Predictive Risk Factors of Cervical Spine Instabilities in Rheumatoid Arthritis: A Prospective Multicenter Over 10-Year Cohort Study

Atlantoaxial Instability in the Course of Rheumatoid Arthritis in Relation to Selected Parameters of Sagittal Balance

Background: Atlantoaxial instability is the most common cervical instability in patients with rheumatoid arthritis (RA). Its course may differ in different patients and may have different degrees of severity and symptoms. Methods: There are a number of studies on systemic factors associated with the development of this instability, but there are few publications in the scientific literature on the influence of biomechanical factors on the development of cervical instability. One of the areas that allows the study of biomechanical factors influencing spine pathologies is the analysis of sagittal balance using radiological parameters. The study of radiological parameters of sagittal balance has contributed to understanding the pathology of selected spine diseases and is currently an indispensable tool in planning surgical treatment. Results: The presented study, conducted on a group of RA patients with cervical instability, was performed to look for a relationship between C1-C2 instability and sagittal balance parameters. Conclusions: Among the examined selected parameters, a statistically relationship between C1-C2 instability and the Cobb angle C1-C7 and OD-HA parameters has been found. This confirms the need for further in-depth research on this areas.

Effects of video-based cervical stabilization home exercises in patients with rheumatoid arthritis: a randomized controlled pilot study

OBJECTIVE

This study aimed to examine the effects of a remote video-based cervical stabilization exercise program on cervical proprioception, functional status, and disease-related quality of life in patients with rheumatoid arthritis (RA).

DESIGN

Patients with RA were evaluated regarding cervical joint positioning error, cervical region functional status (Neck Disability Index), general functional status (Health Assessment Questionnaire), and disease-related quality of life (Rheumatoid Arthritis Quality of Life Scale). Patients were randomized to exercise (n = 14, 10 female) and control (n = 12, 9 female) groups. Patients in the exercise group performed a video-based home exercise program consisting of progressive cervical stabilization exercises three times a week for six weeks in addition to their routine medication. The patients in the control group continued their routine medication only. Evaluations were repeated in both groups in the seventh week following the baseline evaluation.

RESULTS

Groups were similar at baseline (p > 0.05). Patients in both groups had low disease activity (DAS-28 CRP ≤ 3.2). The remote video-based exercise program led to significant improvements in cervical proprioception, functional status, and disease-related quality of life (p < 0.05). No significant changes were detected in any parameters in the control group (p > 0.05). Obtained changes were superior in the exercise group compared to the control group (d > 1.00, p < 0.05).

CONCLUSION

Cervical stabilization exercises may increase cervical proprioception, improve functional status, and enhance disease-related quality of life in patients with RA when administered as a remote program.

TRIAL NUMBER

https://clinicaltrials.gov/study/NCT04948775 , NCT04948775.

Risk factors for cervical instability in rheumatoid arthritis: a meta-analysis

Introduction

The aim of the study was to evaluate the risk factors for cervical instability in rheumatoid arthritis (RA).

Material and methods

Computer searches were conducted in PubMed, Embase, Cochrane Library, the China National Knowledge Infrastructure (CNKI) database, the Wan Fang database, the Chinese Scientific Journal Databases (VIP) database, and the Chinese Biomedical Literature database (CBM) from their establishment until November 2022.

Results

A total of 8 articles were included in this study, including 1 cross-sectional study, 5 case-control studies, and 2 cohort study, including 3078 patients with RA. Meta-analysis results showed that: male sex (OR = 1.70, 95% CI: 1.19-2.42), course of disease (OR = 1.72, 95% CI: 1.29-2.28), long-term glucocorticosteroid use (OR = 2.84, 95% CI: 1.97-2.40), Steinbrocker staging (OR = 2.30, 95% CI: 1.61-3.28), disability at baseline (OR = 24.57, 95% CI: 5.51-109.60), peripheral joint destruction (OR = 2.24, 95% CI: 1.56-3.21), Steinbrocker stage I-IV progression to disability (OR = 20.08, 95% CI: 4.18-96.53), and previous joint surgery (OR = 1.54, 95% CI: 1.06-2.26) are the main risk factors for cervical instability in RA.

Conclusions

There are many risk factors for cervical instability in RA. In clinical practice, special attention should be paid to patients who are male, have a longer course of disease, have long-term glucocorticosteroid use, have previous joint surgery, have peripheral joint damage, and develop disability in Steinbrocker stage I-IV. Attention should be paid to the high-risk groups mentioned above, and effective measures such as early screening and full monitoring should be taken to prevent the occurrence of cervical instability in RA.

