Figure - available from: Current Rheumatology Reports
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Atlanto-axial subluxation (AAS) in neutral position of the neck (a) and anterior flexion (b). Note that in neutral position, the space between the posterior surface of the anterior arch of the atlas and the anterior aspect of the odontoid process is not well visualized (2 mm) and may be missed (black arrow). Thus, an x-ray of the neck must be done in flexion in order to reveal the real space between the two anatomical structures (6 mm—white arrow)
Source publication
Purpose of review:
Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting mainly the peripheral skeleton in a symmetrical manner rather than the axial skeleton, but when it occurs it can affect the cervical spine (CS). Although CS involvement is a frequent radiographic finding in RA, the clinical features are scarce, but potentially...
Citations
... As early as 1890, Garrod AE reported the first description of 178 patients with cervical spine involvement in a series of 500 patients with RA, reporting a prevalence around 30% 3 . Subsequently, many works investigated this issue with different and partially conflicting results [4][5][6][7][8][9][10][11] , highlighting the need of further studies to fully elucidate this topic. In fact, a highly different prevalence of cervical spine involvement is reported in RA patients, ranging between 25 and 88% [4][5][6][7][8] . ...
... Subsequently, many works investigated this issue with different and partially conflicting results [4][5][6][7][8][9][10][11] , highlighting the need of further studies to fully elucidate this topic. In fact, a highly different prevalence of cervical spine involvement is reported in RA patients, ranging between 25 and 88% [4][5][6][7][8] . During RA, the atlas-axis cervical vertebrae 1 and 2 (C1 and C2) articulation may be typically involved, between the transverse ligaments of the atlas and the posterior side of the odontoid. ...
... Subsequently, the compression of the cranial nerves may lead to other clinical features, such as occipital headache, migraines, and neck, mastoid, ear, or facial pain [4][5][6][7] . In later and more severe stages, patients may experience a cervical instability, generally reporting a clinical picture of crepitation associated with a sensation of their head falling forward upon flexion 5,6,8 . In this context, the diagnostic role of computed tomography (CT) and magnetic resonance imaging (MRI) has been recently highlighted in an accurate recognition of this manifestation 7,8 . ...
Atlantoaxial joint is a possible affected site during rheumatoid arthritis (RA) and, in this work, we evaluated its occurrence and associated characteristics in a “real-life” cohort. By a medical records review study of RA patients longitudinally followed-up, the occurrence of severe atlantoaxial joint involvement was estimated (incidence proportion and incidence rate per 1000 person-years at risk). Regression analyses were also exploited to evaluate possible associated factors. Based on these findings, a prospective recruitment was performed to build a descriptive cross-sectional study in evaluating a subclinical atlantoaxial joint involvement in patients with the same clinical characteristics. Retrospectively, 717 patients (female 56.6%, age 64.7 ± 12.3 years) were studied. The incidence proportion of severe atlantoaxial joint involvement was 2.1% [1.5–2.5], occurring in 15 out of 717 patients, and identified by both MRI and CT scan. Considering over 3091 person-years, an incidence rate of 5.2 × 1000 [2.9–8.3] person-years was estimated. Regression analyses suggested that male gender, a longer disease duration, ACPA positivity and extra-articular manifestations resulted to be significantly associated with a severe atlantoaxial joint involvement. Given these findings, 30 asymptomatic patients were selected according to these clinical characteristics and underwent MRI of cervical spine. To date, almost 50% of these asymptomatic patients showed a subclinical atlantoaxial joint involvement. The occurrence of the severe atlantoaxial joint involvement in RA patients was estimated in a “real-life” setting. Male gender, ACPA positivity, long disease duration, and extra-articular manifestations could be associated with the severe atlantoaxial joint involvement in RA. MRI could provide a useful clinical tool to early evaluate the atlantoaxial joint involvement in RA, also in asymptomatic patients.
... This diagnostic tool can also help the surgeon predict postoperative neurologic outcome [24]. PADI < 14 mm has been correlated with adverse surgical outcomes and is more commonly complicated with vertical subluxation [25,26]. ...
