Natural history of rheumatoid cervical luxations

Automatic evaluation of atlantoaxial subluxation in rheumatoid arthritis by a deep learning model

BACKGROUND

This work aims to develop a deep learning model, assessing atlantoaxial subluxation (AAS) in rheumatoid arthritis (RA), which can often be ambiguous in clinical practice.

METHODS

We collected 4691 X-ray images of the cervical spine of the 906 patients with RA. Among these images, 3480 were used for training the deep learning model, 803 were used for validating the model during the training process, and the remaining 408 were used for testing the performance of the trained model. The two-dimensional key points' detection model of Deep High-Resolution Representation Learning for Human Pose Estimation was adopted as the base convolutional neural network model. The model inferred four coordinates to calculate the atlantodental interval (ADI) and space available for the spinal cord (SAC). Finally, these values were compared with those by clinicians to evaluate the performance of the model.

RESULTS

Among the 408 cervical images for testing the performance, the trained model correctly identified the four coordinates in 99.5% of the dataset. The values of ADI and SAC were positively correlated among the model and two clinicians. The sensitivity of AAS diagnosis with ADI or SAC by the model was 0.86 and 0.97 respectively. The specificity of that was 0.57 and 0.5 respectively.

CONCLUSIONS

We present the development of a deep learning model for the evaluation of cervical lesions of patients with RA. The model was demonstrably shown to be useful for quantitative evaluation.

A not-to-miss Cause of Severe Cervical Spine Pain in a Patient with Rheumatoid Arthritis: A Case-Based Review

Background:

Rheumatoid arthritis (RA) may affect any diarthrodial joint with a predilection on the peripheral skeleton in a symmetrical manner. When the axial skeleton is affected, it is the cervical spine (CS) that gets involved with potentially detrimental effects, if not treated promptly.

Case:

A 60-year-old female suffering from RA presented with severe neck pain and stiffness, difficulty of standing and walking with brisk tendon reflexes, Babinski sign positive, and clonus. Despite the high inflammatory markers and high titres of autoantibodies (rheumatoid factor and anticitrullinated protein antibodies), she never received proper treatment. She was using only paracetamol and non-steroidal anti-inflammatory drugs. Conventional radiography (CR) of CS showed extensive degenerative changes affecting the C3–C5 vertebral level. Magnetic Resonance Imaging of the neck showed sub-axial subluxation (SAS) and spinal cord compression at C3 level, and to a lesser extent, in other levels. A multi-level cervical laminectomy and spinal cord decompression were deployed with good results. To this end, literature review was performed until September 2020 and showed that the frequency of radiological findings varies substantially, ranging between 0,7–95% in different studies. The most common radiological feature is the atlanto-axial subluxation (AAS) followed by SAS. Because CS involvement can often be clinically asymptomatic, its assessment should not be forgotten by physicians and should be assessed using CR, which is an easy-to-perform technique and gives important information as a screening tool. On the other hand, RA patients need to be treated in a prompt and efficient manner in order to avoid any potentially fatal complications.

Changes in the incidence of cervical lesions owing to the development of rheumatoid arthritis treatment and the impact of cervical lesions on patients' quality of life

Objectives: To clarify changes in the incidence of cervical lesions in rheumatoid arthritis (RA) patients with advanced treatment and the impact of cervical lesions on the patients' quality of life (QOL).Methods: Incidence of radiographic cervical lesions in 1333 RA patients in 2015 was compared with that in our 1999 survey. The association between cervical lesions and QOL evaluated using three different patient-based questionnaires was also analyzed.Results: The incidence of atlantoaxial subluxation (AAS), vertical subluxation (VS), and subaxial subluxation (SAS) in 2015 decreased by 50%, 75%, and 5%, respectively, compared to the 1999 survey. Although QOL, evaluated using the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ; specific to myelopathy), deteriorated as the cervical lesion progressed, there was no association between cervical lesion progression and QOL evaluated using the Short Form-8™ (SF-8™; comprehensive health-related QOL). Cervical lesion progression was also associated with QOL deterioration evaluated using the Health Assessment Questionnaire Disability Index (HAQ-DI; specific to RA), but age and disease duration had stronger influences.Conclusion: The incidence of cervical lesions decreased in 2015 compared to 1999. Cervical lesion progression may be associated with QOL deterioration due to myelopathy. Age and disease duration have more impact on disease-specific QOL.

Ten-Year Results of Reconstruction for Rheumatoid Cervical Spine Lesions and Occurrence Factor of Subaxial Subluxation

Study Design

Retrospective chart review.

Purpose

This study evaluated long-term surgical outcomes of computer-assisted reconstruction using transarticular or cervical pedicle screws for cervical spine lesions caused by advanced rheumatoid arthritis (RA).

Overview of Literature

We routinely employ C1-C2 transarticular and cervical pedicle screw instrumentation to reconstruct advanced and unstable RA cervical lesions. However, few reports are available on the long-term results of surgical reconstruction for rheumatoid cervical disorders, particularly regarding cervical pedicle screw fixation.

Methods

Six subjects (all female) with RA cervical lesions who underwent atlantoaxial or occipitocervical fixation and were followed for at least 10 years were retrospectively studied. A frameless, stereotactic, optoelectronic, computed tomography-based image guidance system was used for correct screw placement. Variables including the Japanese Orthopaedic Association score, EuroQol, Ranawat value, and C2-C7 angle before and 2, 5, and 10 years after surgery were assessed along with the occurrence of subaxial subluxation (SAS).

Results

Mean age at initial surgery was 58.2±7 years (range, 51-68 years), and mean follow-up period was 141±11 months (range, 122-153 months). Lesions included atlantoaxial subluxation (AAS, n=2) and AAS+vertical subluxation (n=4). Mean C2-C7 lordotic angle before and 2, 5, and 10 years after surgery was 20.1°±6.1°, 21.0°±4.0°, 18.8°±4.7°, and 17.8°±5.3°, respectively. SAS did not occur in cases maintaining the C2-C7 lordotic angle. In two cases where the C2-C7 lordotic angle declined from 5 years postoperatively, SAS occurred at the C2-C3 level in one and at the C4-C5 level in the other, both of which required reoperation.

Conclusions

Patients with rheumatoid cervical lesions who undergo atlantoaxial or occipitocervical fixation using C1-C2 transarticular or pedicle screws carry a risk of SAS for up to 10 years postoperatively, which may require reoperation.

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

STUDY DESIGN

A prospective multicenter cohort study for more than 10 years of outpatients with rheumatoid arthritis (RA).

OBJECTIVE

To identify predictive risk factors of cervical spine instabilities, which may induce compression myelopathy in patients with RA.

SUMMARY OF BACKGROUND DATA

Many reports described the natural course of cervical spine involvement in RA. Only a few studies, however, conducted comprehensive evaluation of its prognostic factors.

