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CERVICAL SPINE IN RHEUMATOID ARTHRITIS

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					Editorial                                                                     J Indian Rheumatol Assoc 2004 : 12 : 1



                              CERVICAL SPINE IN RHEUMATOID ARTHRITIS
                      Cervical spine involvement in rheumatoid arthritis occurs in almost half the patients with RA
            and has adverse impact on survival in RA. The most common abnormality is atlantoaxial dislocation
            (AAD) followed by atlanto-occipital arthritis and lesions of lower cervical spine.
                      In the study by Chellapandian et al in this issue of journal cervical spine abnormalities were
            detected in 43% of patients with 20% of patients having atalantoaxial abnormalities1. The reported
            prevalence of AAD varies between 10-20% in patients with long standing disease2-3. Similar to the
            previous data the present study confirms the association of cervical spine disease with peripheral
            erosive disease, duration of disease, extra-articular features and rheumatoid factor.
                      What is the clinical significance of these abnormalities? Most authors report lack of associa-
            tion between neck pain and radiological abnormalities. However, it is important to screen all patients
            undergoing surgery for AAD to prevent cord-compression during intubation.
                      What is the pathology at the craniocervical junction? Is it the hyperplastic synovium of atlanto-
            axial joint which causes compression? A recent analysis of tissue obtained at transoral resection in pa-
            tients with AAD revealed synovial tissue without hyperplasia, inflammatory cell infiltrate in early cases
            whereas patients with neurological deficit had bland, fibrous, hypovascular tissue with liitle synovium4.
            Thus hyperplastic synovium is not the cause of laxity or destruction of supportive ligaments.
                      What is best modality to evaluate cervical spine? For screening, lateral radiographs in neutral
            position is the best as it reveals AAD, apophyseal joint abnormalities and subaxial dislocation. Radio-
            graphs in flexion and extension are needed to diagnose flexible and mild AAD. CT-myelo and MRI of
            cervical spine are needed prior to surgery to completely evaluate the anatomy and in symptomatic
            patients with equivocal X-rays. MRI is preferred over CT-myelo as it is non-invasive and also gives
            better delineation of soft tissues.
                      How do you treat symptomatic AAD? Minor AAD can be treated with cervical collar and
            avoidance of trauma. Significant AAD, flexible AAD or patients with neurological deficit need sur-
            gery. It involves occipitocervical fusion using various techniques like inside-outside stabilization tech-
            nique5, sublaminar wires or lateral mass screws.

            References:
            1.   Chellapandian D, Panchapekesa Rajendran C, Rukmangatha Rajan S, Parthiban M Mahesh A. The Cervical
                 Spine Involvement in Rheumatoid Arthritis and its Correlation with Disease Severity. J Indian Rheumatol
                 Assoc 2004; 12:2-5.
            2.   Neva MH, Isomaki P, Hannonen P, Kauppi M, Krishnan E, Sokka T. Early and extensive erosiveness in
                 peripheral joints predicts atlantoaxial subluxations in patients with rheumatoid arthritis. Arthritis Rheum
                 2003; 48: 1808-13.
            3.   Aggarwal A, Kulshreshtha A, Chaturvedi V, Misra R. Cervical spine involvement in rheumatoid arthritis:
                 Prevalence and relationship with overall disease severity. J Assoc Physician India. 1996; 44: 468-471.
            4.   O‘Brien MF, Caey AT, Crockard A, Pringle J, Stevens JM. Histology of the craniocervical junction in chronic
                 rheumatoid arthritis: a clinicopathological analysis of 33 operative cases. Spine 2002; 27: 2245-54.
            5.   Sandhu FA, Pait TG, Benzel E, Henderson FC. Occipitocervical fusion for rheumatoid arthritis using the
                 inside-outside stabilization technique. Spine 2003; 28: 414-9.

                                                                                                        Amita Aggarwal
                                                                                             Department of Immunology
                                                                         Sanjay Gandhi Postgraduate Institute of Med. Sci.
                                                                                                                 Lucknow

				
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