Progression of rheumatoid arthritis of the cervical spine: radiographic and clinical evaluation

A not-to-miss Cause of Severe Cervical Spine Pain in a Patient with Rheumatoid Arthritis: A Case-Based Review

Background:

Rheumatoid arthritis (RA) may affect any diarthrodial joint with a predilection on the peripheral skeleton in a symmetrical manner. When the axial skeleton is affected, it is the cervical spine (CS) that gets involved with potentially detrimental effects, if not treated promptly.

Case:

A 60-year-old female suffering from RA presented with severe neck pain and stiffness, difficulty of standing and walking with brisk tendon reflexes, Babinski sign positive, and clonus. Despite the high inflammatory markers and high titres of autoantibodies (rheumatoid factor and anticitrullinated protein antibodies), she never received proper treatment. She was using only paracetamol and non-steroidal anti-inflammatory drugs. Conventional radiography (CR) of CS showed extensive degenerative changes affecting the C3–C5 vertebral level. Magnetic Resonance Imaging of the neck showed sub-axial subluxation (SAS) and spinal cord compression at C3 level, and to a lesser extent, in other levels. A multi-level cervical laminectomy and spinal cord decompression were deployed with good results. To this end, literature review was performed until September 2020 and showed that the frequency of radiological findings varies substantially, ranging between 0,7–95% in different studies. The most common radiological feature is the atlanto-axial subluxation (AAS) followed by SAS. Because CS involvement can often be clinically asymptomatic, its assessment should not be forgotten by physicians and should be assessed using CR, which is an easy-to-perform technique and gives important information as a screening tool. On the other hand, RA patients need to be treated in a prompt and efficient manner in order to avoid any potentially fatal complications.

Changes in the incidence of cervical lesions owing to the development of rheumatoid arthritis treatment and the impact of cervical lesions on patients' quality of life

Objectives: To clarify changes in the incidence of cervical lesions in rheumatoid arthritis (RA) patients with advanced treatment and the impact of cervical lesions on the patients' quality of life (QOL).Methods: Incidence of radiographic cervical lesions in 1333 RA patients in 2015 was compared with that in our 1999 survey. The association between cervical lesions and QOL evaluated using three different patient-based questionnaires was also analyzed.Results: The incidence of atlantoaxial subluxation (AAS), vertical subluxation (VS), and subaxial subluxation (SAS) in 2015 decreased by 50%, 75%, and 5%, respectively, compared to the 1999 survey. Although QOL, evaluated using the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ; specific to myelopathy), deteriorated as the cervical lesion progressed, there was no association between cervical lesion progression and QOL evaluated using the Short Form-8™ (SF-8™; comprehensive health-related QOL). Cervical lesion progression was also associated with QOL deterioration evaluated using the Health Assessment Questionnaire Disability Index (HAQ-DI; specific to RA), but age and disease duration had stronger influences.Conclusion: The incidence of cervical lesions decreased in 2015 compared to 1999. Cervical lesion progression may be associated with QOL deterioration due to myelopathy. Age and disease duration have more impact on disease-specific QOL.

Retro-Odontoid Pseudotumor in a Patient with Atlanto-Occipital Assimilation

A retro-odontoid pseudotumor is an uncommon non-neoplastic mass. They are mostly associated with rheumatoid arthritis and atlanto-axial subluxation. The pathogenesis is degeneration of the transverse ligament due to chronic mechanical stress. In this case report, an atlanto-occipital assimilation altered the biomechanics of the cervical spine, causing chronic mechanical stress on the transverse ligament and subsequently the development of a retro-odontoid pseudotumor. This is in accordance with previous studies that have attributed the development of retro-odontoid pseudotumor to a loss of mobility of the cervical spine, in cases without associated rheumatoid arthritis or atlanto-axial subluxation.

Transdural approach to resection of retro-odontoid cysts in elderly patients: report of 3 cases

Retro-odontoid cysts that arise from the tectorial membrane are uncommon lesions that can occur in elderly patients. They arise secondary to degenerative changes, including calcium pyrophosphate deposition within the ligaments. Surgical treatment is indicated when these lesions result in intractable pain, instability, and/or myelopathy. Several surgical techniques to treat this condition exist, but the optimal approach in elderly patients with comorbidities remains controversial. Here, the authors present a case series of 3 patients who underwent successful resection of a retro-odontoid lesion performed through a transdural approach.

