Long-term follow-up of the cervical spine with conventional radiographs in patients with rheumatoid arthritis

Prevalence of anterior atlantoaxial subluxation and association with established rheumatoid arthritis

OBJECTIVE

Spinal involvement in rheumatoid arthritis (RA) is limited to the upper cervical spine, leading to cervical spine instability. This study aimed to evaluate the prevalence of anterior atlantoaxial subluxation (aAAS) and its associated risk factors in patients with RA.

METHOD

This single-centre cross-sectional study 240 patients consecutively were recruited. Radiographs of the cervical spine were obtained in the flexion and neutral neck positions and read by two blinded observers. The diagnosis of aAAS was based on the distance between the anterior aspect of the dens and the posterior aspect of the anterior arch of the atlas, which was >3 mm during flexion. Statistical analysis was performed to determine the predictive factors of aAAS.

RESULTS

Two hundred and forty patients with a mean ± SD age of 56.4 ± 11.4 years were recruited, and 191 (78%) were female. The mean ± SD duration of the disease was 10.2 ± 8.5 years. Of all 25 cases (10.4%) diagnosed with aAAS, the mean anterior atlantodental interval in patients with AAS was 4.19 ± 1.20 mm. One in three patients with aAAS had no neck pain. Patients with aAAS had longer disease duration, lower age at diagnosis, lower body mass index, higher anti-cyclic citrullinated peptide autoantibodies (anti-CCP), more frequent erosion, joint restriction, and joint prostheses. In the multivariate regression model, joint limitation, history of joint prostheses, low BMI, and higher anti-CCP levels were independent predictors of the aAAS.

CONCLUSION

Thirty-three percent of patients with cervical involvement do not experience neck pain. Cervical involvement should be considered even without neck pain, particularly in established diseases.

Radiological assessment and surgical management of cervical spine involvement in patients with rheumatoid arthritis

The purpose of the present systematic review was to describe the diagnostic evaluation of rheumatoid arthritis in the cervical spine to provide a better understanding of the indications and options of surgical intervention. We performed a literature review of Pub-med, Embase, and Scopus database. Upon implementing specific inclusion and exclusion criteria, all eligible articles were identified. A total of 1878 patients with Rheumatoid Arthritis (RA) were evaluated for cervical spine involvement with plain radiographs. Atlantoaxial subluxation (AAS) ranged from 16.4 to 95.7% in plain radiographs while sub-axial subluxation ranged from 10 to 43.6% of cases. Anterior atlantodental interval (AADI) was found to between 2.5 mm and 4.61 mm in neutral and flexion position respectively, while Posterior Atlantodental Interval (PADI) was between 20.4 and 24.92 mm. 660 patients with RA had undergone an MRI. A pannus diagnosis ranged from 13.33 to 85.36% while spinal cord compression was reported in 0-13% of cases. When it comes to surgical outcomes, Atlanto-axial joint (AAJ) fusion success rates ranged from 45.16 to 100% of cases. Furthermore, the incidence of postoperative subluxation ranged from 0 to 77.7%. With regards to AADI it is evident that its value decreased in all studies. Furthermore, an improvement in Ranawat classification was variable between studies with a report improvement frequency by at least one class ranging from 0 to 54.5%. In conclusion, through careful radiographic and clinical evaluation, cervical spine involvement in patients with RA can be detected. Surgery is a valuable option for these patients and can lead to improvement in their symptoms.

Update on imaging of the cervical spine in rheumatoid arthritis

Rheumatoid arthritis is a multisystem, autoimmune, inflammatory disorder with numerous musculoskeletal manifestations. Involvement of the cervical spine is common and may result in severe complications due to synovitis, erosions, pannus formation, spinal instability and ankylosis. The purpose of this article is to review the current role of imaging in the rheumatoid spine, with emphasis on radiographs and MRI.

