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Rheumatoid Arthritis and the Rheumatoid Arthritis and the Cervical SpineCervical Spine

Radiology RoundsRadiology RoundsNovember 21, 2006November 21, 2006

Derek Derek HaalandHaaland

LaihoLaiho et al. et al. SeminSemin Arthritis Rheum. 2004:34;267.Arthritis Rheum. 2004:34;267.


Rheumatoid Arthritis & Rheumatoid Arthritis & the Cervical Spinethe Cervical Spine

•• RA is the most common inflammatory disorder of the spineRA is the most common inflammatory disorder of the spine•• GarrodGarrod first report Cfirst report C--spine involvement in 178 of 500 RA patients in 1890spine involvement in 178 of 500 RA patients in 1890•• Risk factors for cervical involvement:Risk factors for cervical involvement:

–– MalesMales–– RFRF–– Peripheral activityPeripheral activity–– Corticosteroid useCorticosteroid use

•• In RA:In RA:–– Neck painNeck pain 40 to 88%40 to 88%–– Cervical Cervical subluxationsubluxation 43 to 86%43 to 86%–– NeurologicNeurologic compromisecompromise 7 to 34%7 to 34%

•• Up to 86% of RA patients have CUp to 86% of RA patients have C--spine involvement*spine involvement*•• 50% of patients with radiographic instability are asymptomatic50% of patients with radiographic instability are asymptomatic•• In a In a postmortempostmortem study of 104 RA patients, 10% of deaths were attributed to study of 104 RA patients, 10% of deaths were attributed to medullarymedullary

compressioncompression•• OccipitoOccipito--AtlantoAtlanto and and AtlantoAtlanto--Axial joints predominantly affected because they are purely Axial joints predominantly affected because they are purely synovialsynovial•• Further, the lateral Further, the lateral AtlantoAtlanto--Axial joints are oriented in the axial plane, with no bony interAxial joints are oriented in the axial plane, with no bony interlocking to locking to

prevent prevent subluxationsubluxation in the face of in the face of ligamentousligamentous or capsular destruction or capsular destruction

Nguyen et al. Spine J. 2004:4;329.Nguyen et al. Spine J. 2004:4;329.

**ShenShen et al. Spine J. 2004:4;689.et al. Spine J. 2004:4;689.

Rheumatoid Arthritis & Rheumatoid Arthritis & the Cervical Spinethe Cervical Spine

•• AtlantoAtlanto--axial axial subluxationsubluxation represents 65% of all cervical represents 65% of all cervical subluxationssubluxations

•• Of these majority anterior, 20% lateral and 7% Of these majority anterior, 20% lateral and 7% posterior; posterior; rotatoryrotatory rarerare

•• Can be reducible, partially reducible or fixedCan be reducible, partially reducible or fixed•• Superior migration of the Superior migration of the odontoidodontoid (cranial (cranial

settling/settling/atlantoatlanto--axial impaction/axial impaction/pseudobasilarpseudobasilarinvaginationinvagination) is the second most common RA spine ) is the second most common RA spine deformity deformity –– seen in 20% of ptsseen in 20% of pts

•• SubaxialSubaxial subluxationsubluxation occurs in ~ 15% of patients occurs in ~ 15% of patients




Natural HistoryNatural History

•• Cranial settling almost always preceded by Cranial settling almost always preceded by AASAAS

•• In a 12 year study of 41 patients with AASIn a 12 year study of 41 patients with AAS–– 88% progressed88% progressed–– Of the remainder 80% had cranial settling!Of the remainder 80% had cranial settling!

•• MyelopathyMyelopathy associated with 50% one year associated with 50% one year mortality in one studymortality in one study

ShenShen et al. Spine J. 2004:4;689.et al. Spine J. 2004:4;689.

ClinicalClinical

•• SuboccipitalSuboccipital pain common but pain common but nonspecificnonspecific•• Weakness/decreasing function warrants Weakness/decreasing function warrants

high index of suspicion (31 week delay in high index of suspicion (31 week delay in one study one study b/tb/t symptoms and symptoms and myelopathymyelopathyDxDx))

•• VertebrobasilarVertebrobasilar insufficiencyinsufficiency


RA CRA C--spine: radiographyspine: radiography

•• Initial radiographic assessment should Initial radiographic assessment should include:include:–– Lateral dynamic flexion/extension viewsLateral dynamic flexion/extension views–– Anterior/posterior/lateral static viewsAnterior/posterior/lateral static views