Relationship between Cervical Instability in the Course of Rheumatoid Arthritis and Pelvic Parameters of Sagittal Balance

BACKGROUND

The aim of the study is to search for a relationship between cervical instability in the course of rheumatoid arthritis (RA) and pelvic parameters of sagittal balance and lumbar lordosis (LL).

METHODS

The study included 47 patients with rheumatoid arthritis with instability of the cervical segment, who were referred for a consultation to assess indications for surgical treatment. The patients underwent a radiological functional examination of the cervical region and postural examination of the entire spine. The basic parameters of the lumbar section and pelvis of these patients were compared with the population values. Then, using statistical methods, the correlation between radiological parameters of various types of instability and lumbar lordosis (LL), pelvic parameters (PI, SS, PT), as well as the patient's age and duration of the disease was assessed.

RESULTS

A statistical correlation was found between the instability in the cervical spine C2-C3 level and the value of the PT and PI angles. A statistically significant correlation was discovered between C1-C2 instability and younger patient age. There was no significant difference in the values of the pelvic parameters and lumbar lordosis in patients with rheumatoid arthritis compared to the population values.

CONCLUSIONS

Preliminary results suggest that there is a relationship between selected pelvic parameters and the development of instability in patients with rheumatoid arthritis. This may be important in planning treatment and assessing disease progression. Further studies on a larger group of patients are needed, as well as studies evaluating the correlation between other sagittal balance parameters and cervical instability in patients with RA.

Predictors factors of atlanto-axial subluxation in Tunisian patients with rheumatoid arthritis

BACKGROUND

The aim of this study was to describe clinical and imaging features of atlantoaxial subluxation (AAS) and the associated risk factors in patients with rheumatoid arthritis (RA).

METHODS

We conducted a retrospective and comparative study including 51 RA patients with AAS and 51 RA patients without AAS. Atlantoaxial subluxation was defined by the presence of an anterior C1C2 diastasis on the cervical spine radiograph in hyperflexion and/or an anterior, posterior, lateral or rotatory C1C2 dislocation on MRI with/without inflammatory signal.

RESULTS

In G1, clinical presentations revealing AAS were mainly neck pain (68.7%) and neck stiffness (29.8%). MRI revealed: diastasis C1C2 (92.5%), periodontoid pannus (92.5%), odontoid erosion (23.5%), vertical subluxation (9.8%) and spinal cord involvement (7.8%). A collar immobilisation and corticosteroid boluses were indicated in 86.3% and 47.1% of cases. C1-C2arthrodesis was performed in 15.4% of cases. Atlantoaxial subluxation was significantly associated with: age at disease onset (p = 0.009), history of joint surgery (p = 0.012), disease duration (p = 0.001), rheumatoid factor (p = 0.01), anti-cyclic citrullinated peptide (p = 0.02), erosive radiographic status (p < 0.005), coxitis (p < 0.001), osteoporosis (p = 0.012), extra-articular manifestations (p < 0.001), and high disease activity (p = 0.001). Multivariate analysis identified RA duration (p < 0.001, OR = 1.022 CI[1.01-1.034]) and erosive radiographic status (p = 0.01, OR = 21.236 CI[2.05-219.44]) as predictive factors of AAS.

CONCLUSION

Our study showed that longer disease duration and joint destruction are the major predictive factors of AAS. Early treatment initiation, tight-control and regular monitoring of cervical spine involvement are required in these patients.

Clinical and Radiological Characteristics of Cervical Spondylotic Myelopathy in Young Adults: A Retrospective Case Series of Patients under Age 30

Background and Objectives: Cervical spondylotic myelopathy (CSM) is a degenerative disease and occurs more frequently with age. In fact, the development of non-herniated CSM under age 30 is uncommon. Therefore, a retrospective case series was designed to clarify clinical and radiological characteristics of young adult patients with CSM under age 30. Materials and Methods: A total of seven patients, all men, with non-herniated, degenerative CSM under age 30 were retrieved from the medical records of 2598 hospitalized CSM patients (0.27%). Patient demographics and backgrounds were assessed. The sagittal alignment, congenital canal stenosis, dynamic canal stenosis, and vertebral slips in the cervical spine were radiographically evaluated. The presence of degenerative discs, intramedullary high-signal intensity lesions, and sagittal spinal cord compression on T2-weighted magnetic resonance images (MRIs) and axial spinal cord deformity on T1-weighted MRIs was identified. Results: All patients (100.0%) had relatively high daily sports activities and/or jobs requiring frequent neck extension. Cervical spine radiographs revealed the sagittal alignment as the “reverse-sigmoid” type in 57.1% of patients and “straight” type in 28.6%. All patients (100.0%) presented congenital cervical stenosis with the canal diameter ≤12 mm and/or Torg–Pavlov ratio <0.80. Furthermore, all patients (100.0%) developed dynamic stenosis with the canal diameter ≤12 mm and/or posterior vertebral slip ≥2 mm at the neurologically responsible segment in full-extension position. In MRI examination, all discs at the neurologically responsible level (100.0%) were degenerative. Intramedullary abnormal intensity lesions were detected in 85.7% of patients, which were all at the neurologically responsible disc level. Conclusions: Patients with non-herniated, degenerative CSM under age 30 are rare but more common in men with mild sagittal “reverse-sigmoid” or “straight” deformity and congenital canal stenosis. Relatively high daily activities, accumulating neck stress, can cause an early development of intervertebral disc degeneration and dynamic canal stenosis, leading to CSM in young adults.

