High prevalence of asymptomatic cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopaedic surgery

Abstract

Objective: To study the prevalence of cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopaedic surgery, and symptoms that might be associated with the disorders. Methods: 194 patients with rheumatoid arthritis were referred for orthopaedic surgery at Jyväskylä Central Hospital, 154 (79%) of whom volunteered for the present study including clinical examination, laboratory tests, radiographs of the cervical spine, hands, and feet, and self report questionnaires. Definition of anterior atlantoaxial subluxation (aAAS) was .3 mm and of subaxial subluxation (SAS) >3 mm. Atlantoaxial impaction (AAI) was analysed following to the Sakaguchi-Kauppi method. Results: 67 patients (44%) had cervical spine subluxation or previous surgical fusion. The prevalence of aAAS, AAI, SAS, or previous fusion was 27 (18%), 24 (16%), 29 (19%), and 8 (5%), respectively; 69% of patients with cervical spine subluxations (those with fusions excluded) reported neck pain, compared with 65% of patients without subluxations (p = 0.71). The prevalence of occipital, temporal, retro-orbital, and radicular pain in upper extremities was similar in patients with or without cervical spine subluxations (54% v 43%; 17% v 31%; 25% v 24%; 47% v 48%, respectively). However, patients with subluxations were older, had longer disease duration, more active disease, poorer function according to the Health Assessment Questionnaire, and had more often erosive disease. Conclusions: Asymptomatic cervical spine subluxation is common in patients with rheumatoid arthritis waiting for orthopaedic surgery. Regardless of symptoms, the possibility of cervical spine subluxation in patients with severe rheumatoid arthritis should be considered in preoperative evaluation.

Radiological evaluation of cervical spine involvement in rheumatoid arthritis

“…27,38,44 The standard plain radiographic screening views include upright anteroposterior, lateral, and flexionextension views and an open-mouth view for odontoid visualization. 27,38,44 Bone alignment, quality, and deformities can easily be assessed with plain radiographs, but plain radiographs are limited in their ability to visualize bony erosions, the craniocervical and cervicothoracic junctions (due to superimposition of the cranial base structures and the glenohumeral joints), and soft tissue abnormalities such as pannus and spinal cord compression. If any cervical spine disease is suspected or confirmed with plain radiographs or the patient has any neurological symptom or important cervical pain, then CT and/or MRI examination of the cervical spine is indicated.…”

“…Multilevel subluxations can produce a "staircase" deformity, associated with severe systemic RA. 18,22,27 In this paper, we review and discuss the limitations and benefits of each radiological method used to diagnose cervical instability, as well as the criteria used to classify the most common forms of cervical spine involvement in RA.…”

Rheumatoid vertical and subaxial subluxation can be prevented by atlantoaxial posterior screw fixation

“…However, the development of SAS is regulated by multiple factors, including not only the mechanical effect of fixed atlantoaxial angle and secondary subaxial kyphosis, but also disruption of the extensor muscles in addition to a strong effect due to a natural history of RA. Some authors have reported that the incidence of SAS in RA patients not surgically treated was 15-22 % [1,22,23] and of AAS was 18-61 % [1,22]. In patients who were surgically treated, a higher incidence of newly developed SAS and AAS after AA fusion using wiring systems or transarticular screws has been reported (32.7-39 % [9][10][11] and 100 %, respectively).…”

Increased Mortality Rate in Rheumatoid Arthritis Patients with Neurological Symptoms or Signs Secondary to Cervical Spine Subluxations – Reduced Mortality if Postoperative Ankylosis is Achieved

“…When the cervical spine is involved this risk is increased (Paus et al, 2008;Riise et al, 2001;Shen et al, 2004). In the RA population the estimates of the number of patients with cervical involvement varies from 12% (Naranjo et al, 2004) to 57% (Neva et al, 2006). Cervical spinal disorders should be diagnosed early and treated actively to prevent severe and potentially fatal complications (Neva et al, 2006).…”

“…In the RA population the estimates of the number of patients with cervical involvement varies from 12% (Naranjo et al, 2004) to 57% (Neva et al, 2006). Cervical spinal disorders should be diagnosed early and treated actively to prevent severe and potentially fatal complications (Neva et al, 2006). Early surgery corrects AS and prevents further instability (Grob et al, 1999;Hamilton et al, 2001;McRorie et al, 1996).…”