The purpose of the present systematic review was to describe the diagnostic evaluation of rheumatoid arthritis in the cervical spine to provide a better understanding of the indications and options of surgical intervention. We performed a literature review of Pub-med, Embase, and Scopus database. Upon implementing specific inclusion and exclusion criteria, all eligible articles were identified. A total of 1878 patients with Rheumatoid Arthritis (RA) were evaluated for cervical spine involvement with plain radiographs. Atlantoaxial subluxation (AAS) ranged from 16.4 to 95.7% in plain radiographs while sub-axial subluxation ranged from 10 to 43.6% of cases. Anterior atlantodental interval (AADI) was found to between 2.5 mm and 4.61 mm in neutral and flexion position respectively, while Posterior Atlantodental Interval (PADI) was between 20.4 and 24.92 mm. 660 patients with RA had undergone an MRI. A pannus diagnosis ranged from 13.33 to 85.36% while spinal cord compression was reported in 0–13% of cases. When it comes to surgical outcomes, Atlanto-axial joint (AAJ) fusion success rates ranged from 45.16 to 100% of cases. Furthermore, the incidence of postoperative subluxation ranged from 0 to 77.7%. With regards to AADI it is evident that its value decreased in all studies. Furthermore, an improvement in Ranawat classification was variable between studies with a report improvement frequency by at least one class ranging from 0 to 54.5%. In conclusion, through careful radiographic and clinical evaluation, cervical spine involvement in patients with RA can be detected. Surgery is a valuable option for these patients and can lead to improvement in their symptoms.
... In RA, the prevalence of cervical spine involvement has been estimated to affect 16% to 70.4% with symptoms ranging from neck pains and reduced range of motion to that causing radiculopathy with paresthesia of the hand and fingers (25,26). Symptoms can be elicited through clinical examination of the cervical spine before further imaging with radiographs, CT, and MRI scans. ...
... Symptoms can be elicited through clinical examination of the cervical spine before further imaging with radiographs, CT, and MRI scans. MRI imaging is the most sensitive in the evaluation of the surrounding soft tissue structures and synovitis (25). X-rays provide an important screening tool for the clinician to assess alignment and deformities associated with RA, such as the early changes of joint space narrowing, vertebral plate, and apophyseal joint erosions (25). ...
... MRI imaging is the most sensitive in the evaluation of the surrounding soft tissue structures and synovitis (25). X-rays provide an important screening tool for the clinician to assess alignment and deformities associated with RA, such as the early changes of joint space narrowing, vertebral plate, and apophyseal joint erosions (25). Early radiographical cervical spine changes have been observed in asymptomatic rheumatoid patients, which can be important in the early diagnosis and treatment of RA (10,26). ...
Elite athletes commonly present with joint pains that are attributed to overuse injuries though on occasion it can be due to an inflammatory arthropathy. The diagnostic challenge is that presenting symptoms of benign injuries are similar to inflammatory arthropathies. A holistic review of the athlete can provide clues suggestive of inflammatory arthropathy, before requesting further investigations to confirm the diagnosis. Current imaging modalities are not specific in differentiating inflammatory arthritis with other causes of joint inflammation. Prompt treatment is required to restore the athlete to an optimum level of activity and prevent career ending disability, all in adherence to the regulations of the sporting governing bodies. This review aims to highlight the importance of inflammatory arthropathy in the differentials for an athlete presenting with joint pains.
... The most common radiological manifestations of CS in RA are the atlanto-axial subluxation (AAS), followed by the sub-axial subluxation (SAS), the articulations below the C2 vertebrae. 3,4 Although CS involvement is a common radiological finding in RA patients, the clinical manifestations are scarce, but sometimes potentially severe and life-threatening with serious neurological complications, [5][6][7] as in the case we present below. ...
... Persistent inflammation of this articulation may produce dens erosions, damage of the transverse, alar and apical ligaments, and laxity leading to joint instability. 3,4,7 The distance between the anterior aspect of the odontoid process and the posterior surface of the anterior arch of the atlas usually measures ≤3mm. If this distance increases and exceeds more than 8mm the chance of CS cord compression is high. ...
... Thus, in AAS if the anterior atlanto-dental distance increases more than 3mm and the posterior atlanto-dental distance decreases less than 14mm, then the CS cord is prone to compression. 7,15 Radiological findings of the lateral AAS Lateral AAS is rare, resulting in a rotational deformity. For a better evaluation, the open-mouth view is preferred. ...
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.
... The articular (symmetrical polyarthritis is the clinical hallmark) and extra-articular manifestations of the disease (more frequently subcutaneous and pulmonary nodules, pericardial and pleural effusions, interstitial lung disease but also rare manifestations such as vasculitis and cochlear involvement [1,2]) may lead to functional disability and systemic complications if left untreated [3]. Regarding articular damage, hands and wrists are routinely screened for any possible erosions [4], whereas other sites such as the cervical spine, which, if involved is potentially life-threatening, should be evaluated as well [5]. Additionally, due to the augmented risk of cardiovascular complications [6], a cardiac evaluation needs to be undertaken periodically. ...
Introduction: Rheumatoid arthritis (RA) is an autoimmune disease that is characterized by progressive joint disorders with significant pain and stiffness. In the past, RA was a difficult -to-treat ailment, but nowadays with the advent of biologics and better treatment strategies, disease remission is an achievable goal. Tumor necrosis factor α (TNFα) inhibitors were the first category of biologics to emerge with adalimumab being the first fully human TNFα.
