgical management remains limited.

METHODS

Using PubMed, studies published prior to November 2018 with the keywords "RA, etiology"; "RA, spine management"; "RA, surgical management"; "RA, treatment"; "RA, DMARDs"; "RA, lumbar spine"; "RA, spine surgical outcomes"; "RA, imaging" were evaluated.

RESULTS

The narrative review addresses the epidemiology, manifestations, imaging, surgical complications, and operative and nonoperative management of RA involvement of the lumbar spine.

CONCLUSIONS

Rheumatoid involvement of the lumbar spine can present with lower back pain, neurogenic claudication, radiculopathy, spinal deformity, and instability. Patients with RA have significantly higher rates of vertebral fractures and complications following surgical intervention. However, in the setting of instability and spinal deformity, thoughtful surgical planning in conjunction with optimal medical management is recommended.

Higher serum uric acid levels are associated with reduced risk of hip osteoporosis in postmenopausal women with rheumatoid arthritis

Although the positive correlation between serum uric acid (UA) levels and bone mineral density (BMD) has been reported in the general population, there are little data regarding the effect of serum UA levels on bone loss in patients with rheumatoid arthritis (RA).We investigated whether increased serum UA levels were associated with a reduced risk of osteoporosis in postmenopausal women with RA.In this retrospective cross-sectional study, 447 postmenopausal female patients with RA and 200 age-matched, postmenopausal healthy controls underwent BMD examination by dual energy x-ray absorptiometry and serum UA levels measurement. Osteoporosis was diagnosed when the T-score was <-2.5.The median UA level in postmenopausal RA patients was found to be significantly lower than that in the healthy women (4 vs 4.1 mg/dL, P = .012) and the frequency of osteoporosis incidence in the lumbar spine, hip, and either site in RA patients was 25.5%, 15.9%, and 32.5%, respectively; the values were significantly higher than those of the controls. After adjusting for confounding factors, a significantly lower risk for osteoporosis of the hip in RA patients was observed within the highest quartile (odds ratio [OR] = 0.37, 95% confidence interval [CI] = 0.16-0.72, P = .021) and the second highest quartile (OR = 0.44, 95% CI = 0.2-0.95, P = .038) of serum UA levels as compared with the lowest quartile, but this association was not found to be consistent with respect to the lumbar spine. Serum UA levels also showed an independently positive correlation with femoral neck BMD (β = 0.0104, P = .01) and total hip BMD (β = 0.0102, P = .017), but not with lumbar BMD.Our data suggest that UA may exert a protective effect on bone loss in RA, especially in the hip.

A case of erosive polyarthropathy from Medieval northern Italy (12th-13th centuries)

OBJECTIVE

To evaluate and differentially diagnose erosive skeletal lesions located on multiple joints of an individual archaeologically recovered in 2017.

MATERIALS

Skeletal remains of a well-preserved skeleton dating to the 12th-13th centuries from the medieval church of San Biagio in Cittiglio (Varese, northern Italy).

METHODS

Macroscopic and radiographic imaging.

RESULTS

Erosive marginal symmetrical lesions are present on the metatarsophalangeal, metacarpophalangeal and interphalangeal joints of an adult male, aged 55-75 years. Osteolytic changes, in the form of pocket erosions, surface resorptions and pseudocyst formations, are also macroscopically observed on some carpal and tarsal bones and on several large peripheral joints.

CONCLUSIONS

A careful differential diagnosis of the lesions and their macroscopic and radiological appearance is suggestive of a case of rheumatoid arthritis-like polyarthropathy.

SIGNIFICANCE

This case contributes to the debate regarding the antiquity of erosive polyarthropathies, providing additional evidence for the existence of these diseases in the Old World prior to the European discovery of the Americas.

LIMITATIONS

Small sample size limits discussion of the scope of the disease in antiquity.

SUGGESTIONS FOR FURTHER RESEARCH

This case highlights the need for further macroscopic, radiographic, and biomolecular studies of pre-modern European skeletal samples to investigate the hypothesized pre-existence of these pathological conditions in Europe prior to 1492.

Perioperative outcomes associated with thoracolumbar 3-column osteotomies for adult spinal deformity patients with rheumatoid arthritis

OBJECTIVE

Spinal deformity causing spinal imbalance is directly correlated to pain and disability. Prior studies suggest adult spinal deformity (ASD) patients with rheumatoid arthritis (RA) have more complex deformities and are at higher risk for complications. In this study the authors compared outcomes of ASD patients with RA following thoracolumbar 3-column osteotomies to outcomes of a matched control cohort.

METHODS

All patients with RA who underwent 3-column osteotomy for thoracolumbar deformity correction performed by the senior author from 2006 to 2016 were identified retrospectively. A cohort of patients without RA who underwent 3-column osteotomies for deformity correction was matched based on multiple clinical factors. Data regarding demographics and surgical approach, along with endpoints including perioperative outcomes, reoperations, and incidence of proximal junctional kyphosis (PJK) were reviewed. Univariate analyses were used to compare patients with RA to matched controls.

RESULTS

Eighteen ASD patients with RA were identified, and a matched cohort of 217 patients was generated. With regard to patients with RA, 11.1% were male and the mean age was 68.1 years. Vertebral column resection (VCR) was performed in 22.2% and pedicle subtraction osteotomy (PSO) in 77.8% of patients. Mean case length was 324.4 minutes and estimated blood loss (EBL) was 2053.6 ml. Complications were observed in 38.9% of patients with RA and 29.0% of patients without RA (p = 0.380), with a trend toward increased medical complications (38.9% vs 21.2%, p = 0.084). Patients with RA had a significantly higher incidence of deep vein thrombosis (DVT)/pulmonary embolism (PE) (11.1% vs 1.8%, p = 0.017) and wound infections (16.7% vs 5.1%, p = 0.046). PJK occurred in 16.7% of patients with RA, and 33.3% of RA patients underwent reoperation. Incidence rates of PJK and reoperation in matched controls were 12.9% and 25.3%, respectively (p = 0.373, p = 0.458). At follow-up, mean sagittal vertical axis (SVA) was 6.1 cm in patients with RA and 4.5 cm in matched controls (p = 0.206).