METHODS

Cervical spine instability was radiographically defined as atlantoaxial subluxation with the atlantodental interval greater than 3 mm, vertical subluxation (VS) with the Ranawat value less than 13 mm, and subaxial subluxation with irreducible translation of 2 mm or higher. The "severe" category of instability was defined as atlantoaxial subluxation with the atlantodental interval of 10 mm or lower, vertical subluxation with the Ranawat value of 10 mm or higher, and subaxial subluxation with translation of 4 mm or higher or at multiple levels. Of 503 "definite" or "classical" patients with RA without baseline "severe" instability, 143 were prospectively followed throughout for more than 10 years. The Cox proportional hazards regression analysis was performed to determine predictors for the development of "severe" instabilities. To exclude biases from the low follow-up rate, similar assessments were performed in 223 patients followed for more than 5 years from baseline.

RESULTS

The incidence of cervical spine instabilities and "severe" instabilities significantly increased during more than 10 years in both 143 and 223 cohorts (all P < 0.01). Multivariable Cox proportional hazards models found that baseline mutilating changes (hazard ratio [HR]=19.15, 95% confidence interval [95% CI] = 3.96-92.58, P < 0.01), corticosteroid administration (HR = 4.00, 95% CI = 1.76-9.11, P < 0.01), and previous joint surgery (HR = 1.99, 95% CI = 1.01-3.93, P = 0.048) correlated with the progression to "severe" instability in 143 cases and also in 223 cases (HR = 8.12, 95% CI = 2.22-29.64, P < 0.01; HR = 3.31, 95% CI = 1.68-6.53, P < 0.01; and HR = 2.07, 95% CI = 1.16-3.69, P = 0.014, respectively).

CONCLUSION

Established mutilating changes, concomitant corticosteroid treatment, and previous joint surgery are relatively robust indicators for a poor prognosis of the cervical spine in patients with RA, based on the consistency in more than 10-year analysis of two different settings.

LEVEL OF EVIDENCE

3.

Top 50 most-cited articles on craniovertebral junction surgery

Background:

Craniovertebral junction is a complex anatomical location posing unique challenges to the surgical management of its pathologies. We aimed to identify the fifty most-cited articles that are dedicated to this field.

Methods:

A keyword search using the Thomson Reuters Web of Knowledge was conducted to identify articles relevant to the field of craniovertebral junction surgery. The articles were reviewed based on title, abstract, and methods, if necessary, and then ranked based on the total number of citations to identify the fifty most-cited articles. Characteristics of the articles were determined and analyzed.

Results:

The earliest top-cited article was published in 1948. When stratified by decade, 1990s was the most productive with 16 articles. The most-cited article was by Anderson and Dalonzo on a classification of odontoid fractures. By citation rate, the most-cited article was by Herms and Melcher who described Goel's technique of atlantoaxial fixation using C1 lateral mass screws and C2 pedicle screws with rod fixation. Atlantoaxial fixation was the most common topic. The United States, Barrow Neurological Institute, and VH Sonntag were the most represented country, institute, and author, respectively. The significant majority of articles were designed as case series providing level IV evidence.

Conclusion:

Using citation analysis, we have provided a list of the most-cited articles representing important contributions of various authors from many institutions across the world to the field of craniovertebral junction surgery.

Atlantoaxial Subluxation

Twenty-nine patients with atlantoaxial subluxation (18 with rheumatoid arthritis, 2 due to trauma, 4 with os odontoideum, and one each with polyarteritis nodosa, rheumatic fever, Klippel-Feil syndrome, achondroplasia, and cause unknown) were evaluated using a 0.22 tesla resistive MRI unit. Cord compression was classified into four grades according to the degree on magnetic resonance imaging. There were 7 patients with no thecal sac compression (grade 0), 10 with a minimal degree of subarachnoid space compression without cord compression (grade 1), 7 with mild cord compression (grade 2), and 5 with severe cord compression or cord atrophy (grade 3). Although the severity of myelopathy showed poor correlation with the atlantodental interval on conventional radiography, high correlation was observed between MR grading and the degree of myelopathy. The high signal intensity foci were observed in 7 of 12 patients with cord compression (grades 2 and 3) on T2 weighted images. Other frequently observed findings in rheumatoid arthritis included soft tissue masses of low to intermediate signal intensity in the paraodontoid space, erosions of the odontoid processes, and atlantoaxial impaction on T1 and T2 weighted images.

Factors associated with retro-odontoid soft-tissue thickness in rheumatoid arthritis

OBJECTIVE Increasing soft-tissue mass posterior to the odontoid process causes spinal cord compression. Retro-odontoid pseudotumors are considered to be associated with atlantoaxial instability in patients with rheumatoid arthritis (RA), but the exact mechanism by which these lesions develop has not been elucidated. The purpose of this study was to identify the relationships between retro-odontoid soft-tissue (ROST) thickness and radiological findings or clinical data in patients with RA. METHODS A total of 201 patients with RA who had been followed up at the outpatient clinic of the authors' institution were enrolled in this study. ROST thickness was evaluated on midsagittal T1-weighted MRI. The correlations between ROST thickness and radiographic findings or clinical data on RA were examined. The independent factors related to ROST thickness were analyzed using stepwise multiple regression analysis. RESULTS The average thickness of ROST was 3.0 ± 1.4 mm. ROST thickness showed an inverse correlation with disease duration (r = -0.329, p < 0.01), Steinbrocker stage (r = -0.284, p < 0.01), the atlantodental interval (ADI) in the neutral position (r = -0.326, p < 0.01), the ADI in the flexion position (r = -0.383, p < 0.01), and the ADI in the extension position (r = -0.240, p < 0.01). On stepwise multiple regression analysis, ADI in the flexion position and Steinbrocker stage were independent factors associated with ROST thickness. CONCLUSIONS Although the correlations were not strong, ROST thickness in patients with RA was inversely correlated with ADI and Steinbrocker stage. In other words, ROST thickness tends to be smaller as atlantoaxial instability and peripheral joint destruction worsen. Clinical trial registration no.: UMIN000000980 (UMIN Clinical Trials Registry).

Cervical spine involvement in rheumatoid arthritis over time: results from a meta-analysis

Introduction

Complications in rheumatoid arthritis (RA) seem less common than they were years ago. The prevalence and progression of anterior atlantoaxial subluxations (aAASs), vertical subluxations (VSs), subaxial subluxations (SASs), and associated cervical myelopathy in RA over the past 50 years were determined.

Methods

A literature search was performed by using Medline-OVID/EMBASE, PubMed, and Scopus (from 1960 to June 21, 2014). Prevalence studies were included if the sample size was at least 100 or the prevalence/progression of cervical subluxations was reported. Study quality was assessed by using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. Prevalence of cervical subluxations was calculated for each study. Student’s t test and meta-regression were used to evaluate for significance.

Results

In total, 12,249 citations were identified and 59 studies were included. The prevalence of aAAS decreased from 36% (95% confidence interval (CI) 30% to 42%) before the 1980s to 24% (95% CI 13% to 36%) in the 2000s (P = 0.04). The overall prevalence rates were 11% (95% CI 10% to 19%) for VS, 13% (95% CI 12% to 20%) for SAS, and 5% (95% CI 3% to 9%) for cervical myelopathy, and there were no significant temporal changes. Rates of progression of aAAS, VS, and SAS were 4, 6, and 3 lesions per 100 patients per year, respectively. The incidence of new or progressive cervical myelopathy was 2 cases per 100 patients with known cervical subluxations per year.