Rheumatoid Diseases Involving the Cervical Spine I. History, Definition, and Diagnosis: New Trends and Technologies

The cervical spine might be involved in several conditions: congenital, traumatic, and chronic inflammatory and or degenerative rheumatic disorders. Among the inflammatory rheumatic conditions that can affect the cervical spine, rheumatoid arthritis (RA) is the most common, affecting up to 86% of patients and leading to cervical spine instability and subsequent myelopathy. Other inflammatory diseases include juvenile idiopathic arthritis (JIA) and the spondyloarthritis group (SpA), including psoriatic arthritis. Since many patients do not show symptoms of cervical involvement, diagnosis is often delayed. Radiographs are the first line imaging modality used to detect such involvement, but MRI and CT are superior in terms of early diagnosis and surgical planning.In this review, we provide an overview of cervical involvement in RA, JIA, and SpA.

Rheumatoid Arthritis in Spine Surgery: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVE

The purpose of this study is to synthesize recommendations for perioperative medical management of RA patients and quantify outcomes after spine surgery when compared to patients without RA.

METHODS

A search of available literature on patients with RA and spine surgery was performed. Studies were included if they provided a direct comparison of outcomes between patients undergoing spine surgery with or without RA diagnosis. Meta-analysis was performed on operative time, estimated blood loss, hospital length of stay, overall complications, implant-related complications, reoperation, infection, pseudarthrosis, and adjacent segment disease.

RESULTS

Included in the analysis were 9 studies with 703 patients with RA undergoing spine surgery and 2569 patients without RA. In RA patients compared to non-RA patients undergoing spine surgery, the relative risk of infection was 2.29 times higher (P = .036), overall complications 1.61 times higher (P < .0001), implant-related complications 3.93 times higher (P = .009), and risk of reoperation 2.45 times higher (P < .0001). Hospital length of stay was 4.6 days longer in RA patients (P < .0001).

CONCLUSIONS

Treatment of spinal pathology in patients with RA carries an increased risk of infection and implant-related complications. Spine-specific guidelines for perioperative management of antirheumatic medication deserve further exploration. All RA patients should be perioperatively co-managed by a rheumatologist. This review helps identify risk profiles in RA specific to spine surgery and may guide future studies seeking to medically optimize RA patients perioperatively.

Pathoanatomy, biomechanics, and treatment of upper cervical ligamentous instability: A literature review

BACKGROUND

Cervical spine instability broadly refers to compromise of the articular congruity. It can be stratified according to spinal level, functional compromise, and mechanism of instability. Conventional wisdom advocates for use of bracing and physical therapy with only a subset of patients proceeding to obtain surgical treatment.

OBJECTIVE

The purpose of this review article is to summarize the current state of knowledge on upper cervical ligamentous instability.

METHODS

The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. The full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by 3 authors until an agreement was reached.

RESULTS

Many articles report on the etiological factors including ligamentous laxity, traumatic injury, syndrome instability, iatrogenic instability, congenital, and inflammatory causes. A few recent studies elucidate new findings regarding pathoanatomy through the use of finite element analysis. A few articles demonstrate the diagnosis and show that radiographs alone have a low diagnostic rate and that functional MRI may be able to better quantify instability. Conservative treatment has been described, but there are no outcome studies in the literature. Surgical treatment has been described in many different populations with good radiologic and clinical outcomes. Recently the use of preoperative 3D CT reconstruction has been described with radiographic and immediate postoperative patient-reported outcomes.