The patients were 70, 81, and 74 years old and presented with symptoms of cervical myelopathy. In consideration of their advanced age and the location of their lesion, resection via a posterior approach was considered. A 1- to 2-cm suboccipital craniectomy and C-1 and partial C-2 laminectomy were performed. These lesions could not be accessed via an extradural posterolateral approach, and so a transdural approach was performed. In the first 2 patients, a preexisting deformity prompted an instrumented fusion. In the third patient, only a lesion resection was performed. In each case, the dural opening was made using a paramedian ipsilateral-sided incision, and the lesion was resected through an incision in the anterior dura mater. Only the posterior dura was closed primarily. MR imaging evidence of excellent spinal cord decompression was evident in follow-up examinations.

Transdural resection of retro-odontoid cysts is a viable option for treating asymmetrical ventral extradural cysts. Results from this case series suggest that such an approach is safe and feasible and can provide an alternative to open or endoscopic anterior transpharyngeal approaches.

Dynamic paraspinal muscle impingement causing acute hemiplegia after C1 posterior arch laminectomy: A case report

RATIONALE

Acute neurological deficits following spinal surgery commonly result from epidural hematoma, surgical trauma, vascular compromise, and graft or hardware impingement, with the cause identified by magnetic resonance imaging (MRI). We present a rare case of dynamic paraspinal muscle impingement after C1 posterior arch laminectomy, which was diagnosed by myelography, with no significant findings on MRI.

PATIENT CONCERNS

An 81-year-old, severely obese male, was referred to our department for the treatment of vertebral disease of the lumbar spine. The patient presented with bilateral weakness and numbness of the upper extremities and gait disturbances. Based on MRI, a diagnosis of retro-odontoid pseudotumor was made, and C1 posterior arch laminectomy, in combination with C4 partial laminectomy and C5 to C6 laminoplasty, was performed. On postoperative day 3, the patient's neurological status deteriorated, with right upper extremity and right lower extremity weakness increasing with neck extension. Although there was no evidence of epidural hematoma formation on MRI, obstruction of the flow of contrast medium by an external posterior compression in neck extension at the level of C1 was identified by myelography. Revision surgery was performed and local muscle swelling at the surgical site identified with no hematoma formation. Occiput to C3 fixation, with instrumentation, was performed.

OUTCOMES

Muscle strength of the right upper extremity and lower extremities recovered postsurgery, and the patient has continued to improve function 3 years after surgery, with no further neurological episodes.

LESSONS

Dynamic paraspinal muscle impingement following C1 laminectomy in a muscular man was diagnosed by myelography, with no significant findings on standard MRI.

CONCLUSION

The possibility of dynamic paraspinal muscle impingement should be considered in patients developing acute, progressive, neurological deficits after posterior cervical decompression, with myelography being the imaging method of choice for diagnosis.

Spontaneous anterior arch fracture of the atlas following C1 laminectomy without fusion: A report of three cases and finite element analysis

BACKGROUND

Only four cases of anterior arch fracture after C1 laminectomy without fusion have been previously reported. Although atlas fractures commonly occur in response to high-energy trauma, no obvious trauma that could cause the fracture was observed in these reported cases. The purpose of this study was to elucidate the biomechanical mechanism of anterior arch fracture of the atlas following C1 laminectomy and present three cases of this fracture.

METHODS

Three cases of fracture of the anterior arch of the atlas following C1 laminectomy were retrospectively reviewed. Three atlas models (an intact model, a laminectomy model, and a transverse ligament-resected model) were created from computed tomography data of each case using a three-dimensional finite element method. Axial load was applied on the superior facet to mimic four conditions (neutral, flexion, extension, lateral bending). The distribution of von Mises stress in the anterior arch and the displacement of the posterior arch were compared among the three models.

RESULTS

In all three cases, the anterior arch fracture clinically occurred after C1 laminectomy despite there being no obvious inciting trauma. During the finite element analysis, increased stress was observed in all postures of the laminectomy model as compared with the intact model. The stress-concentrated location observed in the finite element model was consistent with the fracture sites that were clinically observed. In terms of loading condition, much higher stress was observed in extension and lateral bending as compared with other postures. There were no significant differences in stress distribution between the laminectomy model and the transverse ligament-resected laminectomy model.

CONCLUSIONS

Stress distribution concentrates in the anterior arch after C1 laminectomy, leading to fracture of the anterior arch despite no inciting trauma. There may be more frequent occult fractures observed after C1 laminectomy than has been reported. Therefore, surgeons should recognize anterior arch fracture as a possible complication of C1 laminectomy without fusion.