CONCLUSIONS

Findings from this study suggest that RA patients experience a higher incidence of medical complications, specifically DVT/PE. Preoperative lower-extremity ultrasounds, inferior vena cava (IVC) filter placement, and/or early initiation of DVT prophylaxis in RA patients may be indicated. Perioperative complications, morbidity, and long-term outcomes are otherwise similar to non-RA patients.

Prevalence of and factors associated with dysfunctional low back pain in patients with rheumatoid arthritis

PURPOSE

To investigate the prevalence of and factors associated with dysfunctional low back pain (LBP) in patients with rheumatoid arthritis (RA).

METHODS

This cross-sectional study included 1276 RA outpatients from two hospitals. The Roland-Morris Disability Questionnaire was used to address the functional-dysfunctional state criterion. Clinical variables, such as medical status, disease activity, bone mineral density, and spinopelvic alignment parameters, were compared between patients with and without dysfunctional LBP.

RESULTS

Mean age and disease duration were 64.6 and 13.4 years, respectively; the prevalence of dysfunctional LBP was 32.8%. On univariate analysis, significant differences existed in many variables, except sex, body weight, C-reactive protein (CRP) level, and prevalence of biological agent users, between patients with and without dysfunctional LBP. Multivariate logistic regression analysis revealed body mass index (BMI; odds ratio [OR], 1.116; P < 0.001), onset age of RA (OR, 1.020; P = 0.020), disease duration of RA (OR, 1.043; P < 0.001), methotrexate (MTX) use (OR, 0.609; P = 0.007), vertebral fractures (OR, 2.189; P = 0.001), vertebral endplate and/or facet erosion (OR, 1.411; P = 0.043), disease activity score (DAS) in 28 joints-CRP (DAS-28CRP) (OR, 1.587; P = 0.001), pelvic tilt (PT; OR, 1.023; P = 0.019), and sagittal vertical axis (SVA; OR, 1.007; P = 0.043) as associated factors.

CONCLUSION

The factors associated with dysfunctional LBP in patients with RA were more vertebral fractures, higher DAS-28CRP, vertebral endplate and/or facet erosion, higher BMI, longer disease duration, greater PT, older onset age, greater SVA, and less MTX use. Strictly controlling patients' body weight and disease activity with MTX and avoiding spinopelvic malalignment through vertebral fracture prevention are important. These slides can be retrieved under Electronic Supplementary Material.

Prevalence and patterns of peripheral neuropathy in patients of rheumatoid arthritis

Background

Rheumatoid arthritis (RA) is an autoimmune disorder characterized by involvement of multiple small and large joints with multisystem extra-articular manifestations. Peripheral neuropathy is known extra-articular manifestation of RA with the incidence of around 39.19% as per previous studies. Early diagnosis and treatment of peripheral neuropathy has been shown to improve both physical and functional disabilities of patients with RA.

Objectives

The primary objective was to study prevalence and patterns of peripheral neuropathy in patients with RA. The secondary objective was to study demographic, clinical parameters, disease severity, and extra- articular manifestations in patients with RA with and without peripheral neuropathy.

Materials and Methods

Consecutive patients of RA were recruited. Detailed clinical examination and electrophysiological tests were done to diagnose peripheral neuropathy. The demographic and clinical parameters were noted and tabulated. Student's t-test was used to analyze continuous variable, whereas Chi-square test was used for analysis of categorical variables.

Results

Of 89 patients with RA, 75.28% (n = 67) patients had peripheral neuropathy electrophysiologically, whereas 20.89% (14 patients of 67) had superficial touch sensory loss on examination. Subclinical neuropathy was present in 50.74% (n = 34) of patients. Statistically significant association between the presence of neuropathy and age of the patients, disease duration, use of disease-modifying antirheumatoid drugs, disease severity (disease activity score-28), and presence of subcutaneous nodules (P < 0.05).

Conclusion

Patients with RA, especially elderly patients, should undergo electrophysiological testing to rule out peripheral neuropathy. Electrophysiological study is a diagnostic and gold standard tool to diagnose subclinical neuropathy in patients with RA. Presence of peripheral neuropathy in these patients has been found to be significantly associated with deteriorating health status, pain scores, and presence of extra-articular manifestations.

Infectious Spondylitis Mimics: Mechanisms of Disease and Imaging Findings

Infectious processes of the spine are on the rise; in this scenario recognition of entities imitating infection is very important. The discovertebral unit is regarded as one of the most important and active sites in the spine. Importantly, the vertebral bony rim and the anterior corners of the vertebral bodies have significant vascularization, they are the last regions to ossify in the developmental process and suffer mechanical forces. Early septic or aseptic discitis-osteomyelitis, properly called spondylitis, involves these anterior regions. Early degeneration is characterized by disc desiccation; however, there is preferential involvement for the corners of the vertebral bodies as well. Many entities to include degenerative changes, inflammatory spondyloarthropathies, neuropathic spine, or pseudo arthrosis, among others, affect the discovertebral unit and can imitate infection. With some exceptions, important imaging findings for the identification of an infectious mimic include the absence of soft tissue enhancement or fluid collections in the paraspinal or epidural regions, and the involvement of multiple levels or the posterior elements. We review developmental, anatomical, and pathologic concepts correlating with imaging clues. Overall, our goal is to increase awareness and to improve recognition of mimicking entities.

Risk factor analysis of adjacent segment disease requiring surgery after short lumbar fusion: the influence of rheumatoid arthritis

BACKGROUND CONTEXT

The influence of rheumatoid arthritis (RA) on the lumbar spine has received relatively little attention compared with cervical spine, and few studies have been conducted for adjacent segment disease (ASD) after lumbar fusion in patients with RA.