Conclusions

Since the 1960s, only aAAS has decreased dramatically. It is still more than twice as common as VS or SAS. No temporal changes in the development of cervical myelopathy in affected patients with RA were noted. The progression rates of cervical subluxations and myelopathy were unchanged over time.

Neurologic complications of craniovertebral dislocation

Craniovertebral dislocation is uncommon, but its diagnosis is important taking into account the potential severity of the neurologic complications. A number of causes are known; the most common are Down syndrome, rheumatoid arthritis, Paget's disease, other metabolic bone diseases, and craniocervical trauma. Down's syndrome is a relatively common clinical condition but craniovertebral subluxation is only observed in a small percentage of patients. About half of all cervical spine injuries affect the atlanto-occipital region and C2 vertebra. In rheumatoid arthritis, craniocervical dislocation occurs in up to 40% of patients with severe disease. In Paget's disease, involvement of the craniovertebral region occurs in about 30% of all cases. The clinical neurologic syndrome is characterized by local pain, features of upper spinal cord and medullary compression, positive Lhermitte phenomenon, syncope associated with neck flexion, vertebral artery obstruction or dissection leading to stroke, and asymmetrical lower cranial nerve palsies. Neuroimaging is essential to confirm the clinical diagnosis and to categorize severity. The treatment of this disorder is usually surgical, but traction and external immobilization is relevant in some cases. Specific conditions may require additional treatments such as radiotherapy, antibiotics, or chemotherapy.

Accelerated development of cervical spine instabilities in rheumatoid arthritis: a prospective minimum 5-year cohort study

Objective

To clarify the incidence and predictive risk factors of cervical spine instabilities which may induce compression myelopathy in patients with rheumatoid arthritis (RA).

Methods

Three types of cervical spine instability were radiographically categorized into “moderate” and “severe” based on atlantoaxial subluxation (AAS: atlantodental interval >3 mm versus ≥10 mm), vertical subluxation (VS: Ranawat value <13 mm versus ≤10 mm), and subaxial subluxation (SAS: irreducible translation ≥2 mm versus ≥4 mm or at multiple). 228 “definite” or “classical” RA patients (140 without instability and 88 with “moderate” instability) were prospectively followed for >5 years. The endpoint incidence of “severe” instabilities and predictors for “severe” instability were determined.

Results

Patients with baseline “moderate” instability, including all sub-groups (AAS⁺ [VS⁻ SAS⁻], VS⁺ [SAS⁻ AAS^±], and SAS⁺ [AAS^± VS^±]), developed “severe” instabilities more frequently (33.3% with AAS⁺, 75.0% with VS⁺, and 42.9% with SAS⁺) than those initially without instability (12.9%; p<0.003, p<0.003, and p = 0.061, respectively). The incidence of cervical canal stenosis and/or basilar invagination was also higher in patients with initial instability (17.5% with AAS⁺, 37.5% with VS⁺, and 14.3% with SAS⁺) than in those without instability (7.1%; p = 0.028, p<0.003, and p = 0.427, respectively). Multivariable logistic regression analysis identified corticosteroid administration, Steinbrocker stage III or IV at baseline, mutilating changes at baseline, and the development of mutilans during the follow-up period correlated with the progression to “severe” instability (p<0.05).

Conclusions

This prospective cohort study demonstrates accelerated development of cervical spine involvement in RA patients with pre-existing instability—especially VS. Advanced peripheral erosiveness and concomitant corticosteroid treatment are indicators for poor prognosis of the cervical spine in RA.

Mid-term results of computer-assisted cervical reconstruction for rheumatoid cervical spines

STUDY DESIGN

A retrospective single-center study. We routinely have used C1-C2 transarticular and cervical pedicle screw fixations to reconstruct highly destructed unstable rheumatoid arthritis (RA) cervical lesions. However, there is little data on mid-term results of surgical reconstruction for rheumatoid cervical disorders, particularly, cervical pedicle screw fixation.

OBJECTIVES

The purpose of this study was to evaluate the mid-term surgical results of computer-assisted cervical reconstruction for such lesions.

METHODS

Seventeen subjects (4 men, 13 women; mean age, 61 ± 9 years) with RA cervical lesions who underwent C1-C2 transarticular screw fixation or occipitocervical fixation, with at least 5 years follow-up were studied. A frameless, stereotactic, optoelectronic, CT-based image-guidance system, was used for correct screw placement. Variables including the Japanese Orthopaedic Association (JOA) score, Ranawat class, EuroQol (EQ-5D), atlantodental interval, and Ranawat values before, and at 2 and 5 years after surgery, were evaluated. Furthermore, screw perforation rates were evaluated.

RESULTS

The lesions included atlantoaxial subluxation (AAS, n = 6), AAS + vertical subluxation (VS, n = 7), and AAS + VS + subaxial subluxation (n = 4). There was significant neurological improvement at 2 years after surgery, as evidenced by the JOA scores, Ranawat class, and the EQ-5D utility weight. However, at 5 years after surgery, there was a deterioration of this improvement. The Ranawat values before, and at 2 and 5 years after surgery, were not significantly different. Major screw perforation rate was 2.1 %. No neural and vascular complications associated with screw insertion were observed.

CONCLUSIONS

Subjects with rheumatoid cervical lesions who underwent C1-C2 transarticular screw fixation or occipitocervical fixation using a pedicle screw had significantly improved clinical parameters at 2 years after surgery. However, there was a deterioration of this improvement at 5 years post surgery.

Evaluation of clinical results and quality of life after surgical reconstruction for rheumatoid cervical spine

BACKGROUND CONTEXT

The EuroQol (EQ-5D) is a widely used comprehensive measure of health-related quality of life. There has been no study that has evaluated the health-related quality of life before and after the surgical reconstruction of rheumatoid arthritis (RA) cervical spine lesions using EQ-5D.

PURPOSE

The present study aimed to evaluate the improvement of quality of life before and after surgical reconstruction of rheumatoid cervical spine using EQ-5D, and the surgical outcomes of cervical spine affected by RA.

STUDY DESIGN

A retrospective study of the patients who underwent surgical reconstruction of cervical disorders in RA.

PATIENT SAMPLE

Twenty-five patients (seven men, 18 women, mean age 62.2 years) who underwent surgical reconstruction of cervical disorders in RA were enrolled.

OUTCOME MEASURES

Japanese Orthopaedic Association (JOA) score and EQ-5D.

METHODS

Clinical symptoms were evaluated before surgery and at 2 years after surgery by measuring the JOA score. We also investigated health-related quality of life before surgery and outcome at 2 years after surgery using the EQ-5D questionnaire.