CONCLUSION

The presentation of upper cervical spinal instability can be asymptomatic, symptoms of isolated instability, symptoms of nerve irritation, vertebrobasilar insufficiency, or severe neurologic compromise. 3D fine element analysis models and motion-capture systems have the potential to increase our understanding of the pathoanatomic cascade in both traumatic and non-traumatic cases of upper cervical spinal instability. A few modalities on the horizon could increase diagnostic potential. More efforts are needed regarding the use of fine element analysis in understanding the pathoanatomic cascade, the long-term outcomes of children over a spectrum of syndromic causes, and the potential of preoperative virtual simulation to improve surgical outcomes.

Update on imaging of the cervical spine in rheumatoid arthritis

Rheumatoid arthritis is a multisystem, autoimmune, inflammatory disorder with numerous musculoskeletal manifestations. Involvement of the cervical spine is common and may result in severe complications due to synovitis, erosions, pannus formation, spinal instability and ankylosis. The purpose of this article is to review the current role of imaging in the rheumatoid spine, with emphasis on radiographs and MRI.

Recurrent Cervical Subdural Bleeding Because of Atlantoaxial Instability in a Patient with Rheumatoid Arthritis: A Case Report

CASE

Atlantoaxial instability (AAI) is a frequent complication of rheumatoid arthritis (RA), but its involvement in intracranial bleeding is unclear. We present a young woman with history of systemic lupus erythematosus and RA who developed 3 episodes of subdural bleeding at the upper cervical spine and cranial level. Imaging tests showed signs of AAI with odontoid deformity. The case was interpreted as recurrent traumatic cervical subdural hemorrhage because of AAI. No new episodes occurred after surgical C1-C2 fixation.

CONCLUSION

We report a case that had the association of hemorrhage and C1-2 instability in a patient with RA and lupus erythematosus.

Risk Factors Associated with Aggravation of Cervical Spine Lesions in Patients with Rheumatoid Arthritis: A Retrospective Longitudinal Cohort Study

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To examine factors related to severe aggravation of preexisting cervical lesions in patients with rheumatoid arthritis (RA) under current pharmacologic treatments with biologics.

SUMMARY OF BACKGROUND DATA

Advanced RA cervical lesions carry a risk of irreversible damage to the spinal cord; however, risk factors for aggravation are unclear after the use of biologics became more popular.

METHODS

Of 166 patients with preexisting cervical lesions at baseline, 87 who had cervical X-ray images taken at baseline and at the final visit (with an interval of more than 1 yr) were evaluated retrospectively. Aggravated instabilities determined at the final visit, were defined as follows: atlantoaxial subluxation (AAS) = atlantodental interval ≧ 10 mm; vertebral subluxation (VS) = a Ranawat value < 10 mm; and subaxial subluxation (SAS) = an anterior vertebral slip ≧ 4 mm or a multilevel slip ≧ 2 mm. Patients were divided into two groups based on the radiographic results: severe aggravation and non-severe aggravation. Explanatory variables were gender, age of RA onset, duration of disease, average observation period, Disease Activity Score 28 based on C-reactive protein (DAS28-CRP) at baseline, drug treatment history, presence of mutilating deformities in the hands, presence of RA-related joint surgery, and the prevalence of each cervical lesion at baseline.

RESULTS

The severe group comprised 14 patients (16.1%). There was no significant difference between the two groups with respect to demographic data. Multivariate logistic regression analysis revealed that preexisting SAS lesions (odds ratio: 7.59, 95% confidence interval: 1.16-49.6) and no history of biologic treatment (odds ratio, 0.10; 95% confidence interval, 0.17-0.58) were associated with aggravation.

CONCLUSION

Preexisting SAS lesions were associated with aggravation. Meanwhile, biologics may be effective at preventing aggravation.Level of Evidence: 3.

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 associated with cervical spine lesions in patients with rheumatoid arthritis: an observational study

Background

Few reports have described the association between rheumatoid arthritis (RA) cervical lesions and osteoporosis, especially in patients with vertical subluxation (VS) that could be induced by the collapse of lateral masses in the upper cervical spine. Therefore, this study aimed to investigate the prevalence and risk factors for cervical lesions in patients with RA under current pharmacological treatments with biological agents, and to investigate the relationship between osteoporosis and VS development.

Methods

One hundred eighty-five consecutive patients with RA who underwent both cervical plain radiography and bone mineral density (BMD) scanning were enrolled. RA cervical lesions included atlantoaxial subluxation (AAS), VS, and subaxial subluxation (SAS). We assigned patients with AAS, VS, or SAS to the cervical-lesion group, and all other patients to the non-cervical-lesion group. Radiological findings, BMD, and clinical data on RA were collected. We used multivariate logistic regression analyses to assess the risk factors for cervical lesions in patients with RA.