Cervical spine involvement in rheumatoid arthritis over time: results from a meta-analysis

Introduction

Complications in rheumatoid arthritis (RA) seem less common than they were years ago. The prevalence and progression of anterior atlantoaxial subluxations (aAASs), vertical subluxations (VSs), subaxial subluxations (SASs), and associated cervical myelopathy in RA over the past 50 years were determined.

Methods

A literature search was performed by using Medline-OVID/EMBASE, PubMed, and Scopus (from 1960 to June 21, 2014). Prevalence studies were included if the sample size was at least 100 or the prevalence/progression of cervical subluxations was reported. Study quality was assessed by using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. Prevalence of cervical subluxations was calculated for each study. Student’s t test and meta-regression were used to evaluate for significance.

Results

In total, 12,249 citations were identified and 59 studies were included. The prevalence of aAAS decreased from 36% (95% confidence interval (CI) 30% to 42%) before the 1980s to 24% (95% CI 13% to 36%) in the 2000s (P = 0.04). The overall prevalence rates were 11% (95% CI 10% to 19%) for VS, 13% (95% CI 12% to 20%) for SAS, and 5% (95% CI 3% to 9%) for cervical myelopathy, and there were no significant temporal changes. Rates of progression of aAAS, VS, and SAS were 4, 6, and 3 lesions per 100 patients per year, respectively. The incidence of new or progressive cervical myelopathy was 2 cases per 100 patients with known cervical subluxations per year.

Conclusions

Since the 1960s, only aAAS has decreased dramatically. It is still more than twice as common as VS or SAS. No temporal changes in the development of cervical myelopathy in affected patients with RA were noted. The progression rates of cervical subluxations and myelopathy were unchanged over time.

The surgical management of the rheumatoid spine: Has the evolution of surgical intervention changed outcomes?

Context:

Surgery for the rheumatoid cervical spine has been shown to stabilize the unstable spine; arrest/improve the progression of neurological deficit, help neck pain, and possibly decelerate the degenerative disease process. Operative intervention for the rheumatoid spine has significantly changed over the last 30 years.

Aims:

The purpose of this study was to review all cases of cervical rheumatoid spine requiring surgical intervention in a single unit over the last 30 years.

Materials and Methods:

A prospectively-maintained spine database was retrospectively searched for all cases of rheumatoid spine, leading to a review of indications, imaging, Ranawat and Myelopathy Disability Index measures, surgical morbidity, and survival curve analysis.

Results:

A total of 224 cases were identified between 1981 and 2011. Dividing the data into three time-epochs, there has been a significant increase in the ratio of segment-saving Goel-Harms C1-C2: Occipitocervical fixation (OCF) surgery and survival has increased between 1981 and 2011 from 30% to 51%. Patients undergoing C1-C2 fixation were comparatively less myelopathic and in a better Ranawat class preoperatively, but postoperative outcome measures were well-preserved with favorable mortality rates over mean 39.6 months of follow-up. However, 11% of cases required OCF at mean 28 months post-C1-C2 fixation, largely due to instrumentation failure (80%).

Conclusion:

We present the largest series of surgically managed rheumatoid spines, revealing comparative data on OCF and C1-C2 fixation. Although survival has improved over the last 30 years, there have been changes in medical, surgical and perioperative management over that period of time too confounding the interpretation; however, the analysis presented suggests that rheumatoid patients presenting early in the disease process may benefit from C1 to C2 fixation, albeit with a proportion requiring OCF at a later time.

C1 laminectomy for retro-odontoid pseudotumor without atlantoaxial subluxation: review of seven consecutive cases

PURPOSE

A retro-odontoid pseudotumor is usually a reactive fibrocartilaginous mass associated with atlantoaxial subluxation (AAS). However, a retro-odontoid pseudotumor not associated with AAS, which undergoes spontaneous regression following C1 laminoplasty, has been reported. The purpose of this study was to report surgical outcomes of C1 laminectomy for retro-odontoid pseudotumor without AAS.

MATERIALS AND METHODS

The cases of seven patients (mean age 75.6 ± 7.6 years-old) with retro-odontoid pseudotumor without AAS were reviewed. The mean follow up time was 52.3 ± 25.5 months. Each patient underwent a C1 laminectomy with an additional C3-6 expansion laminoplasty in three patients. The Japanese Orthopaedic Association score (JOA score) was used for neurological assessment. Pseudotumor size and additional AAS were analyzed using MRI and radiography.