PURPOSE

The present study aims to determine the incidence of ASD requiring surgery (ASDrS) after short lumbar fusion and to evaluate risk factors for ASDrS, including RA.

STUDY DESIGN

This is a retrospective cohort study.

PATIENT SAMPLE

The present study included 479 patients who underwent lumbar spinal fusion of three or fewer levels, with the mean follow-up period of 51.2 (12-132) months.

OUTCOME MEASURES

The development of ASD and consequent revision surgery were reviewed using follow-up data.

METHODS

The ASDrS-free survival rate of adjacent segments was calculated through Kaplan-Meier method. The log-rank test and Cox regression analysis were used to evaluate risk factors comprising RA, age, gender, obesity, osteoporosis, diabetes, smoking, surgical method, and the number of fusion segments.

RESULTS

After short lumbar fusion, revision surgery for ASD was performed in 37 patients (7.7%). Kaplan-Meier analysis predicted that the ASDrS-free survival rate of adjacent segments was 97.8% at 3 years, 92.7% at 5 years, and 86.8% at 7 years. In risk factor analysis, patients with RA showed a 4.5 times higher risk of ASDrS than patients without RA (p<.001), and patients with three-segment fusion showed a 2.7 times higher risk than patients with one- or two-segment fusion (p=.005).

CONCLUSIONS

Adjacent segment disease requiring surgery was predicted in 13.2% of patients at 7 years after short lumbar fusion. Rheumatoid arthritis and the number of fusion segments were confirmed as risk factors.

Lumbar spine surgery in patients with rheumatoid arthritis (RA): what affects the outcomes?

BACKGROUND CONTEXT

Although the cervical spine is only occasionally involved in rheumatoid arthritis (RA), involvement of the lumbar spine is even less common. A few reports on lumbar spinal stenosis in patients with RA have appeared. Although disc space narrowing occurs in aging, postoperative adjacent segment disease (ASD) in patients with RA has not been subject to much analysis.

PURPOSE

The objective of this study was to investigate differences in ASD and clinical outcomes between lumbar spinal decompression with and without fusion in patients with RA.

STUDY DESIGN/SETTING

This is a retrospective comparative study.

PATIENT SAMPLE

A total of 52 patients with RA who underwent surgery for lumbar spinal disorders were included. Twenty-seven patients underwent decompression surgery with fusion and 25 underwent decompression surgery alone.

OUTCOME MEASURES

Intervertebral disc space narrowing and spondylolisthesis of the segment immediately cranial to the surgical site were measured using a three-dimensional volume rendering software. Pre- and postoperative evaluation of RA activity and Japanese Orthopaedic Association (JOA) scores were conducted.

MATERIALS AND METHODS

All patients had preoperative and annual postoperative lumbar radiographs and were followed up for a mean of 5.1 years (range 3.5-10.9 years). Pre- and postoperative (2 years after surgery) JOA scores were recorded and any postoperative complications were investigated. Degrees of intervertebral disc narrowing and spondylolisthesis at the adjacent levels were evaluated on radiographs and were compared between the two groups. Analysis was performed to look for any correlation between ASD and RA disease activities.

RESULTS

Postoperative JOA scores were significantly improved in both groups. The rate of revision surgery was significantly higher in the fusion group than that in the non-fusion group. The rate of ASD was significantly greater in the fusion group than that in the non-fusion group at the final follow-up examination. Both matrix metalloproteinase 3 (MMP-3) and the 28-joint disease activity score incorporating C-reactive protein levels (DAS28-CRP) were significantly associated with the incidence and severity of ASD.

CONCLUSIONS

Adjacent segment disease and the need for revision surgery were significantly higher in the fusion group than those in the non-fusion group. A preoperative high MMP-3 and DAS28-CRP are likely to be associated with postoperative ASD.

Outcome of balloon kyphoplasty for the treatment of osteoporotic vertebral compression fracture in patients with rheumatoid arthritis

BACKGROUND

Osteoporosis and osteoporotic fractures are widely known as complications of rheumatoid arthritis. Kyphoplasty (KP) is known as an effective treatment modality for reducing pain and correcting kyphotic deformity in osteoporotic vertebral compression fracture (OVCF). However, cutcomes of KP in rheumatoid patients are not well known. The purpose of the study was to investigate the clinical and radiological outcomes of balloon KP on OVCF in patients with rheumatoid arthritis.

METHODS

A total of 23 patients (31 vertebral bodies) with rheumatoid arthritis who received KP for OVCF and could be followed up for at least 1 year were examined. For clinical outcomes, visual analogue scale (VAS) and the Korean version of the Oswestry disability index (KODI) were evaluated. For radiological outcomes, changes in anterior vertebral height and local kyphotic angle were measured, alongside cement leakage, adjacent fracture, and the recollapse of cemented vertebra.

RESULTS

The anterior vertebral height was significantly restored after surgery compared with prior to surgery (p < 0.001). Cement leakage was found in 14 cases (45.1 %), and disc space leakage was prevalent (50 %), while vascular cement leakage was found in one case. Adjacent fracture was found in 3 patients (11.5 %). VAS for lumbago showed a significant decrease (p < 0.001) after surgery (VAS = 2.4) compared with that before (VAS = 8.1); it was somewhat increased after the 1-year follow-up (VAS = 2.8; p = 0.223). KODI also decreased (48.8 %) after surgery compared with before (84.6 %). However, it increased somewhat (49.9 %) after the 1-year follow-up.

CONCLUSION

KP on rheumatoid arthritis patients for OVCF was effective for reducing pain in the early stage and restoring vertebral body height. Recollapse of the treated vertebral body was found relatively frequently alongside the correction loss of local kyphotic angle.

The outcomes of instrumented posterolateral lumbar fusion in patients with rheumatoid arthritis

Aims

The aims of this study were to evaluate the clinical and radiological outcomes of instrumented posterolateral fusion (PLF) performed in patients with rheumatoid arthritis (RA).