RESULTS

Mean observation period was 46.3 months. Mean JOA score significantly improved from 9.1 ± 4.5 points before surgery to 12.4 ± 2.8 at the 2 years after surgery (p=.0001). All the EQ-5D data were improved at the 2 years after surgery, compared with the data before surgery; especially, pain (p=.005), usual activity (p=.005), mobility (p=.008), and anxiety/depression (p=.02) were significantly improved. Utility weight was 0.37 ± 0.27 before surgery and 0.56 ± 0.26 at the 2 years after surgery, showing significant improvement at the 2 years after surgery compared to before surgery (p=.002).

CONCLUSIONS

The surgical reconstruction of rheumatoid cervical spine has been demonstrated to improve patients' health-related quality of life.

Incidence and aggravation of cervical spine instabilities in rheumatoid arthritis: a prospective minimum 5-year follow-up study of patients initially without cervical involvement

STUDY DESIGN

A prospective minimum 5-year follow-up study of the cervical spine in patients with rheumatoid arthritis (RA) initially without cervical involvement.

OBJECTIVE

To clarify the incidence and aggravation of cervical spine instabilities and their predictive risk factors in patients with RA.

SUMMARY OF BACKGROUND DATA

Many reports have shown the progression of cervical spine involvement in RA. However, few articles have described comprehensive evaluation of its prognostic factors.

METHODS

A total of 140 patients with "definite" or "classical" RA initially without cervical involvement were prospectively followed for more than 5 years. Radiographical cervical findings were classified into 3 instabilities: atlantoaxial subluxation (AAS: atlantodental interval >3 mm), vertical subluxation (VS: Ranawat value <13 mm), and subaxial subluxation (SAS: irreducible translation ≥ 2 mm). "Severe" extents were defined as AAS with atlantodental interval 10 mm or more, VS with Ranawat value 10 mm or less, and SAS with translation 4 mm or more or at multiple levels. Incidence of these developments and predictors for "severe" instabilities were investigated.

RESULTS

During 6.0 ± 0.5 years, 43.6% of 140 patients developed cervical instabilities: AAS in 32.1%, VS in 11.4%, and SAS in 16.4% with some combinations. "Severe" instabilities were exhibited in 12.9% of patients: AAS in 3.6%, VS in 6.4%, and SAS in 5.0%. Furthermore, 4.3% presented canal stenosis, with 13 mm or less space available for the spinal cord (SAC) due to "severe" AAS or "severe" VS in 2.9% and 12 mm or less SAC due to "severe" SAS in 2.1%. Multivariable logistic regression analysis identified corticosteroid administration, mutilating changes at baseline, and the development of nonmutilating into mutilating changes during the follow-up period correlated with "severe" instabilities (P < 0.05).

CONCLUSION

A minimum 5-year follow-up reveals the occurrence of cervical instabilities in 43.6%, "severe" aggravation in 12.9%, and decreased SAC in 4.3% of patients with RA. Characteristics of severe disease activity-established mutilating changes, progressive development into mutilating changes, and potentially concomitant corticosteroid treatment-are indicators for poor prognosis of the cervical spine in RA.

Progression of cervical instabilities in patients with rheumatoid arthritis 5.7 years after their first lower limb arthroplasty

We reviewed 101 rheumatoid arthritis (RA) patients who had undergone their first lower limb arthroplasty between 1990 and 2002. None of the patients had received immunosuppressant or biological drugs. Preoperative and follow-up cervical spine radiographs had been performed (more than 2 years after the arthroplasty). Cervical spine instabilities were found in 62 and 82 patients, and a posterior atlantodental interval (PADI) of <14 mm was present in 20 and 22 patients in the respective radiographs. The presence of cervical spine instabilities and PADI <14 mm were correlated with a higher modified Lansbury index (LI) both preoperatively and at final follow-up. Patients with no cervical spine instability throughout the follow-up had a lower average LI. Patients with atlantoaxial subluxation (AAS), vertical subluxation (VS), and subaxial subluxation (SAS) had more joint arthroplasties at final follow-up compared with other patients. The percentage of patients with single and multiple cervical instabilities increased at final follow-up. The incidence of cervical spine instabilities in RA patients requiring a lower limb arthroplasty is extremely high, with progression of these instabilities after the procedure. There is a correlation between the severity of RA activity in peripheral joints and the severity of cervical spine instabilities.

Dissecting aneurysm of the radiculomedullary artery originating from extracranial vertebral artery dissection in a patient with rheumatoid cervical spine disease: an unusual cause of subarachnoid hemorrhage

✓The authors report the case of a 65-year-old woman with atlantoaxial subluxation caused by rheumatoid arthritis. The patient had been hospitalized because of an infection after a total-knee replacement, when she suddenly lost consciousness and became apneic after an episode of intractable neck pain. Cranial computed tomography scanning demonstrated subarachnoid hemorrhage (SAH), and angiography revealed a dissecting aneurysm of the radiculomedullary artery that had originated from an extracranial vertebral artery dissection at the level of the atlantoaxial joint. Although coil embolization for the parent artery, including the dissecting aneurysm, was performed successfully, the patient died of worsening infection. The authors believe that the SAH occurred because of a ruptured dissecting aneurysm in the intradural portion of the radiculomedullary artery.

Timing of cervical spine stabilisation and outcome in patients with rheumatoid arthritis

One complication of rheumatoid arthritis (RA) is the involvement of the cervical spine (CS). Although prophylactic stabilisation is recommended, the timing at which this should occur is poorly defined. The aim of our study was to evaluate the course of neurological symptoms in terms of the timing of surgery. A total of 34 patients with RA and CS involvement were surgically stabilised. These patients were classified using the Ranawat (RW) score both preoperatively and at an average of 54 months post-operatively. For each patient, the presence of atlantoaxial and subaxial subluxation as well as vertical migration of the odontoid was recorded. The anterior atlantodental interval was also assessed pre- and post-operatively. Improvement was obtained in 20 patients, the clinical situation remained unchanged in three patients and three patients manifested disease progression. In terms of the RW score, the 16 patients with pre-operative RW grades I-II showed no deterioration at the post-operative follow-up, with 13 of these patients showing an improvement; the 12 patients with pre-operative RW grades IIIA-IIIB did not show any improvement of neurological symptoms at follow-up, although seven of these patients subjectively assessed the symptoms to be less severe after surgery; three other patients showed a worsening of symptoms. Our results suggest that preventive stabilisation of CS in RA leads to acceptable results, although the complications of the surgery are obvious. However, early operative treatment may delay the detrimental course of cervical myelopathy in RA.

Atraumatic odontoid fractures in patients with rheumatoid arthritis

BACKGROUND CONTEXT

Instability of the cervical spine is a common problem in patients with rheumatoid arthritis. The natural course of rheumatoid arthritis in the cervical spine is well documented. However, the true prevalence of occult fractures of the odontoid process in patients with rheumatoid arthritis is not known.

PURPOSE

To draw attention to the possibility of occult, atraumatic fractures of the odontoid process in patients with rheumatoid arthritis.

STUDY DESIGN

We report on two cases with previously unrecognized fractures of the odontoid process.

