Lateral subluxation of the atlas in rheumatoid arthritis

The spectrum of atlantoaxial facet joint involvement in rheumatoid arthritis

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.

Backward tilting of the posterior atlantal arch in rheumatoid arthritis

In a retrospective survey of 450 patients with rheumatoid arthritis on whom cervical spine radiography was performed, one patient was found with a backward tilting of the posterior arch of the atlas. With preserved relations anteriorly, the posterior arch was rotated downward in front of the spinous process of the axis, encroaching on the space of the spinal canal.

Computed tomographic myelography (CTM) in atlanto-axial rheumatoid arthritis

Thirty-two patients with severe cervical rheumatoid arthritis were investigated preoperatively with cervical myelography (CeM) and computed tomographic myelography (CTM). The severity of their clinical symptoms correlated excellently with a combination of the deformation of the spinal cord at the atlanto-axial level, the lateral dislocation of the cord at the same level, and the deformation of the cord at some lower cervical level. Obstructing soft-tissue excrescences seemed to have little significance. No correlation was found in this study between the deformation of the cord and the main findings of the plain films: the atlanto-axial subluxation (AAS), the vertical subluxation (VS), or their combination.

Radiologic review: the rheumatoid cervical spine

We have reviewed the multiplicity of lesions present in the cervical spine in the adult with RA. The clinicoradiographic correlations are presented, and the techniques available for appropriate investigation are suggested. Readily available, conventional radiology provides useful information for the majority of patients. A standardized system of weighting and grading roentgenographic changes would be a welcome area of future research. Myelography and angiography should be considered in every patient before cervical spine surgery. CT evaluation should be reserved for those without a readily appreciable cause for myelopathy and those undergoing cervical surgical procedures.

Lateral subluxation of the atlas in rheumatoid arthritis: a case report and post-mortem study

The atlantoaxial joints of a patient with lateral subluxation of the atlas were studied post mortem by dissection. There was severe erosion of the left lateral atlantoaxial joint and an asymmetrical erosion of the cartilages of the median atlantoaxial joint which prevented reduction of the lateral subluxation. The atlantoaxial ligaments were remarkably intact. It is emphasised that osseous factors rather than ligaments confer lateral stability to the atlantoaxial joints and that destruction of these leads to lateral subluxation.

Nonreducible rotational head tilt and lateral mass collapse. A prospective study of frequency, radiographic findings, and clinical features in patients with rheumatoid arthritis

Of 126 hospitalized, but otherwise unselected, patients with rheumatoid arthritis, 12 (10%) had a persisting nonreducible rotational head tilt deformity (NRRHT). These 12 were grouped with an additional 12 similar subjects, previously found to have the same condition, and all 24 were compared with the remaining 114 who did not have head tilt. Patients with NRRHT differed significantly from the others in that the former were more likely to have a destructive peripheral arthritis, headache, limited neck motion, and various cervical subluxations. All 24 subjects with NRRHT had predominately unilateral collapse of the lateral masses of the atlas and/or axis, compared with only 2 of the 114 with normal head position. The head always tilted to the side of the lateral mass collapse, which appeared to be the sole or major cause of the abnormal head position.