Results

The cervical-lesion and non-cervical-lesion groups included 106 and 79 patients, respectively. There were 79 patients with AAS, 31 with VS, and 41 with SAS. The cervical-lesion group had a younger age of RA onset, longer RA disease duration, higher RA stage, and lower femoral neck BMD than the non-cervical-lesion group. Multivariate analyses showed that the risk factors for RA cervical lesions were prednisolone usage, biological agent usage, and higher RA stage. Prednisolone usage and femoral neck BMD were the risk factors for VS.

Conclusions

Cervical lesions were confirmed in 57 % of the patients. Prednisolone usage, biological agent usage, and higher RA stage were significant risk factors for cervical lesions in patients with RA. The general status of osteoporosis might contribute to the development of VS.

Cervical Spinal Fusion in Adult Patients With Rheumatoid Arthritis: A National Analysis of Complications and 90-day Readmissions

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study was to utilize the National Readmission Database to determine the national estimates of complication and 90-day readmission rates associated with cervical spinal fusion in adult patients with rheumatoid arthritis (RA).

SUMMARY OF BACKGROUND

RA patients who undergo cervical spine surgery are known to be at high risk for readmissions, which are costly and may not be reimbursed by Medicare.

METHODS

The National Readmission Database was queried for adults (>18 years) diagnosed with RA undergoing cervical spine fusion. Patient, operative, and hospital factors were assessed in bivariate analyses. Independent risk factors for readmissions were identified using stepwise multivariate logistic regression.

RESULTS

From 2013 to 2014, a total of 5597 RA patients (average age: 61.5 ± 11.2 years, 70.9% female) underwent cervical spine fusion. A total of 691 (12.3%) patients were readmitted within 90 days (). Index inpatient complications included dysphagia (readmitted: 7.9% vs. non-readmitted: 5.1%; P = 0.003), urinary tract infection (UTI) (8.8% vs. 3.7%; P < 0.001), respiratory-related complications (7.6% vs. 3.4%; P < 0.001), and implant-related complications (5.4% vs. 2.7%; P < 0.001). Multivariate logistic regression demonstrated the following as the strongest independent predictors for 90-day readmission: intraoperative bleeding (odds ratio [OR]: 3.6, P = 0.001), inpatient Deep Vein Thrombosis (DVT) (OR 4.1, P = 0.004), and patient discharge against medical advice (OR 33.5, P = 0.001).

CONCLUSION

Readmission rates for RA patients undergoing cervical spine surgery are high and most often due to postoperative infection (septicemia, UTI, pneumonia, wound). Potential modifiable factors which may improve outcomes include minimizing intraoperative blood loses, postoperative DVT prophylaxis, and discharge disposition.

LEVEL OF EVIDENCE

3.

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.

Cervical spine manifestations of rheumatoid arthritis: a review

Rheumatoid arthritis (RA) is a progressive autoimmune inflammatory disease affecting 1% of the population with three times as many women as men. As many as 86% of patients suffering from RA have cervical spine involvement. Synovial inflammation in the cervical spine causes instability and injuries including atlantoaxial subluxation, retroodontoid pannus formation, cranial settling, and subaxial subluxation. While many patients with cervical spine involvement are asymptomatic, symptomatic patients often present with nonspecific symptoms resulting from inflammation and additional secondary symptoms that are due to compression of the brainstem, cranial nerves, vertebral artery, and spinal cord. Radiographs are the imaging modality used most often, while MRI and CT are used for assessment of neural element involvement and surgical planning. Multiple classification systems exist. Early diagnosis and treatment of cervical spine involvement is critical. Surgical management is indicated when patients experience symptoms from cervical involvement that result in biomechanical instability and, or a neurological deficit. Atlantoaxial instability managed with atlantoaxial fusion, retroodontoid pannus with neural element compression is managed with posterior decompression and atlantoaxial fusion or occipitocervical fusion. Cranial settling is managed can be managed with anterior decompression and posterior fusion or with dorsal only approaches. Subaxial subluxation is managed with circumferential fusion or posterior only decompression and fusion. Patients with atlantoaxial instability have better functional and neurologic outcomes. RA patients have higher complication rates and more frequent need for revision surgery than the general population of spine surgery patients.

Inflammatory Manifestations of Systemic Diseases in the Central Nervous System

PURPOSE OF REVIEW

This review presents the current recommended therapeutic interventions for inflammatory disease in the central nervous system (CNS) secondary to systemic diseases of immune dysregulation. Treatment recommendations for CNS inflammation associated with rheumatologic conditions, immune-related adverse effects from immune checkpoint inhibitors (ICIs), and demyelinating disease from tumor necrosis factor-α (anti-TNFs) are explored. Additional therapeutic options for inflammation related to postviral syndromes and genetic immunodeficiencies are also discussed.