METHODS

In this case series, we review the individual radiographic findings and clinical observations in two rheumatoid patients in whom a fracture of the odontoid process was diagnosed.

RESULTS

Each one of these two rheumatoid patients had an unrecognized fracture of the odontoid process without any prior history of trauma. Their fracture was identified serendipitously during workup for neck pain.

CONCLUSIONS

Occult, atraumatic fractures of the odontoid process may be found in patients with long-standing rheumatoid arthritis. This injury should be suspected if previously asymptomatic patients complain about new onset of neck pain without significant trauma.

Inadvertent C2-C3 union after C1-C2 posterior fusion in adults

INTRODUCTION

Some authors pointed out that there were more than a few patients with inadvertent C2-C3 union after C1-C2 posterior fusion, although few detailed studies of C2-C3 union have been reported. The purpose of this study was to clarify whether C2-C3 union accelerated adjacent C3-C4 disc degeneration after C1-C2 posterior fusion and to investigate the related factors for C2-C3 union.

METHODS

Sixteen patients with rheumatoid arthritis (RA group) (4 males, 12 females, mean age 60 years, mean follow-up period 4 years and 3 months) and fifteen patients without RA (non-RA group) (11 males, 4 females, mean 52 years, mean follow-up period 3 years and 10 months) who underwent C1-C2 posterior fusion were radiologically assessed. The C2-C3 union was defined as trabecular bone formation at C2-C3 interlamina in lateral radiograph. C3-C4 disc height was measured to evaluate the disc degeneration.

RESULTS

C2-C3 union rate was 56% and 60% in RA group and non-RA group, respectively. In RA group, postoperative C3-C4 disc height was lower (Student's t-test, P = 0.029) and the decrease rate of C3-C4 disc height was higher (Student's t-test, P = 0.015) in patients with C2-C3 union than in patients without C2-C3 union. In non-RA group, the age at operation was older (Student's t-test, P = 0.0007), and the C1-C2 fusion angle (Student's t-test, P = 0.012) was smaller in patients with C2-C3 union than in patients without C2-C3 union.

CONCLUSIONS

C2-C3 union after C1-C2 posterior fusion occurred in more than half of both groups. Inadvertent C2-C3 union should be considered a radiological complication and a potential risk factor due to acceleration of C3-C4 disc degeneration in RA.

Rehabilitation of people with rheumatoid arthritis

Rehabilitation, as an adjunct to pharmacological and surgical therapies in patients with rheumatoid arthritis (RA), aims to minimize the consequences of the disease. For a systematic assessment of the consequences of disease, an appropriate definition and evaluation of the goals of therapy and interventions, and an active partnership with the patient, a structured approach to rehabilitation management is needed.Despite widespread positive clinical experience with rehabilitative interventions, the scientific evidence of their effectiveness is, in general, scanty, owing to a lack of studies with sufficient methodological quality. Further well-designed clinical studies are warranted with respect to several interventions where evidence is falling short.

Rheumatoid arthritis of the cervical spine: current techniques for management

The incidence of rheumatoid arthritis in the European and North American population is significant. Rheumatoid arthritis can result in serious damage to the cervical spine and the central neuraxis, ranging from mild instability to myelopathy and death. Aggressive conservative care should be established early. The treating physician should not be lulled into a false sense of security by reports suggesting that cervical subluxations are typically asymptomatic [76-78]. Gradual spinal cord compression can result in severe neurologic deficits that may be irreversible despite appropriate surgical intervention when applied too late. [figure: see text] The treatment of rheumatoid disease in the cervical spine is challenging. Many details must be considered when diagnosing and attempting to institute a treatment plan, particularly surgical treatment. The pathomechanics may result in either instability or ankylosis. The superimposed deformities may be either fixed or mobile. The algorithm suggested by the authors can be used to navigate through the numerous details that must be considered to formulate a reasonable surgical plan. Although these patients are [figure: see text] frail, an "aggressive" surgical solution applied in a timely fashion yields better results than an incomplete or inappropriate surgical solution applied too late. When surgical intervention is anticipated, it should be performed before the development of severe myelopathy. Patients who progress to a Ranawat III-B status have a much higher morbidity and mortality rate associated with surgical intervention than do patients who ambulate. Although considered aggressive by some, "prophylactic" stabilization and fusion of a [figure: see text] relatively flexible, moderately deformed spine before the onset of severe neurologic symptoms may be reasonable. This approach ultimately may serve the patient better than "observation" if the patient is slowly drifting into a severe spinal deformity or shows signs of early myelopathy or paraparesis.

Cervical spine involvement in rheumatoid arthritis. A review

Cervical spine involvement occurs in over half of patients with rheumatoid arthritis (RA). The most common abnormality is atlantoaxial dislocation, followed by atlantooccipital arthritis with cranial settling and by lesions of the lower cervical spine. Cervical spine involvement usually occurs in patients with severe RA. Pain and evidence of spinal cord injury are the main symptoms. The presence of symptoms is not correlated with the severity of radiological abnormalities. Computed tomography and magnetic resonance imaging provide detailed images of the bone and spinal cord lesions. Because the course is unpredictable, conservatively treated patients usually require regular follow-up. Surgery is in order in patients with pain unresponsive to major narcotics or with progressive neurological impairment. The choice between the anterior and the posterior route depends on the experience of the surgical team. It is reasonable to stabilize the spine before the development of cranial settling or major neurological loss (Ranawat's stage III). The good functional results of spinal surgery are frequently overshadowed by major impairments related to severe peripheral joint disease. Safety is acceptable when somatosensory evoked responses are monitored intraoperatively. Surgery can provide substantial improvements in symptoms, particularly pain.

Correlation between osteochondral changes depicted by magnetic resonance imaging and disease progression

PURPOSE

To determine the consequences of the chronic use of systemic corticosteroids in children with juvenile rheumatoid arthritis by means of evaluating osteochondral effects depicted by magnetic resonance imaging.

PATIENTS AND METHODS

We reviewed clinical and magnetic resonance imaging findings in 69 children (72 knees) with juvenile rheumatoid arthritis. Two groups were studied. Group I: 34 (49.3%) children had previous or current use of systemic corticotherapy (22 girls; 12 boys; mean age: 11.3 years; mean disease duration: 5.9 years; mean corticotherapy duration: 2.9 years; mean cumulative dose of previous corticosteroids: 5000 mg); Group II: 35 (50.7%) children had no previous use of corticosteroids (27 girls; 8 boys; mean age: 11.7 years; mean disease duration: 5.3 years). The groups were compared statistically.

RESULTS

In the group that had received corticotherapy (Group I), osteochondral abnormalities were significantly correlated to long-standing disease (>3.5 years; p<0.001). This correlation was not found in the group that had no previous history of corticotherapy (Group II). No correlations were established between median dose of corticosteroids and magnetic resonance imaging findings.

CONCLUSION

It is important to further investigate the long-term intra-articular effects of systemic corticotherapy to ensure that the side effects of the aggressive therapy will not be more harmful for the joints than the symptoms suffered over the natural course of the disease.