Methods

A total of 40 patients with RA and 134 patients without RA underwent instrumented PLF for spinal stenosis between January 2003 and December 2011. The two groups were matched for age, gender, bone mineral density, the history of smoking and diabetes, and number of fusion segments. The clinical outcomes measures included the visual analogue scale (VAS) and the Korean Oswestry Disability Index (KODI), scored before surgery, one year and two years after surgery. Radiological outcomes were evaluated for problems of fixation, nonunion, and adjacent segment disease (ASD). The mean follow-up was 36.4 months in the RA group and 39.1 months in the non-RA group.

Results

Both groups had significant improvement in symptoms one year after surgery, while the RA group showed some deterioration of outcome scores owing to complications during the second year after surgery. Complications occurred at a higher rate in the group with RA (19 patients, 47.5%) than in those without RA (23 patients, 17.1%) (p < 0.001). A total of 15 patients in the RA group (37.5%) required revision surgery, mainly for implant failure and post-operative infection.

Discussion

Multimodal approaches should be considered when performing instrumented PLF in patients with RA to reduce the rate of complications, such as problems of fixation, post-operative infection and nonunion. Take home message: Specific strategies should be undertaken in order to optimise outcomes in patients with rheumatoid arthritis. Cite this article: Bone Joint J 2016;98-B:102–8.

The relationship between cervical and lumbar spine lesions in rheumatoid arthritis with a focus on endplate erosion

STUDY DESIGN

A cross-sectional imaging study.

OBJECTIVE

To investigate the relationship between cervical and lumbar spine lesions in patients with rheumatoid arthritis (RA), and to analyze associated factors in those with concurrent cervical and lumbar endplate erosion (EE).

SUMMARY OF BACKGROUND DATA

Both the lumbar and cervical spines are often involved in RA, but little is known about the relationship between cervical and lumbar lesions. EE is often found in the spine of RA patients, but its prevalence and associated factors have not been well studied.

METHODS

We enrolled 201 RA patients in this study. Cervical lesions (horizontal and vertical atlantoaxial dislocation, subaxial subluxation) and lumbar lesions (vertebral fracture, scoliosis, spondylolisthesis) were evaluated on plain radiographs. EE was evaluated on sagittal T1-weighted magnetic resonance images, and graded into 4 categories. The prevalence of each lesion was calculated, and correlations between general cervical and lumbar lesions and between cervical and lumbar EE were analyzed. To assess the clinical condition of RA, we evaluated disease duration, Steinbrocker stage, modified Stanford Health Assessment Questionnaire results, and Disease Activity Score for 28 joints with the erythrocyte sedimentation rate. Factors associated with concurrent lumbar and cervical EE were analyzed using multiple logistic regression analysis.

RESULTS

Cervical lesions were found in 42.3% of patients and lumbar lesions in 56.2%. There was no significant correlation between the presence of cervical and the presence of lumbar lesions, but patients with cervical subaxial subluxation were significantly more likely to have lumbar spondylolisthesis. Cervical EE (≥1 points) was found in 61.2% of patients and lumbar EE in 39.3%. Total cervical EE score was significantly correlated with lumbar EE score. Moderate/high disease activity, Steinbrocker stage IV, and severe cervical or lumbar disk degeneration were associated with concurrent cervical and lumbar EE.

CONCLUSIONS

Some cervical lesions are significantly associated with lumbar spinal lesions. Concurrent cervical and lumbar EE are related to RA disease activity and peripheral joint deterioration, suggesting that RA activity may play an important role in total spinal involvement.

Scoliosis-related factors in patients with rheumatoid arthritis: A cross-sectional study

OBJECTIVES

This study aimed to identify the prevalence of scoliosis and scoliosis-related factors of rheumatoid arthritis (RA).

METHODS

In this study, 411 patients who underwent coronal total spine and lower limb radiography were enrolled. Patients with a Cobb angle ≥10° were diagnosed with scoliosis. Statistical analysis was performed to compare between patients with and those without scoliosis, and between patients without scoliosis and those with a Cobb angle >20°.

RESULTS

The prevalence of scoliosis in patients with RA was 30.7%. The mean Cobb angles were 8.5° ± 7.2° in all the patients, 16.1° ± 8.6° in patients with scoliosis, and 5.1° ± 2.3° in patients without scoliosis. According to a multivariate analysis, the scoliosis-related factors of RA were age and vertebral fracture. Significant differences in age, corticosteroid use, and malalignment of lower limbs were observed between patients with a Cobb angle >20° and those without scoliosis.

CONCLUSIONS

With RA treatment, the need for corticosteroid use is reduced and vertebral fracture is prevented. Moreover, the joints and spinal and lower limb alignments should be examined.

Surgical outcomes of long spinal fusions for scoliosis in adult patients with rheumatoid arthritis

OBJECT

In this study, the authors compared outcomes and complications in patients with and without rheumatoid arthritis (RA) who underwent surgery for spinal deformity.

METHODS

The authors searched the Johns Hopkins University database for patients with RA (Group RA) and without RA (Group NoRA) who underwent long spinal fusion for scoliosis by 3 surgeons at 1 institution from 2000 through 2012. Groups RA and NoRA each had 14 patients who were well matched with regard to sex (13 women/1 man and 12 women/2 men, respectively), age (mean 66.3 years [range 40.5–81.9 years] and 67.6 years [range 51–81 years]), follow-up duration (mean 35.4 months [range 1–87 months] and 44 months [range 24–51 months]), and number of primary (8 and 8) and revision (6 and 6) surgeries. Surgical outcomes, invasiveness scores, and complications were compared between the groups using the nonpaired Student t-test (p < 0.05).

RESULTS

For Groups RA and NoRA, there were no significant differences in the average number of levels fused (10.6 [range 9–17] vs 10.3 [range 7–17], respectively; p = 0.4), the average estimated blood loss (2892 ml [range 1300–5000 ml] vs 3100 ml [range 1700–5200 ml]; p = 0.73), or the average invasiveness score (35.5 [range 21–51] vs 34.5 [range 23–58]; p = 0.8). However, in Group RA, the number of major complications was significantly higher (23 vs 11; p < 0.001), the number of secondary procedures was significantly higher (14 vs 6; p < 0.001), and the number of minor complications was significantly lower (4 vs 12; p < 0.001) than those in Group NoRA.