The Influence of Reducing Disease Activity Score on Cervical Spine Deformity in Rheumatoid Arthritis: A Systematic Review

Background. Rheumatoid arthritis (RA) can cause deformity in particularly the craniocervical but also in the lower cervical region. Objectives. The aim of this study is to give an overview of current literature on the association of disease activity score (DAS) and the prevalence and progression of rheumatoid arthritis-associated cervical spine deformities. Methods. A literature search was done in PubMed, Embase, and Web of Science using a sensitive search string combination (Supplemental File). Studies describing the association between DAS and the incidence and progression of atlantoaxial subluxation, vertical subluxation, and subaxial subluxation were selected by predefined selection criteria, and risk of bias was assessed using a Cochrane checklist adjusted for this purpose. Results. Twelve articles were retrieved, and risk of bias on study level was low to moderate. In the eight longitudinal studies, patients demonstrated high DAS at baseline, which decreased upon treatment with medication: cervical deformity at the end of follow-up was associated with higher DAS values. The four cross-sectional studies did not demonstrate a straightforward correlation between DAS and cervical deformity. Deformity progression was evaluated in three studies, but no convincing association with DAS was established. Conclusion. A positive association between prevalence of cervical spine deformities and high disease activity was demonstrated, but quality of evidence was low. Progression of cervical deformity in association with DAS control over time is only scarcely studied, and future investigations should focus on halting of deformity progression.

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.

类风湿关节炎合并颈椎失稳的人群分布及临床特征

OBJECTIVE

To investigate the population distribution of cervical spine instability in rheumatoid arthritis (RA) patients, and to analyze the clinical characteristics in RA patients with cervical spine instability.

METHODS

A total of 439 RA patients who had completed cervical spine X-ray examination from Department of Rheumatology and Immunology of Peking University Shenzhen Hospital and Peking University Third Hospital from August 2015 to March 2019 were enrolled. The clinical data, laboratory data and cervical radiographic data were collected and analyzed by t-test, rank sum test and Chi-square test to clarify the clinical characteristics in the RA patients with cervical spine instability.

RESULTS

Of the 439 RA patients, 80.9% (355/439) were female, with an average age of (52.9±13.9) years, a median duration of the disease was 60 months, the shortest history was 2 weeks, and the longest history was up to 46 years. 29.6% (130/439) of the RA patients showed cervical spine instability. Among them, 20 RA patients were complicated with two different types of cervical instability, the atlantoaxial subluxation (AAS) accounted for 24.6% (108/439), the vertical subluxation (VS) accounted for 7.3% (32/439) and the subluxial subluxations (SAS) accounted for 2.3% (10/439). The patients with cervical spine instability had a longer duration of disease [120 (36, 240) months vs. 48 (12, 120) months], a higher proportion of peripheral joint deformity (56.9% vs. 29.9%), and a higher visual analog scale (VAS) measuring general health score (4.89±2.49 vs. 3.93±2.38), a lower hemoglobin [(111.31±19.44) g/L vs. (115.56±16.60) g/L] and a higher positive rate of anti-cyclic citrullina-ted peptide (CCP) antibody (90.8% vs. 76.6%). There were no significant differences in gender, age, number of swollen joints, number of tenderness joints, erythrocyte sedimentation rate, rheumatoid factor level, 28-joint disease activity score, positive rate of anti keratin antibody, duration of glucocorticoid use and duration of disease modifying anti-rheumatic drugs use between the two groups.

CONCLUSION

In the study, 29.6% of the RA patients showed cervical spine instability. RA patients with cervical spine instability had a long-term disease, a higher proportion of peripheral joint deformity, a higher VAS measuring general health score, a lower hemoglobin and a higher positive rate of anti-CCP antibody.