Mortality associated with cervical spine disorders: a population-based study of 1666 patients with rheumatoid arthritis who died in Finland in 1989

OBJECTIVE

To evaluate the mortality associated with cervical spine deformities in rheumatoid arthritis (RA) based on national data.

METHODS

The role of rheumatoid disorders of the cervical spine as a cause of death was studied in 1666 subjects who died in Finland in 1989 and had been entitled under the national sickness insurance scheme to receive reimbursed medication for RA. Death certificates and certificates for drug reimbursement of these 1666 patients and the clinical files of 853 patients were examined for the mention of cervical spine disorders. Thereafter, the cervical spine radiographs and detailed clinical histories of patients with diagnosed cervical spine disorder were evaluated separately.

RESULTS

According to the official death certificates, cervical spine disorder was not an underlying, contributory or immediate cause of death in any of these patients. Cervical spine abnormalities had been diagnosed only in 38/853 (4.5%) patients. Cervical spine radiographs from 33 patients were available for examination, and in 17 patients cervical spine deformities were found to be severe enough to be a potential cause of fatal complications. Among these 17 cases, four sudden and four postoperative deaths were recorded (one after cervical spine operation) and three patients were suffering from quadriparesis or paraparesis at the time of death. Among the other 16 patients with cervical spine radiographs, the cervical deformities were less severe and their death histories differed from those of the group with more severe deformities.

CONCLUSIONS

Cervical spine disorders in RA should be diagnosed early and treated actively to prevent severe and potentially fatal complications. Deaths caused by these disorders are rare, but they should be remembered when the death certificates are written.

A long-term follow-up study of cervical lesions in rheumatoid arthritis

To determine the natural history of cervical lesions in rheumatoid arthritis, 161 patients who had been followed for a minimum of 5 years were enrolled in this study. The average follow-up period was 10.2 years (range, 5 to 20 years). The severity of the rheumatoid arthritis was classified into three types based on the multiplicity of peripheral joint rheumatoid involvement: a least erosive subset, a more erosive subset, and a mutilating disease subset. Ninety-two patients (57%) had upper cervical involvement, which progressed in the order of anterior atlantoaxial subluxation, anterior atlantoaxial subluxation combined with vertical subluxation, and vertical subluxation alone. Subaxial subluxation was found in 18 patients (11%). In 17 of these 18 patients, upper cervical lesions were also noted. The incidence of cervical involvement in each disease subset was 39% in the least erosive group, 83% in the more erosive group, and 100% in the mutilating disease group. Fifty percent of the patients with cervical involvement had neck pain, and the remaining patients were asymptomatic. Neural involvement occurred in 10 patients. In 7 of these 10 patients, vertical subluxation of the atlas was responsible for the neural deficit. Six patients required surgical intervention because of progressive myelopathy.

Progression of rheumatoid arthritis of the cervical spine: radiographic and clinical evaluation

Cross-sectional and longitudinal studies were conducted to observe progression of rheumatoid arthritis in the cervical spine. Two hundred and ninety-seven patients were enrolled in the cross-sectional study. Both upper and lower cervical spine involvement increased with disease duration. The relationship between atlanto-axial motion and the development of subaxial subluxation was inconclusive. Eighty-seven patients were enrolled in the longitudinal study and were followed for at least 5 years. In about half of these patients, rheumatoid changes started from the upper cervical spine, with rheumatoid changes beginning from the lower cervical spine in about 8% of patients. Neurological deficits were correlated with radiographic changes but neck pain did not correlate with radiographic changes. As to the upper cervical spine, the parameter most influencing neurological deficits was found to be the minimum value of the atlanto-axial angle in flexion, by multivariate analysis using a multiple logistic model. Neurological deficits were seen in more than half the patients when the atlanto-axial angle in flexion was 5 degrees or less.

Occipitocervical stabilization for myelopathy in patients with rheumatoid arthritis. Implications of not bone-grafting

BACKGROUND

Approximately 0.9 percent of the white adult population of the United States and 1.1 percent of the adult population in Europe are affected by seropositive rheumatoid arthritis. As many as 10 percent of those patients may need an operation for atlantoaxial subluxation. Severe instability, especially when associated with vertical subluxation of the odontoid process, can result in progressive cervical myelopathy. Typically, occipitocervical fixation has been performed for these patients with use of autograft bone to achieve long-term stability through a solid fusion. Harvesting the bone graft increases the operative risk to the patient and may result in increased morbidity. In our experience, patients who have had no clear radiographic evidence of fusion following use of occipitocervical instrumentation seemed to have done as well as those who have had obvious fusion. One assumption is that the clinical improvement might be attributable simply to stabilization of the joint rather than to osseous fusion. A longitudinal study was performed on patients with rheumatoid arthritis who required an operation because of craniocervical or upper cervical instability.

METHODS

The results of clinical, radiographic, functional, and self-evaluations were studied to determine the efficacy of treatment and to compare the outcomes of bone-grafting with those of procedures done without bone-grafting in a group of 150 patients who underwent posterior occipitocervical stabilization with use of a contoured metal implant (a Ransford loop) that was affixed by sublaminar wires. Internal fixation was performed in 120 patients without bone-grafting and in thirty patients with use of autogenous bone-grafting. Preoperatively, 23 percent (thirty-five) of the 150 patients had mild neurological involvement (class II, according to the system of Ranawat et al.), 45 percent (sixty-eight) had objective findings of weakness and long-tract signs but were able to walk (class III-A), and 29 percent (forty-three) were quadriparetic and unable to walk (class III-B). The age of the patients at the time of the operation ranged from twelve to eighty-three years (mean, sixty-two years).

RESULTS

There were significant improvements in postoperative Ranawat classes at all time-periods (range, p < 0.00005 to p = 0.0066) and in patient ratings of neck pain (range, p < 0.00005 to p = 0.0044) compared with preoperative scores. With the numbers available, there were no significant differences between the patients managed with a graft and those managed without grafting with respect to survival after the operation, Ranawat class, head or neck-pain rating, presence of subaxial abnormalities, radiographic craniovertebral motion, or vertical subluxation. Overall mortality at one month was 10 percent (fifteen of 150), although this value varied directly with the degree of preoperative disability. A second cervical spine operation was required in 11 percent (sixteen) of the 150 patients.

CONCLUSIONS

While patients who have rheumatoid disease with anterior atlantoaxial subluxation should be treated with posterior atlantoaxial arthrodesis with use of bone-grafting and internal fixation, we believe that those who present with vertical instability and multi-level involvement can be treated with posterior occipitocervical stabilization with use of a contoured occipitocervical loop and sublaminar wire fixation without bone-grafting. Furthermore, we believe that the use of preoperative traction, bone cement, or a postoperative halo vest is unnecessary. Avoiding the harvesting of autogenous bone for grafting reduced the morbidity of this operation without compromising the outcome in these already sick patients.

Complete reduction of retro-odontoid soft tissue mass in os odontoideum following the posterior C1-C2 tranarticular screw fixation

STUDY DESIGN

A case report of os odontoideum with retro-odontoid soft tissue hypertrophy treated by the transarticular screw fixation.