CONCLUSIONS

Long spinal fusion in patients with RA is associated with higher rates of major complications and secondary procedures than in patients without RA.

Advances in the treatment of cervical rheumatoid: Less surgery and less morbidity

Rheumatoid arthritis is a chronic systemic inflammatory disease that often affects the cervical spine. While it was initially thought that cervical involvement was innocuous, natural history studies have substantiated the progressive nature of untreated disease. Over the past 50 years, there has been further elucidation in the pathophysiology of the disease, as well as significant advancements in medical and surgical therapy. The introduction of disease modifying drugs and biologic agents has reduced the amount of patients with advanced stages of the disease needing surgery. Advancement in instrumentation techniques has improved patient outcomes and fusion rates. The introduction of endoscopic approaches for ventral decompression may further lower surgical morbidity. In this review, we give a brief overview of the pertinent positives of the disease. A discussion of historical techniques and the evolution of surgical therapy into the modern era is provided. With improved medical therapies and less invasive approaches, we will likely continue to see less advanced cases of disease and less surgical morbidity. Nonetheless, a thorough understanding of the disease is crucial, as its systemic involvement and need for continued medical therapy have tremendous impact on overall complications and outcomes even in patients being seen for standard degenerative disease with comorbid rheumatoid.

The pitfalls in surgical management of lumbar canal stenosis associated with rheumatoid arthritis

There have been few clinical studies in the area of cervical spine that focused on surgery for treating degenerative lumbar disease in patients with rheumatoid arthritis (RA). High rates of wound complications and instrumentation failure have been reported more for RA than for non-RA patients, although clinical outcomes are similar between the two groups. Lumbar canal stenosis in RA is caused not only by degeneration but also by RA-related spondylitis, which includes facet arthritis and inflammation around the vertebral endplate. The pitfalls in surgical management of lumbar canal stenosis in RA patients are highlighted in this study. The study reviewed 12 patients with RA,who were surgically treated for lumbar canal stenosis. Two out of five patients with pulmonary fibrosis died of worsened pulmonary condition, even though there were no perioperative pulmonary complications. Two patients with pedicle screw fixation showed no instrumentation failure, but two patients with spinous process fixation needed re-operation or vertebral fracture. Surgical treatment for lumbar canal stenosis in RA patients needs to be individually adjusted. Preoperative assessments and treatments of pulmonary fibrosis and osteopenia are essential. Surgery for lumbar canal stenosis with RA should be deferred for patients with advanced pulmonary fibrosis because of its potential life-threatening risk. Fusion surgery is indicated only in patients with kyphosis or severe symptoms caused by intervertebral instability. Pedicle screw fixation with hydroxyapatite granules or sublaminar tape is recommended. Closer follow-up after surgery is necessary because of possible delayed wound infection, instrumentation failure, pathological fracture, and respiratory deterioration.

Lumbar scoliosis in rheumatoid arthritis: epidemiological research with a DXA cohort

STUDY DESIGN

A retrospective cross-sectional study.

OBJECTIVE

The aim of this study was to identify the prevalence of and risk factors for lumbar scoliosis in patients with rheumatoid arthritis (RA) using lumbar images obtained from dual-energy x-ray absorptiometry (DXA).

SUMMARY OF BACKGROUND DATA

The prevalence of lumbar scoliosis in the normal adult population has been reported, but that in patients with RA remains unclear.

METHODS

Subjects comprised 241 patients with RA who underwent annual DXA. Cobb angles of the lumbar spine were measured by lumbar anteroposterior DXA and the prevalence of lumbar scoliosis (curvature ≥10°) was calculated. Correlations between lumbar scoliosis and potential risk factors (age, sex, duration of RA, T score of lumbar spine and hip, medications for RA [daily predonisolone dose, use of biological agents] and osteoporosis, disease activity score-C-reactive protein, progression stage and functional classification of RA, and severity of hand deformity were analyzed.

RESULTS

The prevalence of lumbar scoliosis in patients with RA was 32.0%. Mean Cobb angle was 7.1º ± 5.5º among all subjects, compared with 13.6º ± 4.4º (range, 10º-32º) among subjects with scoliosis. Subjects with scoliosis were significantly older (67.8 yr) than those without (61.6 yr, P < 0.0001). The daily prednisolone dose was significantly higher in subjects with scoliosis (4.14 mg) than in those without (3.46 mg, P = 0.0389). The T score of the hip was significantly smaller in subjects with scoliosis (-1.79) than in those without (-1.26, P = 0.0005). A multivariate logistic regression analysis revealed age as the sole risk factor for lumbar scoliotic changes in patients with RA (odds ratio, 1.068; 95% confidence interval, 1.031-1.107; P = 0.0003).

CONCLUSION

The prevalence of lumbar scoliosis in patients with RA was 32.0%, about 3- or 4-times higher than its prevalence as obtained from previous reports of DXA cohorts irrespective of RA. Increased age represented an independent risk factor for lumbar scoliosis in patients with RA.

LEVEL OF EVIDENCE

4.