Risk of the high-riding variant of vertebral arteries at C2 is increased over twofold in rheumatoid arthritis: a meta-analysis

Rheumatoid arthritis (RA) might lead to atlantoaxial instability requiring transpedicular or transarticular fusion. High-riding vertebral artery (HRVA) puts patients at risk of injuring the vessel. RA is hypothesized to increase a risk of HRVA. However, to date, no relative risk (RR) has been calculated in order to quantitatively determine a true impact of RA as its risk factor. To the best of our knowledge, this is the first attempt to do so. All major databases were scanned for cohort studies combining words "rheumatoid arthritis" and "high-riding vertebral artery" or synonyms. RA patients were qualified into the exposed group (group A), whereas non-RA subjects into the unexposed group (group B). Risk of bias was explored by means of Newcastle-Ottawa Scale. MOOSE checklist was followed to ensure correct structure. Fixed-effects model (inverse variance) was employed. Four studies with a total of 308 subjects were included in meta-analysis. One hundred twenty-five subjects were in group A; 183 subjects were in group B. Mean age in group A was 62,1 years, whereas in group B 59,9 years. The highest risk of bias regarded "comparability" domain, whereas the lowest pertained to "selection" domain. The mean relative risk of HRVA in group A (RA) as compared with group B (non-RA) was as follows: RR = 2,11 (95% CI 1,47-3,05), I² = 15,19%, Cochrane Q = 3,54 with overall estimate significance of p < 0,001. Rheumatoid arthritis is associated with over twofold risk of developing HRVA, and therefore, vertebral arteries should be meticulously examined preoperatively before performing craniocervical fusion in every RA patient.

Simple Erosion Narrowing Score of the hands as a predictor of cervical spine subluxation in rheumatoid arthritis

Background

Involvement of the cervical spine is common in patients with rheumatoid arthritis and can lead to devastating or even fatal consequences. Currently no guidelines exist as to whether radiographs of the cervical spine should be included in follow-up visits.

Objectives

To determine whether the Simple Erosion Narrowing Score (SENS) of the hands correlate with the presence of cervical spine subluxation in patients with rheumatoid arthritis.

Method

This was a retrospective, observational, cross-sectional study. A total of 56 rheumatoid arthritis patients with hand radiographs and lateral radiographs of the cervical spine were evaluated. The SENS of the hands and the presence of cervical spine subluxation were compared. The SENS of the hands was correlated with the prevalence of cervical spine subluxation, as was the erosion and joint space narrowing scores of the hands.

Results

A correlation between the SENS of the hands and the prevalence of cervical spine subluxation was confirmed. A higher prevalence of cervical spine subluxation correlated with an increase in the SENS of the hands (p = 0.0002). The erosion and joint space narrowing scores of the hands also correlated with the prevalence of cervical spine subluxation (p = 0.0001).

Conclusion

This study confirmed that a correlation exists between cervical spine subluxation, peripheral joint space erosions and joint space narrowing in patients with rheumatoid arthritis and SENS may therefore be used as a predictor of cervical spine disease.

Risk factors for cervical spine instability in patients with rheumatoid arthritis

INTRODUCTION

Cervical spine (C-spine) instability is a unique and significant characteristic of rheumatoid arthritis (RA) because its occurrence is not rare and it can cause compressive cervical myelopathy, which may lead to serious neurologic sequelae. This study evaluated the prevalence and risk factors of C-spine instabilities in RA patients with a focus on anti-citrullinated protein antibody (ACPA) and biologic disease-modifying antirheumatic drug (DMARD) therapies.

METHODS

The presence of C-spine instabilities in 1114 patients with RA was evaluated using C-spine radiographies according to the defined metrics. Multivariable logistic regression analyses were performed to identify independent predictors of C-spine instability. The initiation of biologic DMARDs was assessed via a Kaplan-Meier analysis and compared using log-rank tests.

RESULTS

In total, 306 (27.5%) patients presented with C-spine instabilities. The most common type was atlantoaxial subluxation (AAS; n = 199 [17.9%]). Male sex, positivity for rheumatoid factor and ACPA, erosive change in the peripheral joints, and presence of osteoporosis were independently associated with C-spine instabilities (all P < 0.05). In particular, positivity for ACPA was the most powerful risk factor (odds ratio: 2.33 [95% confidence interval: 1.37, 3.96], P = 0.002), and it was closely associated with AAS. Patients with AAS were at a higher risk for early initiation of biologic DMARDs.

