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

Abstract

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.

Endothelial Dysfunction and Extra-Articular Neurological Manifestations in Rheumatoid Arthritis

“…The cervical vertebrae C1 and C2 are the typical targets of the pathology and the involvement of the cervical spine can present various forms including erosions of the vertebral endplates, erosions of the spinous process, and changes in the apophyseal joint followed by osteoporosis [ 40 ]. These inflammatory lesions of the cervical spine, associated with frequent subluxations, occur within the first ten years after the diagnosis of RA, although many patients remain completely asymptomatic [ 41 ]. Diagnosis of cervical myelopathy is carried out by X-rays, through which it is possible to assess the parameters of the cranio-cervical junction.…”

Endothelial Dysfunction and Extra-Articular Neurological Manifestations in Rheumatoid Arthritis

“…These symptoms are caused by compression of the spinal cord and brain stem [38]. The cervical vertebrae C1 and C2 are the typical targets of the pathology and the involvement of the cervical spine can present various forms including erosions of the vertebral endplates, erosions of the spinous process, changes in the apophyseal joint followed by osteoporosis [39]. These inflammatory lesions of the cervical spine, associated with frequent subluxations, occur within the first ten years after the diagnosis of RA, although many patients remain completely asymptomatic [40].…”

Application of 2D Gait Analysis for the Assessment of Gait Disturbance in Patients with Spastic Tetraparesis

“…An increase in muscle tone of the upper and lower limbs is symptomatic for many diseases affecting the cervical spine. Up to 93% of patients with spinal cord trauma at the cervical level and up to two-thirds of patients with spondylogenic and vascular myelopathy show signs of muscle spasticity [ 1 , 2 ]. In most cases, an increase in tone leads to gait abnormalities and, as a consequence, to a low quality of life and a high percentage of disability in this group of patients [ 3 – 5 ].…”