RESULTS

All patients exhibited neurological improvement following surgery, the JOA score improved from 7.2 ± 3.2 to 14.1 ± 2.6. The mean O-C2 and C2-7 angle decreased from -3.2 ± 2.1° to -3.9 ± 1.7°, showing a slight kyphotic change. Postoperative AAS was not observed. All pseudotumors spontaneously resolved, and recurrence and regrowth were not observed. Five patients had MRIs after gadolinium administration; four patients who showed enhancement of the pseudotumor had almost complete reduction within 1 year following surgery.

DISCUSSION

Our study, assessing the outcome of C1 laminectomy for retro-odontoid pseudotumor, found neurological improvement in all cases. Since all pseudotumors were reduced and additional AAS was not observed, C1 laminectomy for retro-odontoid pseudotumor, in the absence of AAS, is recommended as a therapeutic strategy.

Surgical outcome in rheumatoid Ranawat Class IIIb myelopathy

OBJECTIVE

Rheumatoid arthritis frequently affects the craniovertebral junction (CVJ) and may lead to severe neck pain, quadriparesis, and respiratory dysfunction. Surgery in rheumatoid nonambulatory (Ranawat Class IIIb) patients carries a significant risk. This study presents the surgical outcome of Class IIIb patients with CVJ rheumatoid myelopathy and reviews the literature.

METHODS

One hundred twelve consecutive patients with rheumatoid cervical myelopathy underwent surgical decompression and stabilization. Thirty-two of the patients (mean age, 66.81 +/- 10.25 yr) with CVJ rheumatoid arthritis were in Class IIIb, and all had atlantoaxial subluxation. A halo brace was applied before surgery and continued during surgery. Eleven patients with reducible atlantoaxial subluxation underwent direct posterior fusion. Twenty-one patients with fixed atlantoaxial subluxation underwent transoral decompression and then posterior fusion while they were under anesthesia.

RESULTS

At a mean follow-up of 39 months, four patients improved to Class II and 14 improved to Class IIIa, whereas six remained in Class IIIb. Neck pain was relieved in all patients. There was one perioperative death after transoral surgery (posterior fusion not done), and seven other patients died subsequently of causes unrelated to surgery. The morbidity of surgery included construct failure, cerebrospinal fluid leak, superficial wound or graft donor site infection, transient dysphagia, and lung infection.

CONCLUSION

A large subset of patients with CVJ rheumatoid myelopathy may reach Class IIIb. These patients have unique management considerations. Surgery (despite high morbidity) often remains the best therapeutic option available to them. Improvement of even one grade in their Ranawat score from Class IIIb to Class IIIa brought about by surgery confers on them a significant benefit in terms of their quality of life and survival.

Rationale and design of The Delphi Trial – I(RCT)2: international randomized clinical trial of rheumatoid craniocervical treatment, an intervention-prognostic trial comparing 'early' surgery with conservative treatment [ISRCTN65076841]

Background

Rheumatoid arthritis is a chronic inflammatory disease, which affects 1% of the population. Hands and feet are most commonly involved followed by the cervical spine. The spinal column consists of vertebrae stabilized by an intricate network of ligaments. Especially in the upper cervical spine, rheumatoid arthritis can cause degeneration of these ligaments, causing laxity, instability and subluxation of the vertebral bodies. Subsequent compression of the spinal cord and medulla oblongata can cause severe neurological deficits and even sudden death. Once neurological deficits occur, progression is inevitable although the rapidity of progression is highly variable. The first signs and symptoms are pain at the back of the head caused by compression of the major occipital nerve, followed by loss of strength of arms and legs. The severity of the subluxation can be observed with radiological investigations (MRI, CT) with a high sensitivity.

The authors have sent a Delphi Questionnaire about the current treatment strategies of craniocervical involvement by rheumatoid arthritis to an international forum of expert rheumatologists and surgeons. The timing of surgery in patients with radiographic instability without evidence of neurological deficit is an area of considerable controversy. If signs and symptoms of myelopathy are present there is little chance of recovery to normal levels after surgery.

Design

In this international multicenter randomized clinical trial, early surgical atlantoaxial fixation in patients with rheumatoid arthritis and radiological abnormalities without neurological deficits will be compared with prolonged conservative treatment. The main research question is whether early surgery can prevent radiological and neurological progression. A cost-effectivity analysis will be performed. 250 patients are needed to answer the research question.

Discussion

Early surgery could prevent serious neurological deficits, but may have peri-operative morbidity and loss of rotation of the head and neck. The objective of this study is to identify the best timing of surgery for patients at risk for the development of neurological signs and symptoms.