CONCLUSIONS

Positivity for ACPA was a significant risk factor for C-spine instability, and AAS was remarkably correlated to the early initiation of biologic DMARDs, a surrogate index of poor long-term outcomes. Key Points • The presence of antibodies against citrullinated proteins was a strong risk factor for C-spine instability in patients with rheumatoid arthritis. • Atlantoaxial subluxation was significantly associated with early initiation of biologic DMARDs, a surrogate index of poor long-term outcome.

Prevalence of cervical spine instability among Rheumatoid Arthritis patients in South Iraq

AIM OF THE WORK

This study analysed the prevalence of cervical spine instability in Rheumatoid Arthritis (RA) patients following at a single centre in Basrah.

PATIENTS AND METHODS

Data were collected directly from patients through cervical spine examinations. Each patient was sent for dynamic (flexion and extension) lateral cervical radiographic imaging to assess the presence of atlantoaxial subluxation (AAS), superior migration of the odontoid (SMO) and sub-axial subluxation (SAS). Patients with positive radiographic findings were sent for MRI scans of the cervical spine to assess neurological compression.

RESULTS

The prevalence rate of cervical spine instability in RA was 15/203 (7.4%) of the total sample, occurring primarily in patients of 37-65 years old (mean: 48 ± 8.9 years), were 3/15 (20%) aymptomatic. The majority (60%) being at the moderate stage of the disease activity (using a Clinical Disease Activity Index [CDAI). In terms of type of cervical spine involvement, isolated AAS was found to have the highest occurrence (73.3%), followed by combined SAS and SMO (13.3%), combined AAS and SMO (6.7%), and combined AAS and SAS (6.7%). A significant relationship was found between the type of cervical spine involvement in RA and a disease onset duration, disease activity, body mass index and peripheral erosion with P value < 0.05.

CONCLUSION

Cervical spine subluxation in RA patients may be asymptomatic It is therefore essential to obtain a dynamic radiographic image of the cervical spine in order to diagnose cervical spine involvement and protect the patient from severe outcomes.The clinical trial registration number included in a the official document from Ministry of Higher Education and Science Research/Basrah University/Faculty of Medicine to Basrah Health Directorate/Research and Development Division is 72/3588 in 7 Jan 2017.

Cervical proprioceptive impairment in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) involving the cervical spine can lead to various neurologic defects and impairment of proprioception is just one of them. The aim of this study was the assessment of cervical proprioception and its relation with radiographic, clinical, and functional characteristics of patients with RA. One hundred and six rheumatoid arthritis patients who diagnosed according to the 2010 American College of Rheumatology/European League Against Rheumatism criteria and age, gender, educational status matched one hundred and six healthy volunteers were enrolled in this study. Cervical joint position error test (CJPET) was applied to healthy volunteers and RA patients for cervical proprioception assessment. Fatigue, depression, balance, quality of life and balance scales were administered to all patients. Cervical radiography was used to assess cervical subluxations. Regression analysis was used for grading the factors which had relations with cervical proprioception. Mean age of patients and healthy volunteers was 51 ± 11.1 and 48.9 ± 9.2, respectively. Scores of CJPET were statistically significantly higher in RA group than healthy volunteers (p = 0.001). CJPET scores were negatively correlated with Berg balance scale findings in right rotation, left rotation, flexion and extension (rho = - 0.421,- 0.473,- 0.448,- 0.515). There was weak or not significant correlation between the scores of CJPET and fatigue, depression, and quality of life scales. Scores of CJPET in patients with atlantoaxial subluxations (AAS) were statistically significantly higher than those without AAS (p < 0.05). Regression analysis results showed that the AAS was related to impaired cervical proprioception on right and left rotations. There was no correlation between CJPET scores and functional parameters. Cervical proprioception impaired in RA patients. This impairment was related to the existence of AAS and balance problems.

