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Rheumatoid Arthritis and the Cervical Spine: A Review on the Role of Surgery.

Gillick JL, Wainwright J, Das K - Int J Rheumatol (2015)

Bottom Line: Cervical spine involvement in RA can pose a challenge to the clinician and the appropriate role of surgical intervention is controversial.Both the medical and surgical treatment options for RA have improved, so has the prognosis of the cervical spine disease.With the advent of disease modifying antirheumatic drugs (DMARDs), fewer patients are presenting with cervical spine manifestations of RA; however, those that do, now have improved surgical techniques available to them.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, NY Medical College, 19 Skyline Drive, Hawthorne, NY 10532, USA.

ABSTRACT
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease affecting a significant percentage of the population. The cervical spine is often affected in this disease and can present in the form of atlantoaxial instability (AAI), cranial settling (CS), or subaxial subluxation (SAS). Patients may present with symptoms and disability secondary to these entities but may also be neurologically intact. Cervical spine involvement in RA can pose a challenge to the clinician and the appropriate role of surgical intervention is controversial. The aim of this paper is to describe the pathology, pathophysiology, clinical manifestations, and diagnostic evaluation of rheumatoid arthritis in the cervical spine in order to provide a better understanding of the indications and options for surgery. Both the medical and surgical treatment options for RA have improved, so has the prognosis of the cervical spine disease. With the advent of disease modifying antirheumatic drugs (DMARDs), fewer patients are presenting with cervical spine manifestations of RA; however, those that do, now have improved surgical techniques available to them. We hope that, by reading this paper, the clinician is able to better evaluate patients with RA in the cervical spine and determine in which patients surgery is indicated.

No MeSH data available.


Related in: MedlinePlus

Lateral radiographs of a patient with atlantoaxial instability. In the neutral view the AADI (arrowhead) is 1 mm and the PADI (double arrow) is 20 mm (a). In flexion the AADI increases to 7 mm and the PADI decreases to 13 mm (b). In extension the AADI and PADI reduce to their neutral measures (c).
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fig2: Lateral radiographs of a patient with atlantoaxial instability. In the neutral view the AADI (arrowhead) is 1 mm and the PADI (double arrow) is 20 mm (a). In flexion the AADI increases to 7 mm and the PADI decreases to 13 mm (b). In extension the AADI and PADI reduce to their neutral measures (c).

Mentions: Given the high prevalence of asymptomatic cervical instability in RA patients, understanding the appropriate diagnostic evaluation is crucial to early detection. In the majority of patients without significant symptoms of cervical instability, plain radiographs consisting of standard anterior/posterior, lateral, and open mouth views in addition to dynamic lateral flexion/extension views are an appropriate initial evaluation as they are easy to obtain and inexpensive [1, 2, 7]. The flexion/extension views are critical as the standard static lateral projections have been reported to miss detection of AAI, underestimate its severity, and poorly evaluate stability [33]. When evaluating plain radiographs for cervical instability, several measurements can be made to assess for the presence and severity of disease. In order to evaluate for AAI, the anterior atlantodental interval (AADI) and the posterior atlantodental interval (PADI) can be measured. The AADI is the distance from the posterior margin of the anterior arch of C1 to the anterior margin of the dens measured along the transverse axis of C1 which in normal adults is less than 3 mm. AAI is defined as an AADI that is greater than 3 mm and not fixed with flexion and extension as it generally increases with flexion and may reduce with extension (Figure 2) [1–3]. Various cutoffs between 6 and 10 mm for maximum AADI have been suggested as indications for surgery [1–3, 7]. A limitation to the use of the AADI occurs in patients who have developed CS. Due to the conical shape of the dens, CS can result in a decrease in the AADI, which may become fixed, resulting in a pseudostabilization when in fact the patient has significant disease [2, 32, 34]. Due to the limitations of the AADI, PADI has been found to be a more reliable indicator of the potential for neurologic compromise [1, 2, 35]. This value is obtained by measuring from the posterior margin of the dens to the anterior margin of the posterior arch of C1 (Figure 2). Values for PADI less that 13 or 14 mm have been suggested as indications for surgery [3, 7].