RECENT FINDINGS

In addition to treatment of mild, moderate, and severe CNS rheumatologic disease as guided by the European League Against Rheumatism (EULAR), early consideration of rituximab for severe IgG4-related disease and induction with anti-TNF therapy for severe neurosarcoidosis should be considered. Although often not first line, treatment options for CNS inflammatory diseases based on disease mechanism are emerging, including tocilizumab for Behcet's disease, natalizumab for ICI associated autoimmune encephalitis, and abatacept for treatment of infiltrative disease secondary to CTLA-4 deficiency. Hematopoietic stem cell treatments represent highly efficacious but risky options for autoimmunity related to genetic immunodeficiency.

SUMMARY

While early high dose steroids remains first line therapy for most CNS inflammatory conditions, a rapidly expanding arsenal of immune targeted therapies offers clinicians tailored disease specific options for treatment.

Risk factors for cervical spine instability in patients with rheumatoid arthritis

INTRODUCTION

Cervical spine (C-spine) instability is a unique and significant characteristic of rheumatoid arthritis (RA) because its occurrence is not rare and it can cause compressive cervical myelopathy, which may lead to serious neurologic sequelae. This study evaluated the prevalence and risk factors of C-spine instabilities in RA patients with a focus on anti-citrullinated protein antibody (ACPA) and biologic disease-modifying antirheumatic drug (DMARD) therapies.

METHODS

The presence of C-spine instabilities in 1114 patients with RA was evaluated using C-spine radiographies according to the defined metrics. Multivariable logistic regression analyses were performed to identify independent predictors of C-spine instability. The initiation of biologic DMARDs was assessed via a Kaplan-Meier analysis and compared using log-rank tests.

RESULTS

In total, 306 (27.5%) patients presented with C-spine instabilities. The most common type was atlantoaxial subluxation (AAS; n = 199 [17.9%]). Male sex, positivity for rheumatoid factor and ACPA, erosive change in the peripheral joints, and presence of osteoporosis were independently associated with C-spine instabilities (all P < 0.05). In particular, positivity for ACPA was the most powerful risk factor (odds ratio: 2.33 [95% confidence interval: 1.37, 3.96], P = 0.002), and it was closely associated with AAS. Patients with AAS were at a higher risk for early initiation of biologic DMARDs.

CONCLUSIONS

Positivity for ACPA was a significant risk factor for C-spine instability, and AAS was remarkably correlated to the early initiation of biologic DMARDs, a surrogate index of poor long-term outcomes. Key Points • The presence of antibodies against citrullinated proteins was a strong risk factor for C-spine instability in patients with rheumatoid arthritis. • Atlantoaxial subluxation was significantly associated with early initiation of biologic DMARDs, a surrogate index of poor long-term outcome.

Risk prediction of degenerative scoliosis combined with lumbar spinal stenosis in patients with rheumatoid arthritis: a case-control study

The purpose of this study is to compare incidence of degenerative scoliosis (DS) in patients who diagnosed lumbar spinal stenosis (LSS) with or without rheumatoid arthritis (RA) and identify the risk factors of DS severity in RA patients. 61 LSS patients with RA (RA group) and 87 demographic-matched LSS patients without RA (NoRA group) from January 2013 to April 2018 were enrolled. The extracted information includes RA-related parameters such as Steinbrocker classification, disease-modifying anti-rheumatic drugs (DMARDs), and DS-related information such as Cobb angle, apical vertebra, along with osteoporosis and history of total knee arthroplasty (TKA). Comparisons between RA and NoRA group and between DS and non-DS subgroup with RA were performed, as well as the risk factors on DS severity in RA patients. The incidence of DS in RA group was 42.6%, larger than that of NoRA group (P = 0.002). The mean Cobb angle between the two groups was of no difference (P = 0.076). The apical vertebrae were both mainly focused on L3 and L4 vertebrae in both groups with no significant difference on the distribution of apical vertebrae (P = 0.786). Female took a larger proportion in DS subgroup than that of NoDS subgroup in patients with RA (P = 0.039), while Steinbrocker classification was irrelevant to the occurrence of DS and Cobb angle. Multiple regression analysis showed that TKA was a risk factor for the severity of Cobb angle (P = 0.040). The incidence of DS in LSS patients with RA is higher than non-RA patients. RA patients performed TKA sustained less severity of DS.