OBJECTIVES

To present a case of os odontoideum that showed complete reduction of retro-odontoid soft tissue mass caused by atlantoaxial subluxation after the C1-C2 transarticular screw fixation.

SUMMARY OF BACKGROUND DATA

Hypertrophy of the periodontoid soft tissue has been reported to be associated with chronic atlantoaxial subluxation and progressive myelopathy. While the rheumatoid pannus has been reported to become reduced of disappear after fixation of the unstable segment, the reduction of the hypertrophied soft tissue mass has never been reported in atlantoaxial subluxation of nonrheumatoid origin, especially in the case of os odontoideum.

METHODS

Posterior C1-C2 transarticular screw fixation was performed in a patient with os odontoideum, who showed signs of progressive myelopathy by the compression of retro-odontoid soft tissue mass and atlantoaxial subluxation.

RESULTS

The fixation of atlantoaxial subluxation achieved not only the complete reduction of the retro-odontoid soft tissue mass, but also clinical improvement of the myelopathy.

CONCLUSIONS

Posterior atlantoaxial fixation is worth trying in slow progressing myelopathy by the compression of hypertrophy of the soft tissue even in nonrheumatoid atlantoaxial subluxation, thereby obviating the need for direct removal of the mass via the transoral route.

Natural history of rheumatoid arthritis of the cervical spine

This article reviews the natural history of rheumatoid arthritis involving the cervical spine with special attention given to predictors of paralysis. Understanding the natural history of rheumatoid arthritis of the cervical spine is necessary to determine the benefit of various interventions. The primary treatment goal for cervical instability is prevention of irreversible neurologic injury. The natural history of rheumatoid arthritis for a period of 10 years or more is one of significant disease progression. The natural history of cervical instability in patients with rheumatoid arthritis is more variable, with only some patients having a neurologic deficit develop. Recent studies support prophylactic stabilization of the rheumatoid cervical spine to prevent paralysis in high risk patients. However, proponents for prophylactic arthrodesis must acknowledge that not all cervical instability in rheumatoid arthritis progresses to neurologic deficit, and surgical intervention in patients with rheumatoid arthritis incurs added morbidity and mortality. Identifying the risk factors for progression of cervical instability is the first step in eliminating morbidity and mortality from spinal cord and brain stem compression. Surgical stabilization is indicated not only for those patients with paralysis, but for the subgroups of patients with cervical rheumatoid disease who are at risk for spinal cord and brain stem compression. The posterior atlantodental interval is the most reliable screening tool and predictor of progressive neurologic deficit.

Rheumatoid Pannus of the Cervical Spine: A Case Report of an Unusual Cause of Dysphagia

Dysphagia as an initial complaint in rheumatoid arthritis is rare. We describe the case of a 69-year-old woman with rheumatoid arthritis who presented with a 2-day history of acute dysphagia. Our evaluation revealed the cause of the dysphagia was the presence of rheumatoid pannus that involved the anterior cervical spine and compressed the esophagus. Although the otolaryngologic manifestations of rheumatoid arthritis usually relate to synovial involvement of the temporomandibular and cricoarytenoid joints, our case establishes that a rheumatoid pannus on the anterior cervical spine can cause dysphagia. We believe that this may be the first reported case of this clinical entity.

Headmaster collar restricts rheumatoid atlantoaxial subluxation

STUDY DESIGN

A radiographic study of the effect of a modern orthotic device in the treatment of rheumatoid atlantoaxial subluxation.

OBJECTIVE

To study the ability of a new open-type collar to restrict atlantoaxial subluxation.

SUMMARY OF BACKGROUND DATA

Atlantoaxial subluxation is common in rheumatoid arthritis, and thus, the development of conservative treatments is important. It has been shown that a custom-made stiff collar significantly restricts atlantoaxial subluxation in approximately half of patients with unstable atlantoaxial subluxation.

METHODS

In 30 successive patients with rheumatoid atlantoaxial subluxation, lateral view radiographs were taken in flexion, extension, and neutral positions without a collar and in flexion with the Headmaster collar.

RESULTS

The mean atlantoaxial distance during flexion was 7.1 +/- 1.8 mm and during extension was 1.0 +/- 1.0 mm, and the mean instability was 6.1 +/- 2.3 mm. In the 20 cases with the greatest stabilizing effect, the mean atlantoaxial distance during flexion with a collar was 1.1 +/- 1.3 mm, whereas in 10 patients with lesser effect it was 6.7 +/- 2.5 mm (P < 0.0001). The lesser stabilizing effect was associated with the presence of atlantoaxial subluxation in the neutral position.

CONCLUSION

The Headmaster collar is an effective and useful tool in the conservative treatment of simple unstable atlantoaxial subluxation, but an ordinary custom-made stiff collar is still often needed. These two collars are complementary, and their selection and use must be determined individually.

Determining surgical priorities in rheumatoid arthritis

Rheumatoid arthritis often affects multiple joints simultaneously with pain, deformity and loss of function. The indications for surgical treatment are presented along with guidelines for determining the surgical priorities along with guidelines for determining the surgical priorities when multiple joints require surgery.

The role of preoperative cervical spine X-rays in rheumatoid arthritis

The cervical spine is frequently involved in rheumatoid arthritis and yet there exists no consensus on the need to screen for cervical spine subluxations preoperatively. We reviewed retrospectively 77 patients who underwent 132 operations under general or regional anaesthesia over a 44-month period. We found that while the majority of patients had received preoperative X-ray screening for cervical spine instability, a third of the X-ray examinations done had been inadequate. Many anaesthetists did not repeat cervical spine X-rays if there were previously performed views available. We showed that a complete X-ray examination of the cervical spine should include flexion and extension stress views in addition to frontal views of the odontoid and entire cervical spine. Anterior atlantoaxial subluxation was the most common subluxation encountered in our study population. The detection of cervical spine instability was found to significantly affect anaesthetic management, favouring techniques that avoided unprotected manipulations of the neck under anaesthesia.

Cervical lesions related to the systemic progression in rheumatoid arthritis

STUDY DESIGN

Cross-sectional study of cervical involvement in rheumatoid arthritis.

OBJECTIVES

To clarify the correlation between the deterioration of cervical lesions and the systemic progression of rheumatoid arthritis.

SUMMARY OF BACKGROUND DATA

The natural course of cervical lesions varies. To date, no systemic parameter has been clarified to predict the progression.

METHODS

One hundred seventy-three patients with rheumatoid arthritis participated in this study. The authors studied the progression of cervical lesions and investigated the relation between the types of cervical subluxation at the end of study and the following four variables: the serum level of C-reactive protein, the number of joints with erosion, carpal height ratio, and disease subset (least erosive subset, more erosive subset, and mutilating disease subset).