Rheumatoid Arthritis and the Cervical Spine: A Review on the Role of Surgery.

Gillick JL, Wainwright J, Das K - Int J Rheumatol (2015)

Lateral radiographs of a patient with atlantoaxial instability. In the neutral view the AADI (arrowhead) is 1 mm and the PADI (double arrow) is 20 mm (a). In flexion the AADI increases to 7 mm and the PADI decreases to 13 mm (b). In extension the AADI and PADI reduce to their neutral measures (c).
© Copyright Policy - open-access
Related In: Results  -  Collection

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fig2: Lateral radiographs of a patient with atlantoaxial instability. In the neutral view the AADI (arrowhead) is 1 mm and the PADI (double arrow) is 20 mm (a). In flexion the AADI increases to 7 mm and the PADI decreases to 13 mm (b). In extension the AADI and PADI reduce to their neutral measures (c).
Mentions: Given the high prevalence of asymptomatic cervical instability in RA patients, understanding the appropriate diagnostic evaluation is crucial to early detection. In the majority of patients without significant symptoms of cervical instability, plain radiographs consisting of standard anterior/posterior, lateral, and open mouth views in addition to dynamic lateral flexion/extension views are an appropriate initial evaluation as they are easy to obtain and inexpensive [1, 2, 7]. The flexion/extension views are critical as the standard static lateral projections have been reported to miss detection of AAI, underestimate its severity, and poorly evaluate stability [33]. When evaluating plain radiographs for cervical instability, several measurements can be made to assess for the presence and severity of disease. In order to evaluate for AAI, the anterior atlantodental interval (AADI) and the posterior atlantodental interval (PADI) can be measured. The AADI is the distance from the posterior margin of the anterior arch of C1 to the anterior margin of the dens measured along the transverse axis of C1 which in normal adults is less than 3 mm. AAI is defined as an AADI that is greater than 3 mm and not fixed with flexion and extension as it generally increases with flexion and may reduce with extension (Figure 2) [1–3]. Various cutoffs between 6 and 10 mm for maximum AADI have been suggested as indications for surgery [1–3, 7]. A limitation to the use of the AADI occurs in patients who have developed CS. Due to the conical shape of the dens, CS can result in a decrease in the AADI, which may become fixed, resulting in a pseudostabilization when in fact the patient has significant disease [2, 32, 34]. Due to the limitations of the AADI, PADI has been found to be a more reliable indicator of the potential for neurologic compromise [1, 2, 35]. This value is obtained by measuring from the posterior margin of the dens to the anterior margin of the posterior arch of C1 (Figure 2). Values for PADI less that 13 or 14 mm have been suggested as indications for surgery [3, 7].

Bottom Line: Cervical spine involvement in RA can pose a challenge to the clinician and the appropriate role of surgical intervention is controversial.Both the medical and surgical treatment options for RA have improved, so has the prognosis of the cervical spine disease.With the advent of disease modifying antirheumatic drugs (DMARDs), fewer patients are presenting with cervical spine manifestations of RA; however, those that do, now have improved surgical techniques available to them.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, NY Medical College, 19 Skyline Drive, Hawthorne, NY 10532, USA.

ABSTRACT
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease affecting a significant percentage of the population. The cervical spine is often affected in this disease and can present in the form of atlantoaxial instability (AAI), cranial settling (CS), or subaxial subluxation (SAS). Patients may present with symptoms and disability secondary to these entities but may also be neurologically intact. Cervical spine involvement in RA can pose a challenge to the clinician and the appropriate role of surgical intervention is controversial. The aim of this paper is to describe the pathology, pathophysiology, clinical manifestations, and diagnostic evaluation of rheumatoid arthritis in the cervical spine in order to provide a better understanding of the indications and options for surgery. Both the medical and surgical treatment options for RA have improved, so has the prognosis of the cervical spine disease. With the advent of disease modifying antirheumatic drugs (DMARDs), fewer patients are presenting with cervical spine manifestations of RA; however, those that do, now have improved surgical techniques available to them. We hope that, by reading this paper, the clinician is able to better evaluate patients with RA in the cervical spine and determine in which patients surgery is indicated.

No MeSH data available.


Related in: MedlinePlus