•• Repeat q2Repeat q2--3 years esp. in pts requiring 3 years esp. in pts requiring intubationintubation or with new symptomsor with new symptoms


AAS MeasurementsAAS Measurements

•• Anterior Anterior AtlantodentalAtlantodental interval (AADI)interval (AADI)–– Lateral radiographLateral radiograph–– Posterior aspect of anterior ring of Atlas to anterior densPosterior aspect of anterior ring of Atlas to anterior dens–– Normal < 3mmNormal < 3mm–– increases on flexion with instabilityincreases on flexion with instability–– Surgery if 8Surgery if 8--10mm (although poor predictor of 10mm (although poor predictor of neurologicneurologic

dysfunction)dysfunction)

•• Posterior Posterior AtlantodentalAtlantodental interval (PADI)interval (PADI)–– Posterior dens to anterior aspect of lamina of AtlasPosterior dens to anterior aspect of lamina of Atlas–– Among 73 patients Among 73 patients BodenBoden et al. (1993) found PADI </= 14mm et al. (1993) found PADI </= 14mm

97% sensitive for paralysis (but 94% false positive rate!); AADI97% sensitive for paralysis (but 94% false positive rate!); AADIdid not correlatedid not correlate


Roche et al. Clinical Radiology. 2002:57;241.Roche et al. Clinical Radiology. 2002:57;241.




AAI/Basilar AAI/Basilar InvaginationInvaginationMeasurements:Measurements:•• 1) Clark Station1) Clark Station•• 2) 2) RanawatRanawat CriterionCriterion•• 3) 3) RedlundRedlund--JohnellJohnell measurementmeasurement

•• RiewRiew and colleagues (2001) examined lateral Cand colleagues (2001) examined lateral C--spine plain film vs. tomography/CT/MRI as gold spine plain film vs. tomography/CT/MRI as gold standard in 67 RA patients in the assessment of standard in 67 RA patients in the assessment of basilar basilar invaginationinvagination–– Test characteristics of 8 plain film diagnostic methods Test characteristics of 8 plain film diagnostic methods

were evaluatedwere evaluated

RiewRiew et al. J Bone Joint et al. J Bone Joint SurgSurg. 2001:83;194.. 2001:83;194.



1) Clark station1) Clark station



2) 2) RedlundRedlund--JohnellJohnell CriterionCriterion



3) 3) RanawatRanawat CriterionCriterion


Basilar Basilar InvaginationInvagination

•• If any one method positive If any one method positive --> > considered as positive test:considered as positive test:–– Sensitivity 94%Sensitivity 94%–– NPV 91%NPV 91%–– PPV 56%PPV 56%




Indications for surgeryIndications for surgery

•• Clear indications:Clear indications:–– Intractable pain and/or Intractable pain and/or neurologicneurologic deficitdeficit

•• “Preventive” surgery in AAS:“Preventive” surgery in AAS:–– Cervical collars do not prevent AAS Cervical collars do not prevent AAS

progressionprogression–– PADI < 14mm PADI < 14mm --> MRI> MRI–– If space available for the cord (SAC) <13mm If space available for the cord (SAC) <13mm

consider surgeryconsider surgery


Indications for surgeryIndications for surgery

•• ““Preventive surgery” in cranial settling:Preventive surgery” in cranial settling:–– Cranial settling on plain films Cranial settling on plain films --> MRI> MRI–– Cord compression Cord compression --> surgery> surgery

•• “Preventive surgery” in SAS:“Preventive surgery” in SAS:–– Posterior canal diameter < 14mm Posterior canal diameter < 14mm --> MRI> MRI

•• SAC < 13mm or SAC < 13mm or •• segmental mobility > 3.5mm segmental mobility > 3.5mm --> surgery> surgery


THANKS!THANKS!

•• LaihoLaiho et al. et al. SeminSemin Arthritis Rheum. 2004:34;267.Arthritis Rheum. 2004:34;267.•• Nguyen et al. Spine J. 2004:4;329.Nguyen et al. Spine J. 2004:4;329.•• RiewRiew et al. J Bone Joint et al. J Bone Joint SurgSurg. 2001:83;194.. 2001:83;194.•• Roche et al. Clinical Radiology. 2002:57;241.Roche et al. Clinical Radiology. 2002:57;241.•• ShenShen et al. Spine J. 2004:4;689.et al. Spine J. 2004:4;689.




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Rheumatoid Arthritis and the Cervical Spine › rheumres › docs › r-arthritis_and_cervical_spi… · Rheumatoid Arthritis & the Cervical Spine • Atlanto-axial subluxation represents