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Rheumatoid Arthritis of the Cervical Spine. Zikou Anastasia Radiology Department University Hospital of Ioannina. Introduction. Rheumatoid arthritis (RA) is a chronic multisystemic disease of unknown cause. Characteristic feature: inflammatory synovitis

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slide1

Rheumatoid Arthritis of the Cervical Spine

Zikou Anastasia

Radiology Department

University Hospital of Ioannina

slide2

Introduction

Rheumatoid arthritis (RA) is a chronic multisystemic disease of unknown cause.

Characteristic feature: inflammatory synovitis

- peripheral joints / symmetrical distribution

- cartilage destruction / bone erosion

- joint deformity

After the metacarpophalangeal joints,

the most common region to be involved in RAis the cervical spine.

History: 1890, *Garrod reported that 36% of his pts with RA had c-spine involvement.

* Garrod, A.Griffins Medical Series.1890. Available at: http://books.google. Accessed July 11, 2011.

slide3

Introduction

Radiographic signs: 43-86%

*Pellicci et al ( 5 yrs study / 106 RA pts)

radiological evidence of c-spine involvement: 43% of pts / baseline

86% of pts / follow-up

**Mikulowski et al: fatal cord compresion 10% in pts with RA

Wasserman B,et al.Bull NYU Hospfor Jt Dis. 2011;69(2):136-48.

* Pellicci P et al.J Bone Joint Surg Am. 1981;63:342-50.

** Mikulowski P et al. ActaMed Scand. 1975;198(6):445-51.

slide4

Introduction

  • Risk factors for c-spine involvement:

– Males

– RF

- Rheumatoid nodules

  • – Peripheral activity
  • - Vasculitis
  • – Corticosteroid use
  • Clinical signs:
  • – Neck pain 40 to 88%
  • – Neurologic compromise 7 to 34%

* Wasserman B,et al.Bull NYU Hospfor Jt Dis. 2011;69(2):136-48

slide5

RA & C-Spine Imaging

  • • Atlanto-axial subluxation( 65% of all cervicalsubluxations )
  • - majority anterior
  • - 20% lateral
  • - 7%posterior
  • - rotatory rare
  • • Superior migration of the odontoid
  • - second most common deformity
  • - 20% of pts
  • - odontoid erosions
  • Subaxial c-spine involvement
  • - Subaxial subluxation :15% of pts
  • - Apophyseal joint ankylosis

* Wasserman B,et al.Bull NYU Hospfor Jt Dis. 2011;69(2):136-48

slide7

RA & C-Spine Imaging

Radiography

  • Anterior atlantoaxial subluxation
  • Vertical subluxation
  • Subaxial spinal involvement

- Subaxial subluxation

Magnetic Resonance Imaging

  • Pannus
  • Spinal cord
slide8

RA & C-Spine Imaging

Radiography

  • Anterior atlantoaxial subluxation (AAS)

AAS : 50% of pts symptomatic

The role of plain radiography is to establish whether

there are risk factors for cord compression.

slide9

AAS

- Anterior atlantodental interval (AADI)

AADI > 3-6 mm: early instability

transverse lig.

AADI > 6 mm

transverse & alar lig.

AADI > 9 mm

surgical stabilization.

AADI : yellow line

slide10

AAS

Neutral

Flexion

AADI : yellow line

slide11

AAS

- Posterior atlantodental interval (PADI)

  • All cervical spinal levels
  • cord: 10 mm
  • CSF: 2 mm
  • dura: 2 mm
  • PADI > 14 mm
  • (avoid cord compression)
  • spinal canal: 17-29 mm at C1

PADI : red line

PADI : red line

slide12

AAS

Neutral

Flexion

PADI : red line

slide14

Vertical subluxation

McGregor´s line-Odontoid tip > 4.5 mm

slide15

Vertical subluxation

Ranawat method (♂ > 15 mm & ♀ > 13 mm)

slide16

Vertical subluxation

Clark’s stations

slide17

Vertical subluxation

cervicomedullary angle

(normalrange: 135° to 175°)

slide20

Subaxial subluxation

Subluxation > 1mm

> 3,5 mm !!!

  • Cervical Height Index (CHI)
  • - subluxations at multiple levels
  • - loss of disk height
  • bony collapse
  • CHI < 2(neurologic compromise)
slide21

Subaxial subluxation

Zikou AK, et al.J Rheumatol 32: 801-806, 2005.

slide22

Sudaxial spinal involvement

  • Apophyseal joints ( erosions - ankylosis)
  • Intervertebral disk - space narrowing
  • Irregularity of the subchondral margins of the vertebral bodies
  • Erosion and sclerosis
  • Corticosteroid - ischemic necrosis of bone - vertebral collapse
slide24

RA & C-Spine Imaging

Magnetic Resonance Imaging

  • Major indications for c-spine MRI in RA:
  • abnormal measurements on plain radiographs
  • unremitting suboccipital /cervical pain
  • progressive / severe subluxations
  • symptoms of cord/brainstem/vert. art. compression

MRI : evaluation of the spinal cord and neural elements

- Presence and effect of pannus on the spinal cord

- Spinal cord signal can be assessed

(edematous spinal cord changes: poor clinical status, poor prognosis & poor postoperative outcome)

slide25

AAS

“pannus”

slide27

Odontoid erosions - “pannus”

Zikou AK, et al. Clin Exp Rheumatol 23: 665-670, 2005.

slide28

Subaxial subluxation

Zikou AK, et al. Clin Exp Rheumatol 23: 665-670, 2005.

slide29

AAS

Subaxial subluxations

slide31

Take home messages

Plain radiography : Flexion / extension views

- the level of involvement

- evidence of instability

Further imaging with MRI : pannus & spinal cord

AADI > 9 mm or PADI < 14 mm

Vertical subluxation

Subaxial subluxation > 3,5 mm

The major role for MRI : pre & after operative assessment

slide33

* 165 RA pts ( 143♀/ 22♂)

mean age: 59,6 ± 12,5 yrs

disease duration: 12,3 ± 7,9 yrs

RF (+) : 63,6%

Radiological findings: 146 pts

- AAS: 20,6%

- Odontoid erosions: 2,4%

- Sudaxial subluxations: 43,6%

- Disk space narrowing: 66,1%

- Vertebral plate erosions - sclerosis: 43,6%

C - spine involvement: frequent finding

mild severity

** 51 RA pts ( 42♀/ 9♂)

mean age: 56,5 ± 10,4 yrs

disease duration: 12,4 ± 8,5 yrs

RF (+) : 64,7%

clinical signs : c-pain & stiffness 30%

Rx / MR findings: 40 / 44 pts

- Peridental pannus: 88%

- Odontoid erosions: 23,5%

- AAS: 13,7%

- Brainstem compression: 5,9%

- Sudaxial subluxations: 10%

Peridental pannus correlated (p<0,05) with:

- DAS-28

- RF(+)

- Erosive changes hand-wrist

(Larsen criteria)

*Zikou AK, et al.Radiological cervical spine involvement in patients with rheumatoid arthritis:

a cross sectional study. J Rheumatol 32: 801-806, 2005.

**Zikou AK, et al.Magnetic resonance imaging findings of the cervical spine in patients with rheumatoid arthritis:

a cross sectional study.Clin Exp Rheumatol 23: 665-670, 2005.