Areas covered: the authors provide an overview of the historical events that led to the discovery of TNFα inhibitors and more specifically the drug adalimumab. Several key trials are presented regarding the safety of the drug as well as its successful journey, but there is also a narrative description of the drug’s future after patent expiration.
Expert opinion: Adalimumab is a fully human TNFα inhibitor with a fairly rapid onset of action. It has a generally good safety and efficacy profile. Clinicians must be aware of the possible side effects and treat them in a timely manner or discontinue the drug where appropriate. Due to the success of the bio-originator adalimumab, a multitude of biosimilars have emerged but not, thus far, for all of the indications of the bio-originator.
Rheumatoid Arthritis (RA) is an autoimmune disease that is characterised by progressive joint disorder with significant pain and stiffness, which lead to functional disability and systemic complications if left untreated. The direct (health care costs) and indirect (productivity loss) socioeconomic costs of the disease are of major significance.
The craniocervical junction (CCJ) is a complex anatomical structure comprising the occiput, the atlas, and the axis. The CCJ plays an important role in maintaining stability, providing protection, and supporting neurovascular structures. The CCJ can be affected by a wide range of congenital variants and traumatic, degenerative, inflammatory, and tumoral pathologies. This pictorial review the normal anatomy of the CCJ and presents the most common anatomical variants and pathologic conditions affecting the CCJ.
Objectives
The purpose of this study was to examine the reproducibility of vertical subluxation parameters using X-ray, computed tomography and tomosynthesis while comparing the head-loading effects.
Methods
The vertical subluxation parameters of 26 patients (retrospective review) were evaluated. Using the intra-class correlation coefficient, we statistically examined the intra-rater and inter-rater reliabilities of the parameters. Head-loaded and -unloaded imagings were compared using a Wilcoxon signed-rank test.
Results
The intra-rater reliability of tomosynthesis and computed tomography showed intra-class correlation coefficients of ≥0.8 (X-ray range: 0.6–0.8), with similar results for the inter-rater reliabilities. Further, in the head-loading imaging, the tomosynthesis had significantly higher vertical subluxation scores than computed tomography (P < 0.05).
Conclusions
In comparison with the X-ray, tomosynthesis and computed tomography were more accurate and reproducible. In terms of head loading, the vertical subluxation values for tomosynthesis were worse than those for computed tomography, indicating that tomosynthesis was more effective than computed tomography in diagnosing vertical subluxation.
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.
Objective:
To study the proportion of cervical spine instability in treatment-naive rheumatoid arthritis (RA) patients, to investigate the associated neck symptoms, and to analyze the clinical characteristics in treatment-naive RA patients and treated RA patients.
Methods:
RA patients who underwent cervical spine X-ray imaging from the Department of Rheumatology and Immunology of Peking University Third Hospital and Peking University Shenzhen Hospital from August 2015 to October 2019 and had clinical records of medication administration were included. Clinical and laboratory data including cervical symptoms and X-ray imaging data of cervical spine were collected. The constituent ratio of cervical spine instability in treatment-naive RA patients was statistically analyzed. The clinical data and laboratory data were analyzed by t-test, u-test and chi square to explore the clinical characteristics of the treatment-naive RA patients with cervical instability.
Results:
Of the 408 RA patients, 105 patients were treatment-naive. Of the 105 treatment-naive patients, 82.9% (87/105) were female, with an average age of (52±14) years, the median duration of the disease was 24 months, the shortest history was 2 weeks, and the longest history was 30 years. 28.6% (30/105) of the treatment-naive RA patients showed cervical spine instability. The prevalence of cervical instability was 13.6% in the treatment-naive RA patients with disease duration less than 24 months. Among them, there were no significant differences in neck symptoms between cervical spine instability group and none cervical spine instability group. The patients with cervical spine instability had a longer duration of disease [60 (18, 180) months vs.16 (8, 51) months], a higher proportion of peripheral joint deformity (63.3%vs.21.3%), and a lower hemoglobin [(106.90±21.61) g/L vs. (115.77±14.69) g/L]. There was no significant difference in the occurrence of cervical instability in the treatment-naive RA patients compared with treated RA patients. Among the RA patients with cervical instability, there was no statistically significant difference in the composition of each type between the patients with treatment-naive RA and patients with treated RA, except for a shorter duration of disease [120.0 (72.0, 240.0) months vs. 60.0 (27.0, 167.5) months].
Conclusion:
28.6% of treatment-naive RA patients showed cervical spine instability. Cervical instability was also common in RA patients with a duration less than 24 months. There was no significant correlation between cervical instability and neck symptoms. Patients with cervical spine instability had a long-term disease, a higher proportion of peripheral joint deformity and a lower hemoglobin. Controlling the condition of RA early may help to control the progression of cervical involvement in patients with RA.