Cervical Myelopathy in Patients Suffering from Rheumatoid Arthritis-A Case Series of 9 Patients and A Review of the Literature

Cervical myelopathy occurs in approximately 2.5% of patients suffering from rheumatoid arthritis (RA) and is associated with notable morbidity and mortality. However, the surgical management of patients affected by cervical involvement in the setting of RA remains challenging and not well studied. To address this, we conducted a retrospective analysis of our clinical database between May 2007 and April 2017, and report on nine patients suffering from cervical myelopathy due to RA. We included patients treated surgically for cervical myelopathy on the basis of diagnosed RA. Clinical findings, treatment and outcome were assessed and reported. In addition, we conducted a narrative review of the literature. Four patients were male. Mean age was 64.8 ± 20.5 years. Underlying cervical pathology was anterior atlantoaxial instability (AAI) associated with retrodental pannus in four cases, anterior atlantoaxial subluxation (AAS) in two cases and basilar invagination in three cases. All patients received surgical treatment via posterior fixation, and in addition two of these cases were combined with a transnasal approach. Preoperative modified Japanese orthopaedic association scale (mJOA) improved from 12 ± 2.4 to 14.6 ± 1.89 at a mean follow-up at 18.8 ± 23.3 months (range 3-60 months) in five patients. In four patients, no follow up was available, and the mJOA of these patients at time of discharge was stable compared to the preoperative score. One patient died two days after surgery, where a pulmonary embolism was assumed to be the cause of mortality, and one patient sustained a temporary worsening of his neurological deficit postoperatively. Surgery is generally an effective treatment method in patients with inflammatory arthropathies of the cervical spine. Given the nature of the RA and potential instability, fixation in addition to cord decompression is generally required.

Cervical Spine Involvement among Patients with Rheumatoid Arthritis Treated Actively with Treat-to-target Strategy: 10-year Results of the NEO-RACo Study

Objective.

To evaluate the development of radiological changes of the cervical spine in patients with rheumatoid arthritis (RA) in the NEO-RACo trial treated with an intensive, remission-targeted combination of conventional synthetic disease-modifying antirheumatic drugs (csDMARD) and additional infliximab (IFX) or placebo (PLA) for the first 6 months.

Methods.

Ninety-nine patients with early, DMARD-naive RA were treated with a triple combination of csDMARD and prednisolone, and randomized to double-blindly receive either IFX (FIN-RACo+IFX) or PLA (FIN-RACo+PLA) infusions during the first 6 months. After 2 years the treatment strategies became unrestricted, but the treatment goal was strict NEO-RACo remission. At the 10-year visit, radiographs of the cervical spine were taken of 85 patients (38 in the FIN-RACo+IFX group and 47 in the FIN-RACo+PLA group). The study was registered at ClinicalTrials.gov (NCT 00908089).

Results.

There were 4/85 patients (4.7%) with cervical spine involvement (CSI) by 10 years. Atlantoaxial subluxation was found in 2/85 patients (2.4%), both in the FIN-RACo+IFX group, and none in the FIN-RACo+PLA group. Atlantoaxial impaction was found in 1/85 patients (1.2%) in the FIN-RACo+IFX group. Subaxial subluxation was found in 1/85 patients (1.2%).

Conclusion.

Early and intensive remission-targeted treatment has reduced the incidence of CSI and our results show that intensive treatment also prevents its development in the long run.

[Rheumatoid instability in the cervical spine : Diagnostic and therapeutic strategies]

BACKGROUND

The involvement of the cervical spine in rheumatoid arthritis (RA) continues to be of clinical importance even in this age of biologics. Pathophysiological changes begin with an isolated atlantoaxial subluxation and may progress to a complex craniocervical and subaxial instability. The onset of cervical myelopathy can occur at any time and leads to a deterioration of the prognosis for the patient.

THERAPY

Treatment of the rheumatoid cervical spine should be aimed at improvement of the symptoms and prevention of further progress of the disease. In the case of instability, this is only possible by surgical treatment. The increasing usage of biological agents has led to a change in the clinical picture of the cervical involvement in RA patients. There are fewer patients presenting with isolated atlantoaxial instability. In contrast, the number of patients with complex craniocervical and/or subaxial instabilities is increasing. Complex cervical instabilities may require a longer fusion from the occiput to the upper thoracic spine. Modern operative techniques make this complex surgery also possible in severely disabled patients with a high comorbidity.