RESULTS

Of the 173 patients, 55 already had cervical subluxation before entering the study. During the follow-up period, 44 patients deteriorated radiographically, and 77 (45%) had cervical involvement, including involvement of upper cervical lesions in 65 patients, upper lesions combined with subaxial subluxation in 10, and subaxial subluxation alone in 2. The upper cervical subluxation progressed in the order of anterior atlantoaxial subluxation, atlantoaxial subluxation combined with vertical subluxation, and vertical subluxation alone. Deterioration of upper cervical lesion and occurrence of subaxial subluxation were closely correlated with an elevation of serum C-reactive protein level, an increase in the number of joints with erosion, and a decrease in the carpal height ratio. The incidence of cervical involvement and the extent of deterioration were different among the disease subsets.

CONCLUSIONS

The serum level of C-reactive protein, the number of joints with erosion, and the carpal height ratio correlated closely with the extent of the cervical subluxation. The average C-reactive protein values during the follow-up period correlated with progression of the cervical lesions. The classification of rheumatoid disease subset was useful for predicting the terminal feature of the cervical lesions.

Cervicomedullary compression: an unrecognized cause of vocal cord paralysis in rheumatoid arthritis

Cervicomedullary compression (CMC) from traumatic, infectious, or congenital processes of the atlanto-axial joint is a known cause of vocal cord immobility. Cervicomedullary compression can also occur from destructive arthritic changes and inflammatory pannus formation at the occipito-atlanto-axial joint in patients with rheumatoid arthritis (RA). We present findings suggesting that CMC in patients with RA is an unrecognized cause of vocal cord immobility. Previously, vocal cord immobility in patients with RA has been assumed to be cricoarytenoid arthritis with joint fixation. We report 3 patients with RA and radiographically demonstrated CMC with vocal cord immobility. One patient had bilateral vocal cord immobility and airway obstruction; 2 patients had unilateral cord paralysis and contralateral paresis without airway compromise. All patients had myelopathy and neck pain in addition to brain stem symptoms. All patients underwent transoral-transpharyngeal decompression of the anterior craniocervical junction with subsequent posterior fusion. These patients demonstrated full return of vocal cord function within 3 months of decompression. We propose that CMC is a cause of vocal cord paralysis in patients with RA that may go unrecognized without appropriate imaging studies of the skull base and physician awareness of symptoms of occipito-atlanto-axial subluxation and/or basilar invagination with brain stem compression. Our results demonstrate that CMC in RA is a potentially reversible cause of vocal cord paralysis.

Functional turbo spin echo magnetic resonance imaging versus tomography for evaluating cervical spine involvement in rheumatoid arthritis

STUDY DESIGN

Comparison of findings in plain radiography and conventional tomography with findings in plain radiography and magnetic resonance imaging of the upper cervical spine in consecutive patients with rheumatoid arthritis and with known or suspected abnormalities of the cervical spine.

OBJECTIVES

To determine whether plain radiography and magnetic resonance imaging provide enough information to dispense with tomography in investigations of cervical spine involvement in rheumatoid arthritis.

SUMMARY OF BACKGROUND DATA

With the recent advances in magnetic resonance imaging technology and the proliferation of magnetic resonance imaging techniques for specific clinical conditions.

METHODS

Twenty-eight patients with rheumatoid arthritis and with known or suspected abnormalities of the cervical spine underwent a clinical neurologic examination; plain radiography, including full flexion lateral radiography; anteroposterior and lateral tomography at C1-C2; and magnetic resonance imaging at the same level in neutral position and in flexion. Two radiologists evaluated one image set consisting of plain radiography and conventional tomographic images and another image set consisting of plain radiography and magnetic resonance images, for each patient.

RESULTS

Compared with conventional tomography and plain radiography, magnetic resonance imaging and plain radiography showed cystic lesions and erosions of the odontoid process and vertical atlantoaxial subluxation more often, showed anterior subluxation as often, and showed lateral atlantoaxial subluxation less often.

CONCLUSION

Magnetic resonance imaging produces sufficiently distinct images of destruction of the odontoid and subluxations for it to replace conventional tomography in investigations of upper cervical spine involvement in rheumatoid arthritis.

Decision making in rheumatoid arthritis. Determining surgical priorities

Consideration of the individual, his or her needs, and what he or she hopes to gain through surgery is of primary importance in determining a surgical plan for the rheumatoid patient. Nevertheless, procedures undertaken to save life or prevent neurologic demise must, of course, take precedence. Alleviation of pain and correction of disabling deformity take next priority. Many other considerations go into the formulation of the list of surgical priorities. A full understanding of these considerations and a well-integrated team approach to the rheumatoid patient provide the best chance for optimal outcome following surgery.

Early diagnosis of rheumatoid cervical myelopathy

The purpose of this study was to detect early signs of cervical myelopathy on the basis of clinical finding, radiographs, somatosensory evoked potentials (SSEPs) for n. medianus in 56 patients and transcranial dopler (TCD) for vertebral arteries in 35 patients. Radiological findings, SSEPs, and TCD were registered in neutral and functional scanning positions. Forward AA dislocation was verified in 25 patients with mean value 4.7 mm. The total of 12 (3 in neutral and 9 in functional positions) out of 56 patients had pathological findings of SSEPs for n. medianus. Out of 35 patients 13 (8 in standard imaging position and 5 in rotations) had abnormal values of mean blood flow velocities (MBFV). Movements can provoke neural conduction disturbances through spinal cord and interrupt vertebral arteries blood flow. The early detection of the cervical myelopathy is possible when changing the head position during SSEPs and TCD recordings. On the basis of clinical, x-ray, SSEPs and TCD analyses we suggest that patients with risk of developing myelopathy should be separated.

Rheumatoid Arthritis of the Cervical Spine

Cervical involvement in patients with rheumatoid arthritis occurs primarily in the upper cervical spine. The characteristic deformities are atlantoaxial subluxation, vertical settling, and subaxial subluxation. The typical patient complaints are neck pain and occipital pain. Subtle signs of myelopathy may also be present. Useful radiologic studies include plain radiography, tomography, and functional magnetic resonance imaging. The most helpful radiographic measurements are the anterior atlantodens interval, the posterior atlantodens interval, and assessment of vertical settling. Atlantoaxial subluxation greater than 9 mm with vertical settling and a posterior atlantodens interval less than 14 mm correlate with neurologic deficit. Nonoperative management does not change the natural history of cervical disease. Traditional surgical indications include intractable pain and neurologic deficit. The author discusses more controversial indications and proposes a rationale and protocol for treatment. The primary surgical objectives are to achieve stabilization of the affected segments and to relieve neural compression by reduction of subluxations or direct decompression. Arthrodesis provides reliable pain relief. Neurologic recovery occurs more consistently in patients with lower grades of preoperative myelopathy.

Cerebrovascular complications of rheumatic disease

Cerebral ischemia and infarction, intracerebral hemorrhage, subarachnoid hemorrhage, cerebral venous thrombosis, and cerebral vasculitis are dreaded but largely uncommon complications of most rheumatic diseases. In some conditions, however, such as the antiphospholipid syndrome or Behcet's disease, stroke may be the presenting complaint. A format for approaching the patient and localizing the cerebrovascular lesion has been presented along with a summary of the specific rheumatologic diseases implicated for each stroke subtype.