Magnetic resonance imaging of the craniovertebral junction in early rheumatoid arthritis

OBJECTIVE

To assess the involvement of the atlantoaxial joint in patients with early rheumatoid arthritis (ERA) and to elucidate the risk profile for the individual patient.

MATERIALS AND METHODS

Consecutive ERA patients (disease duration < 12 months) were included in our study. A cervical spine magnetic resonance imaging (MRI) and X-rays (cervical spine, hands, wrists, and feet) were performed in all patients. The MRI features were correlated with clinical, radiological, and biochemical variables.

RESULTS

Fifty patients (13 men and 37 women) with a mean age of 58.2 years (range, 36-79 years) were included in the study. In 12 (24%) patients were detectable MRI findings suggestive of the craniovertebral junction involvement. Compared with patients without cervical involvement, the patients with atlantoaxial synovitis showed a significantly higher anti-citrullinated protein antibodies (ACPA) titer [mean 200.25 UI (SD 262.44) vs. mean 22.05 (SD 40.21) (p < 0.001)]; a worse Disease Activity Score 44 joints (DAS44) [mean 5.72 (SD 0.44) vs. mean 4.52 (SD 0.53) (p < 0.001)]; a worse Health Assessment Questionnaire Disability Index (HAQ-DI) [mean 1.55 (SD 0.37) vs. mean 1.09 (SD 0.33) (p < 0.001)], and a higher Simple Erosion Narrowing Score (SENS) [mean 15.83 (SD 4.52) vs. mean 7.71 (SD 3.43) (p < 0.001)]. The multivariate analysis revealed a meaningful relationship between atlantoaxial synovitis and ACPA, DAS44, and the presence of an erosive disease.

CONCLUSIONS

The craniovertebral junction is frequently involved in ERA patients. ACPA, high disease activity, and erosive disease at baseline are predictors of atlantoaxial involvement.

The role of imaging in rheumatoid arthritis

Conventional radiographs of the hands and feet have traditionally been used in the diagnosis, management and monitoring of patients with rheumatoid arthritis (RA). However, they are not sensitive enough to detect changes early in the disease process. Erosions may only be visible up to two years after the onset of disease, and soft tissue involvement may not be detected at all. Early diagnosis can also be made challenging as markers such as erythrocyte sedimentation rate and C-reactive protein may be normal in up to 20% – 25% of cases. The latest classification criteria (American College of Rheumatology/European League Against Rheumatism [ACR/EULAR] Rheumatoid Arthritis Classification criteria 2010), often used to diagnose RA, incorporate the role of ultrasound and magnetic resonance imaging detection of synovitis, enabling earlier diagnosis and correct classification of patients. This article looks at the role of the various imaging modalities used in the diagnosis and management of RA.

Can neck pain be an initial symptom of rheumatoid arthritis? A case report and literature review

Although rheumatoid arthritis (RA) is most commonly associated with peripheral joints, cervical spine involvement can be seen in almost 80% of patients in the presence of long-term disease, joint erosion, and risk factors such as male sex and rheumatoid factor positivity. It is very rare to have cervical involvement in the initial period of RA. If a patient has isolated cervical spine involvement without peripheral arthritis, it is highly likely that inappropriate investigations and delayed treatment may occur. Any damage that occurs in cervical spine may cause symptoms varying from slight instability to atlantoaxial subluxation, spinal cord and brain stem compression and even death. Therefore, physician should be aware that there may be isolated cervical involvement, albeit rare, in patients with RA. In this report, we presented a case of RA presenting with cervical spine involvement without peripheral arthritis to underline the importance of this kind of involvement in clinical practice. We also briefly reviewed other cases similar to ours in light of literature.

Risk Factors for the Development and Progression of Atlantoaxial Subluxation in Surgically Treated Rheumatoid Arthritis Patients, Considering the Time Interval between Rheumatoid Arthritis Diagnosis and Surgery

Objective

Rheumatoid arthritis (RA) is a systemic disease that can affect the cervical spine, especially the atlantoaxial region. The present study evaluated the risk factors for atlantoaxial subluxation (AAS) development and progression in patients who have undergone surgical treatment.