Effect and treatment of chronic pain in inflammatory arthritis

Pain is the most common reason patients with inflammatory arthritis see a rheumatologist. Patients consistently rate pain as one of their highest priorities, and pain is the single most important determinant of patient global assessment of disease activity. Although pain is commonly interpreted as a marker of inflammation, the correlation between pain intensity and measures of peripheral inflammation is imperfect. The prevalence of chronic, non-inflammatory pain syndromes such as fibromyalgia is higher among patients with inflammatory arthritis than in the general population. Inflammatory arthritis patients with fibromyalgia have higher measures of disease activity and lower quality of life than inflammatory patients who do not have fibromyalgia. This review article focuses on current literature involving the effects of pain on disease assessment and quality of life for patients with inflammatory arthritis. It also reviews non-pharmacologic and pharmacologic options for treatment of pain for patients with inflammatory arthritis, focusing on the implications of comorbidities and concurrent disease-modifying antirheumatic drug therapy. Although several studies have examined the effects of reducing inflammation for patients with inflammatory arthritis, very few clinical trials have examined the safety and efficacy of treatment directed specifically towards pain pathways. Most studies have been small, have focused on rheumatoid arthritis or mixed populations (e.g., rheumatoid arthritis plus osteoarthritis), and have been at high risk of bias. Larger, longitudinal studies are needed to examine the mechanisms of pain in inflammatory arthritis and to determine the safety and efficacy of analgesic medications in this specific patient population.

High frequency of inflammatory back pain and other features of spondyloarthritis in patients with rheumatoid arthritis

The aim of this study was to investigate the frequency of patients with rheumatoid arthritis (RA) who have inflammatory back pain (IBP) and meet the existing classification criteria for ankylosing spondylitis (AS) and spondyloarthritis (SpA). We included 167 patients fulfilling the ACR 1987 revised criteria for RA. After obtaining a medical history and performing a physical examination, standard pelvic X-rays for examination of the sacroiliac joints (SIJ) were ordered in all patients. A computed tomography (CT) or magnetic resonance imaging (MRI) of SIJ was performed in patients with suspected radiographic sacroiliitis and MRI of SIJ in those who have IBP but no radiographic sacroiliitis. IBP was defined according to both Calin and experts' criteria. The modified New York (mNY) criteria were used to classify AS, both ESSG and Amor criteria for SpA and ASAS classification criteria for axial SpA. There were 135 female and 32 male patients with a mean age of 54.8 years. The mean disease duration was 9.8 years. RF was positive in 128 patients (79.2 %) and anti-CCP in 120 patients (81.1 %). Twenty-eight patients with RA (16.8 %) had IBP (Calin criteria), and four (2.4 %) had radiographic sacroiliitis of bilateral grade 3. Three patients (1.8 %) fulfilled the mNY criteria for AS, 31 (18.6 %) ESSG and 26 (15.6 %) Amor criteria for SpA. Nine patients (five with MRI sacroiliitis) (5.3 %) were classified as having axial SpA according to new ASAS classification criteria. This study suggests that the prevalence of SpA features in patients with RA may be much higher than expected.

Destructive discovertebral degenerative disease of the lumbar spine

The uncommon variant of degenerative hip joint disease, termed rapidly progressive osteoarthritis, and highlighted by severe joint space loss and osteochondral disintegration, is well established. We present a similar unusual subset in the lumbar spine termed destructive discovertebral degenerative disease (DDDD) with radiological features of vertebral malalignment, severe disc resorption, and "bone sand" formation secondary to vertebral fragmentation. Co-existing metabolic bone disease is likely to promote the development of DDDD of the lumbar spine, which presents with back pain and sciatica due to nerve root compression by the "bone sand" in the epidural space. MRI and CT play a complimentary role in making the diagnosis.

Spinal facet joint biomechanics and mechanotransduction in normal, injury and degenerative conditions

The facet joint is a crucial anatomic region of the spine owing to its biomechanical role in facilitating articulation of the vertebrae of the spinal column. It is a diarthrodial joint with opposing articular cartilage surfaces that provide a low friction environment and a ligamentous capsule that encloses the joint space. Together with the disc, the bilateral facet joints transfer loads and guide and constrain motions in the spine due to their geometry and mechanical function. Although a great deal of research has focused on defining the biomechanics of the spine and the form and function of the disc, the facet joint has only recently become the focus of experimental, computational and clinical studies. This mechanical behavior ensures the normal health and function of the spine during physiologic loading but can also lead to its dysfunction when the tissues of the facet joint are altered either by injury, degeneration or as a result of surgical modification of the spine. The anatomical, biomechanical and physiological characteristics of the facet joints in the cervical and lumbar spines have become the focus of increased attention recently with the advent of surgical procedures of the spine, such as disc repair and replacement, which may impact facet responses. Accordingly, this review summarizes the relevant anatomy and biomechanics of the facet joint and the individual tissues that comprise it. In order to better understand the physiological implications of tissue loading in all conditions, a review of mechanotransduction pathways in the cartilage, ligament and bone is also presented ranging from the tissue-level scale to cellular modifications. With this context, experimental studies are summarized as they relate to the most common modifications that alter the biomechanics and health of the spine-injury and degeneration. In addition, many computational and finite element models have been developed that enable more-detailed and specific investigations of the facet joint and its tissues than are provided by experimental approaches and also that expand their utility for the field of biomechanics. These are also reviewed to provide a more complete summary of the current knowledge of facet joint mechanics. Overall, the goal of this review is to present a comprehensive review of the breadth and depth of knowledge regarding the mechanical and adaptive responses of the facet joint and its tissues across a variety of relevant size scales.

Bilateral pars fractures complicating long fusion to L5 in a patient with rheumatoid arthritis

STUDY DESIGN

Case report.

OBJECTIVE

To report bilateral pars fractures at L5 complicating a long fusion for adult idiopathic scoliosis in a patient with rheumatoid arthritis.

SUMMARY OF BACKGROUND DATA

To our knowledge, there are no reports in the literature regarding bilateral pars fractures at the end instrumented vertebrae of a long fusion at the lumbosacral junction, nor reports that have evaluated long spinal deformity corrections in patients with rheumatoid arthritis. The question of ending a long fusion at L5 or S1 is controversial, and a review is presented.

METHODS

We present the patient's history, physical examination, and radiographic findings; describe the surgical treatment and long-term follow-up; and provide a literature review.

RESULTS

Bilateral pars fractures at the end instrumented vertebrae of a long construct (T4-L5) that we discovered were subsequently revised by extension of the fusion to the sacrum. Anterior structural support at L5-S1 was also provided. At the latest follow-up (46 months), the patient has had no recurrence of her symptoms. Her radiographs showed a stable construct without loss of alignment in the sagittal or coronal planes. Her rheumatoid arthritis continues to be treated with biologic, disease-modifying antirheumatic drugs.

