The spectrum of atlanto axial facet joint involvement in rheumatoid arthritis

Abstract

Six hundred fifty outpatients with rheumatoid arthritis (RA) were evaluated and followed up during a 7‐year period. As part of their routine evaluation or because of neck‐shoulder girdle symptoms, 48% of the patients underwent routine cervical spine radiography. Sixty‐one RA patients (9% of the total population) had C1‐C2 involvement. Compared with the 589 patients with no evidence of C1‐C2 involvement, these 61 patients were significantly more likely to be younger, female, and seropositive, and they had significantly more nodules and erosions, as well as a longer disease duration. Based on radiographic evidence of C1‐C2 disease severity, 3 groups emerged. Group 1 (28 patients) had lateral mass collapse, group 2 (27 patients) had lateral facet joint sclerosis, erosion, or loss of joint space with no collapse, and group 3 (6 patients) had lateral subluxation with no bone or cartilage changes. Nine patients in group 1 had severe pain, and 25 had a nonreducible rotational tilt of the head. None of the patients in the other 2 groups had either of these signs or symptoms. Moreover, patients in group 1 were more likely to have other C1‐C2 or subaxial subluxations and were more likely to have myelopathy. C1‐C2 lateral facet joint involvement is common in RA, correlates with disease severity generally and specifically with that in the cervical spine, and, when severe, causes nonreducible rotational tilt of the patient's head.

Early and extensive erosiveness in peripheral joints predicts atlantoaxial subluxations in patients with rheumatoid arthritis

“…The present study confirms the previous observation that atlantoaxial subluxations of the cervical spine are associated with the extent of erosions in the peripheral joints (7,8,10,(27)(28)(29). However, our report is the first to present an estimation of the risk ratio for atlantoaxial subluxations, based on the radiographic scores in the peripheral joints during the first years of RA.…”

Involvement of the cervical spine in rheumatoid arthritis

“…Similar findings have been noted by Santavirta and coworkers (24), and these observations have been expanded to patients seen primarily in an outpatient setting (25). In the latter group, 7.8% were found to have radiographic evidence of Cl-C2 lateral facet joint involvement.…”

“…Severe involvement was more common in the inpatient group, however. Clinically, symptoms did not necessarily correlate with the severity of radiographic changes, but NRRHT occurred exclusively in patients with lateral mass collapse (25).…”

“…Postmortem studies revealed intact atlantoaxial ligaments, and the authors postulated that bone erosion may be the most important factor in the development of lateral subluxation. It is possible, however, for the synovitis in the lateral joints to result in lateral subluxation secondary to capsular and ligamentous laxity without significant erosive changes (13,25). Clinically, the final result is the same, with the major complaint being neck pain, sometimes intractable.…”

Stage-related surgery for cervical spine instability in rheumatoid arthritis

“…Dynamic forces generated by the weight of the skull, osteoporosis, and progressive inflammatory degradation of cartilaginous and bony structures of the lateral atlantoaxial joints [28] lead to a destruction of the anterior column at C2, resulting in progressive atlanto-axial kyphosis. During the second stage the atlas slips gradually over the axis in an anterior-caudal direction and produces a larger upward movement of the posterior arch of the atlas, resulting in a greater anteverted C1/C2 kyphosis angle (Fig.…”