Methods

We retrospectively analyzed the data of 62 patients with RA and surgically treated AAS between 2002 and 2015. Additionally, we identified 62 patients as controls using propensity score matching of sex and age among 12667 RA patients from a rheumatology registry between 2007 and 2015. We extracted patient data, including sex, age at diagnosis, age at surgery, disease duration, radiographic hand joint changes, and history of methotrexate use, and laboratory data, including presence of rheumatoid factor and the C-reactive protein (CRP) level.

Results

The mean patient age at diagnosis was 38.0 years. The mean time interval between RA diagnosis and AAS surgery was 13.6±7.0 years. The risk factors for surgically treated AAS development were the serum CRP level (p=0.005) and radiographic hand joint erosion (p=0.009). The risk factors for AAS progression were a short time interval between RA diagnosis and radiographic hand joint erosion (p<0.001) and young age at RA diagnosis (p=0.04).

Conclusion

The CRP level at RA diagnosis and a short time interval between RA diagnosis and radiographic hand joint erosion might be risk factors for surgically treated AAS development in RA patients. Additionally, a short time interval between RA diagnosis and radiographic hand joint erosion and young age at RA diagnosis might be risk factors for AAS progression.

Prevention of Stroke in Rheumatoid Arthritis

The risk of cerebrovascular disease is increased among rheumatoid arthritis (RA) patients and remains an underserved area of medical need. Only a minor proportion of RA patients achieve suitable stroke prevention. Classical cardiovascular risk factors appear to be under-diagnosed and undertreated among patients with RA. Reducing the inflammatory burden is also necessary to lower the cardiovascular risk. An adequate control of disease activity and cerebrovascular risk assessment using national guidelines should be recommended for all patients with RA. For patients with a documented history of cerebrovascular or cardiovascular risk factors, smoking cessation and corticosteroids and non-steroidal anti-inflammatory drugs at the lowest dose possible are crucial. Risk score models should be adapted for patients with RA by introducing a 1.5 multiplication factor, and their results interpreted to appropriately direct clinical care. Statins, angiotensin-converting enzyme inhibitors, and angiotensin-II receptor blockers are preferred treatment options. Biologic and non-biologic disease-modifying anti-rheumatic drugs should be initiated early to mitigate the necessity of symptom control drugs and to achieve early alleviation of the inflammatory state. Early control can improve vascular compliance, decrease atherosclerosis, improve overall lipid and metabolic profiles, and reduce the incidence of heart disease that may lead to atrial fibrillation. In patients with significant cervical spine involvement, early intervention and improved disease control are necessary and may prevent further mechanical vascular injury.

Radiological evaluation of cervical spine involvement in rheumatoid arthritis

Cervical spine involvement commonly occurs in patients with rheumatoid arthritis (RA), especially those with inadequate treatment or severe disease forms. The most common site affected by RA is the atlantoaxial joint, potentially resulting in atlantoaxial instability, with cervical pain and neurological deficits. The second most common site of involvement is the subaxial cervical spine, often with subluxation, resulting in nerve root or spinal cord compression. In this paper, the authors review the most commonly used plain radiographic criteria to diagnose cervical instabilities seen with RA. Finally, we discuss the advantages and disadvantages of cervical CT and MRI in the setting of cervical involvement in RA.

Neuropsychiatric manifestations in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic disease characterized by persistent synovitis, systemic inflammation, and the presence of autoantibodies. Neuropsychiatric manifestations are quite common in RA, including depression, cognitive dysfunction, behavior changes, spinal cord compression and peripheral nerve involvement. Potential causes include systemic inflammatory process, neural compression due to bone and joint destruction, side effects of medications and copying difficulties due to the chronicity of the disease. A high level of suspicious is required for an adequate diagnosis and treatment. In this review, we will discuss topographically the main neuropsychiatric manifestations described in RA patients, in an attempt to help in the management of these complex and multifaceted disease.

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.