CONCLUSION

To our knowledge, this is the first report of the treatment and long-term outcome of a patient with rheumatoid arthritis and bilateral pars fractures at the end instrumented vertebrae (L5) of a long deformity correction construct.

Lumbar radiculopathy caused by foraminal stenosis in rheumatoid arthritis

STUDY DESIGN

Case-series study.

OBJECTIVE

To describe the clinical presentation, characteristic findings of imaging studies, and treatment of lumbar radiculopathy caused by foraminal stenosis in rheumatoid arthritis. BACKGROUND. Lumbar lesions in rheumatoid arthritis are relatively rare, with a limited number of systemic reports.

METHODS

Six patients with lumbar radiculopathy caused by foraminal stenosis in rheumatoid arthritis were treated. The patients were all women with a mean age of 69 years and mean rheumatoid arthritis duration of 15 years. The medical records and imaging studies of all patients were reviewed.

RESULTS

The affected nerve roots were L4 in four patients and L3 in two patients. Foraminal stenosis was not demonstrated in magnetic resonance images in four of the six patients. Selective radiculography with nerve root block reproduced pain, manifested blocking effect, and demonstrated compression of the nerve root by the superior articular process of the lower vertebra in all patients. Conservative treatment was performed on one patient, and surgery was conducted for the rest of the five patients; radiculopathy was improved in all patients.

CONCLUSIONS

Lumbar foraminal stenosis is a characteristic pathology of rheumatoid arthritis, and should be kept in mind in the diagnosis of lumbar radiculopathy. Selective radiculography is useful in the diagnosis of affected nerve roots.

The lumbar facet joint: a review of current knowledge: part 1: anatomy, biomechanics, and grading

We present a two-part review article on the current state of knowledge of lumbar facet joint pathology. This first article discusses the functional anatomy, biomechanics, and radiological grading systems currently in use in clinical practice and academic medicine. Facet joint degeneration is presented within the larger context of degenerative disc disease to enable the reader to better understand the anatomical changes underlying facet-mediated lower back pain. Other less-common, but equally important etiologies of lumbar facet joint degeneration are reviewed. The existing grading systems are discussed with specific reference to the reliability of CT and MR imaging in the diagnosis of lumbar facet osteoarthritis. It is hoped that this discussion will stimulate debate on how best to improve the diagnostic reliability of these tests so as to improve both operative and non-operative treatment outcomes.

Multiple vertebral involvement of rheumatoid arthritis in thoracolumbar spine: a case report

Although little attention has been paid to the less common rheumatoid involvement of the thoracic and lumbar regions, some studies have shown that rheumatoid synovitis with erosive changes can develop in these diarthrodial joints. We report a patient with seropositive rheumatoid arthritis (RA) involving the thoracic and lumbar vertebra with a collapse of the T12 vertebra, who was treated with percutaneous vertebroplasty. In this case of a painful pathological fracture due to RA, percutaneous vertebroplasty was found to be helpful in eliminating the pain. The paper presents the histological evidence, the pathogenesis and treatment of the thoracolumbar lesions affected by RA with a review of the relevant literature.

Spread of spinal block in patients with rheumatoid arthritis

BACKGROUND

In clinical practice, we noticed a greater than expected spread of sensory spinal block in patients with rheumatoid arthritis. We decided to test this impression and compared the spread of standard spinal anaesthesia in rheumatoid and non-rheumatoid control patients.

METHODS

Spinal anaesthesia with 3.4 ml (17 mg) of plain bupivacaine was administered to 50 patients with seropositive rheumatioid arthritis and to 50 non-rheumatoid control patients. The protocol was standardised for all patients. All the patients were undergoing lower limb surgery and the rheumatoid patients were operated on due to their rheumatoid disease. The spread of sensory block was recorded 30 min from the dural puncture using a pin prick test and a cold ice-filled container. The impact of body mass index (BMI), height and age on the spread were analysed.

RESULTS

The spread of sensory block was greater in patients with rheumatoid arthritis (15.6+/-3.1 dermatomes) than in non-rheumatoid patients (14.1+/-3.3 dermatomes) (P<0.05). Increasing BMI was related to cephalad spread of block in the rheumatoid group (P<0.05), but not in the control group.

CONCLUSION

The mean spread of sensory block 30 min after the injection of plain bupivacaine was 1.5 segments cephalad in patients with rheumatoid arthritis than in those without this disease. BMI might be a patient-related factor contributing to the extent of the block in rheumatoid patients. These findings should be considered when performing a spinal block in rheumatoid patients.

Radiological features of lumbar spinal lesions in patients with rheumatoid arthritis with special reference to the changes around intervertebral discs

BACKGROUND CONTEXT

Compared with the cervical spine, little attention has been paid to rheumatoid arthritis (RA)-related lumbar disorders. Only a few articles have described the status of the lumbar spine affected by RA based on plain X-ray films and magnetic resonance imaging (MRI).

PURPOSE

To describe the features and prevalence of radiological changes of the lumbar spine of patients with RA and to clarify the correlations of such features with disease activity.

STUDY DESIGN

Transverse radiological study.

PATIENT SAMPLE

We radiographically examined 104 patients with RA whose age ranged from 21 to 78 years (mean, 51.0). In each, the duration of RA exceeded 10 years (mean, 17.7 years).

OUTCOME MEASURES

Clinical outcomes included Ochi's classification, Lansbury index, C-reactive protein (CRP) (mg/dL), rheumatoid factor (RF) (U/mL), and platelet (count/mm). Radiological outcomes included radiography and MRI.