[Cervical spine involvement in rheumatoid arthritis : Diagnostics and treatment of instability due to rheumatism]

In addition to involvement of small peripheral joints, the cervical spine is the second most affected body region in rheumatoid arthritis (RA). Due to improvement of pharmaceutical treatment in recent years, new data show that there is a decreasing prevalence of cervical involvement; however, depending on the severity of cervical lesions surgical treatment still plays an important role. The sequelae of involvement of the cervical spine are craniocervical and atlantoaxial instability, which can cause severe pain, neural deficits and even death. Multimodal conservative treatment can lead to an alleviation of pain but in cases of therapy-resistant pain or neural deficits surgical treatment alone is essential to improve patient outcome. For isolated atlantoaxial instability (AAS), atlantoaxial fusion by posterior C1-2 fixation according to Harms and Goel is the method of choice. Posterior stabilization including C0 should be avoided whenever possible due to substantial limitations in range of movement.

Comparison of adult spinal deformity patients with and without rheumatoid arthritis undergoing primary non-cervical spinal fusion surgery: a nationwide analysis of 52,818 patients

BACKGROUND CONTEXT

Numerous studies have analyzed the impact of rheumatoid arthritis (RA) on the cervical spine and its related surgical interventions. However, there is a paucity of literature available conducting the same analyses in patients with non-cervical spine involvement.

PURPOSE

The objective of this study was to compare patient characteristics, comorbidities, and complications in patients with and without RA undergoing primary non-cervical spinal fusions.

STUDY DESIGN/SETTING

This is a retrospective national database review.

PATIENT SAMPLE

A total of 52,818 patients with adult spinal deformity undergoing non-cervical spinal fusions (1,814 patients with RA and 51,004 patients without RA).

OUTCOME MEASURES

The outcome measures in the study include patient characteristics, as well as complication and mortality rates.

MATERIALS AND METHODS

Using the Nationwide Inpatient Sample from 2003 to 2014, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes were used to identify patients aged ≥18 years old with and without RA undergoing primary non-cervical spinal fusions. Univariate analysis was used to determine patient characteristics, comorbidities, and complication values for each group. Bivariate analysis was used to compare the two groups. Significance was set at p<.05.

RESULTS

Patients with RA were older (p<.001), were more likely to be women (p<.001), had increased rates of osteoporosis (p<.001), had a greater percentage of their surgeries reimbursed by Medicare (p<.001), and more often had weekend admissions (p=.014). There was no difference in all the other characteristics. Patients with RA had higher rates of iron deficiency anemia, congestive heart failure, chronic pulmonary disease, depression, and fluid and electrolyte disorders (all, p<.001). Patients without RA had higher rates of alcohol abuse (p=.027). There was no difference in all the other complications. There was no difference in mortality rate (p=.99). Total complications were greater in patients with RA (p<.001). Patients with RA had higher rates of infection (p=.032), implant-related complications (p=.010), incidental durotomies (p=.001), and urinary tract infections (p<.001). No difference existed among the other complications.

CONCLUSIONS

Patients with RA have an increased number of comorbidities and complication rates compared with patients without RA. Such knowledge can help surgeons and patients with RA have beneficial preoperative discussions regarding outcomes.

Normative values for CT-based texture analysis of vertebral bodies in dual X-ray absorptiometry-confirmed, normally mineralized subjects

OBJECTIVES

To develop age-, gender-, and regional-specific normative values for texture analysis (TA) of spinal computed tomography (CT) in subjects with normal bone mineral density (BMD), as defined by dual X-ray absorptiometry (DXA), and to determine age-, gender-, and regional-specific differences.

MATERIALS AND METHODS

In this retrospective, IRB-approved study, TA was performed on sagittal CT bone images of the thoracic and lumbar spine using dedicated software (MaZda) in 141 individuals with normal DXA BMD findings. Numbers of female and male subjects were balanced in each of six age decades. Three hundred and five TA features were analyzed in thoracic and lumbar vertebrae using free-hand regions-of-interest. Intraclass correlation (ICC) coefficients were calculated for determining intra- and inter-observer agreement of each feature. Further dimension reduction was performed with correlation analyses.

RESULTS

The TA features with an ICC < 0.81 indicating compromised intra- and inter-observer agreement and with Pearson correlation scores r > 0.8 with other features were excluded from further analysis for dimension reduction. From the remaining 31 texture features, a significant correlation with age was found for the features mean (r = -0.489, p < 0.001), variance (r = -0.681, p < 0.001), kurtosis (r = 0.273, p < 0.001), and WavEnLL_s4 (r = 0.273, p < 0.001). Significant differences were found between genders for various higher-level texture features (p < 0.001). Regional differences among the thoracic spine, thoracic-lumbar junction, and lumbar spine were found for most TA features (p < 0.021).

CONCLUSION

This study established normative values of TA features on CT images of the spine and showed age-, gender-, and regional-specific differences in individuals with normal BMD as defined by DXA.