RESEARCH - Both flexion and extension x-rays urged to rule out cervical RA

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Both flexion and extension x-rays urged to rule out cervical involvement in

RA patients

Rheumawire

March 7, 2005

Janis

Heinola, Finland - Cervical spine involvement is common in rheumatoid

arthritis (RA) and other inflammatory rheumatic disease such as psoriatic

arthritis. Chronic inflammation can injure the stabilizing ligaments of the

neck and lead to atlantoaxial impaction or subluxation. To determine whether

early intervention is warranted, Dr Markku Kauppi (Rheumatism Foundation

Hospital, Heinola, Finland) recommends in the March 2005 issue of the ls

of the Rheumatic Diseases that screening radiography include the neck in

both full flexion and full extension lateral views [1].

" I think that for screening purposes a lateral-view radiograph during full

flexion would usually be enough, but a radiograph taken during full

extension is needed if any subluxations or major erosions are seen in the

flexion picture. It is reasonable to take these 2 radiographs if a patient

with chronic arthritis is examined, " Kauppi tells rheumawire.

Surgery rarely needed, but other interventions are

" Rheumatoid cervical spine disorders are so common that cervical spine

radiographs should be taken in every patient with RA during the disease

course; they all are potential cases of [anterior atlantoaxial subluxation]

aAAS, " Kauppi writes. " Patients with highly active disease might be

screened, for example, every third or fourth year even without cervical

symptoms. "

Kauppi writes, " The chronic inflammation may injure the stabilizing

ligaments of the atlantoaxial area. In this case, the head pulls the atlas

away from the axis, at least during flexion of the neck, and anterior

atlantoaxial subluxation takes place. If the inflammation is chronic in both

atlantoaxial facet joints, their cartilage surfaces and also bony structures

may be destroyed, and the weight of the skull will press the atlas down

around the axis, and atlantoaxial impaction (AAI) (often called vertical

AAS, although no true subluxation takes place) develops, " Kauppi writes.

These problems are illustrated with 2 case reports: the first of a woman

with aAAS and synovitis pannus such that the pannus impinged on the spinal

cord, and a second in which the cervical spine showed a vertical AAS but

magnetic resonance imaging (MRI) showed no spinal-cord compression. The

first patient responded well to neurosurgery referral and fusion of the Cq1

and C2 spinous process with the occiput, plus methotrexate. The second

patient required no surgery and did well by using a hard neck collar " in

risky activities such as traveling. "

Kauppi notes that aAAS may develop early in RA, with a prevalence of about

10% after the first 2 years of disease and increased prevalence with

continued inflammatory activity. About half of RA patients presented with

some rheumatoid cervical involvement in a recent study, but Kauppi says that

this rate is likely to decrease with more widespread use of

disease-modifying antirheumatic drugs (DMARDs).

Neck pain and stiffness remain common complaints in inflammatory arthritis,

however, and Kauppi says that lateral-view plain radiography taken during

full flexion of the neck is an essential part of differential diagnosis,

because about half of unstable aAAS cases would not be diagnosed by

neutral-position radiographs alone.

In difficult cases, an open mouth anteroposterior projection radiograph may

be required, and MRI " is the best means of assessing active synovitis and

possible neural structure compressions in the cervical spine, " Kauppi

writes. However, he advises that MRI is needed only in special cases, mainly

as a preoperative examination.

Treatment is typically conservative, based on symptomatic relief and trying

to retard progression with DMARDs, plus symptomatic treatment such as

NSAIDs, massage, collars, physical exercises, and occupational therapy.

" Inflammatory changes in the cervical spine are very common in chronic

arthritis. Most of them are not severe, and thus they can be treated

conservatively but should not be ignored, since in severe cases operative

treatment may be needed, " Kauppi says.

Source

Kauppi MJ, Barcelos A, da Silva JAP. Cervical

complications of rheumatoid arthritis. Ann Rheum Dis 2005; 64:355-358.

Not an MD

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Mayo Clinic in Rochester

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s Hopkins Medicine

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