METHODS

One hundred four RA patients were included in this study regardless of the presence/absence of low back pain. We examined discs from L1-2 to L5-S, including endplates, in each patient on plain X-ray films and magnetic resonance images and used a comprehensive grading system to evaluate each feature of the lumbar spine affected by RA based on the present findings and published reports. The correlations of these radiological features with RA activity and Ochi's classification were examined. To quantify disease activity, we determined the Lansbury index, serum CRP (mg/dL), RF (U/mL), and platelet count (count/mm) at the time of radiological examinations.

RESULTS

Of the 104 patients, 47 (45.2%) exhibited a lumbar lesion. There were two types of lumbar disc lesions related to RA: disc narrowing and disc ballooning. The Lansbury index of patients with the most severe lesions was significantly higher than that of patients with less severe lesions (p<.01). The frequency of lumbar involvement also increased as the number of affected peripheral joints increased, and Ochi's classification appeared to be useful in predicting the occurrence of lumbar lesions.

CONCLUSION

Of 104 patients, 47 (45.2%) exhibited abnormalities on X-ray films and MRI. There were two types of disorders, disc narrowing and disc ballooning. Both the Lansbury index and Ochi's classification reflected the severity of lumbar lesions in RA patients.

Lumbar fusion outcomes in patients with rheumatoid arthritis

Although outcomes after cervical fusion in rheumatoid arthritis (RA) patients are widely published, outcomes of lumbar fusion in RA patients has not been reported. Nineteen patients with RA, identified using ICD-9 and CPT codes, who underwent instrumented posterolateral lumbar fusion were matched for age, gender, smoking status, date, and level of surgery to a contemporaneous non-RA group. Medical records and radiographs were reviewed by the primary author who had no role in the treatment of these patients. The average age was 64 years in the RA group and 65 years in the non-RA group. The male to female ratio was 2:17 and 1:18, respectively. There were three smokers and two diabetics in each group. An average of 1.5 levels was fused in each group. Average follow-up was 24 and 27 months, respectively. In the RA group, 15 patients were taking DMARDs with 7 of those also taking oral steroids; 4 patients were taking NSAIDs only. There were seven complications (37%) in the RA group versus four (21%) in the non-RA group; wound infections in three patients (16%) in the RA group versus one (5%) in the non-RA group; and non-union in two patients (11%) in the RA group versus three (16%) in the non-RA group. Clinical outcomes were similar between the two groups with 74% of patients achieving good to excellent results in the RA group compared to 63% in the non-RA group (p = 0.692). Surgeons and their RA patients who undergo an instrumented lumbar fusion can expect a slightly higher complication rate than patients without RA which may be related to osteopenia and immunosuppression.

[Radiological characteristics of the lumbar spine in patients with rheumatoid arthritis]

AIM

The aim of this study was to assess the prevalence and severity of lumbar lesions on radiography of patients with rheumatoid arthritis (RA) and of population controls and to study the correlation between lumbar lesions and RA severity.

METHODS

RA patients who met the revised American College of Rheumatology criteria were matched with population controls for age, sex, and the presence (or absence) of low back pain. Thoracolumbar radiographs were read by two observers looking for vertebral fractures, disc space narrowing, endplate erosion, facet joint involvement, and osteophytosis. A severity score was assigned to each lesion.

RESULTS

This study included 60 RA patients and 60 controls, matched for sex (54 women and 6 men in each group) and age (mean age was 47.8+/-14 years in the RA group and 48.4+/-14 years in the control group). Prevalence of lumbar lesions was 83% in RA patients and 85% in the control subjects (p=0.8). Vertebral fractures were significantly more frequent in RA patients (p=0.042). In the RA group, disc space narrowing and the severity of endplate erosion were both correlated with higher Larsen grades (p=0.02 and 0.007 respectively), and the severity of endplate erosion was correlated with coxitis (p=0.03).

DISCUSSION

In our study, radiological lumbar lesions, except for vertebral fractures, were no more common among RA patients than among population controls. Endplate erosion and vertebral disc destruction were correlated with RA severity scores.

Posterior spinal shortening for paraparesis following vertebral collapse due to osteoporosis

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To assess the efficacy of posterior spinal shortening for paraparetic patients following vertebral collapse owing to osteoporosis, especially on instrumentation loosening.

SETTING

Department of orthopaedic surgery, Jichi Medical University Hospital and Omiya Medical Center in Japan.

METHODS

The clinical records and radiographs of 13 patients with paraparesis following vertebral collapse owing to osteoporosis treated with posterior spinal shortening were retrospectively reviewed to evaluate the usefulness of this method. Assessment of the clinical course was done by direct examination in all cases. Ambulatory ability was divided into four categories.

RESULTS

Upon final observation, nine cases were able to walk with a cane or crutch, one case remained in gait training, two cases remained unable to stand and one case with urinary incontinence improved in urinary function. In one case, paralysis deteriorated. Vertebral compression fracture of the end vertebrae that were fixed occurred in three cases complicated with rheumatoid arthritis.

CONCLUSION

The posterior spinal shortening can be a choice for treating delayed paraparesis following vertebral collapse owing to osteoporosis.

Upper thoracic myelopathy caused by vertebral collapse and subluxation in rheumatoid arthritis: report of two cases

We report two cases of rheumatoid arthritis (RA) with upper thoracic myelopathy and a review of the literature. Clinical data of a 47-year-old woman (case 1) and a 54-year-old woman (case 2) are described. Case 1 showed a transverse-type myelopathy at the T2 segment level of the spinal cord and case 2 had the same type of myelopathy at the T4 segment level. Case 1 had anterior vertebral subluxation of C7 due to marked vertebral collapse and Case 2 had subluxation of T2 with vertebral destruction. These two patients had the mutilating type of RA with multilevel spontaneous fusion in the cervical spine. The lesions in the thoracic spine might be caused by the severe destructive inflammation that is characteristic in mutilating disease. The vertebral collapse might lead to subluxation of the upper thoracic vertebra, resulting in spinal cord compression. Upper thoracic subluxation might be caused by vertebral collapse due to RA and the increased motion as a compensation for decreased mobility caused by spontaneous fusion in the cervical spine.