ReviewCervical spine involvement in rheumatoid arthritis — A systematic review☆,☆☆
Introduction
Rheumatoid arthritis (RA) is a systemic chronic inflammatory disorder that predominantly affects bone, joints and ligaments. However, as a systemic disease, RA can also involve other organ systems, such as the eye, lungs and vessels (vasculitis) [1], [2]. Its clinical course is quite variable, ranging from a chronic and insidious presentation to acute severe outbreaks, sometimes altered with long periods of quiescence. The proliferative and erosive synovitis progresses to destruction of the articular cartilage, especially in the metatasophalangeal joints, the most commonly involved joints. The cervical spine is also commonly compromised, being the second most involved region in some series, resulting in spinal instability and neurological impairment in severe cases [1], [2], [3], [4]. Up to 80% of the patients with RA can have some degree of cervical involvement [1], [5], [6]. The chronic inflammatory synovitis in the cervical spine results in severity that progresses to bone erosion and ligamentous laxity, leading to late spinal instability. The most common radiological presentations of spinal involvement in RA are: atlantoaxial subluxation (AAS) (the most common form of cervical compromise), cranial settling (also known as basilar impression, atlantoaxial impaction or superior migration of the odontoid [SMO], the most severe form of spinal instability in RA), subaxial subluxation (SAS) or a combination of them [1], [5].
The erosive pannus formation at the C1–2 joints antecedes bone destruction, leading to posterior laxity of the ligamentous complex that restrains the atlas in the axis, especially the transverse ligament but also the articular capsular joint of C1–2. The loss of ligamentous support results in AA instability, most commonly the anterior. In AAS, the anterior atlantodental interval (AADI) increases from its normal range of less than 3 mm, and the posterior atlantodental interval decreases (PADI), compressing the upper spinal cord [5]. Posterior atlantoaxial subluxation is rare, generally secondary to fracture of the dens and carry a higher risk of cord injury than AAS. Lateral subluxation can also occur sporadically, resulting in a rotational deformity. In patients with a high degree of atlantoaxial joints destruction, cranial settling can result in apparent cranial migration of the odontoid (actually is the cranium that settles caudally), most of the times with concomitant pannus development, and brainstem compression by the dens and/or the pannus itself. Cardiac arrest, stroke and obstructive hydrocephalus are potential causes of sudden death in these patients, justifying surgical treatment in the setting of cranial settling [6].
SAS, the second more common form of cervical instability in RA, is due to destruction of the facet joints and the intervertebral disc, appearing in isolation or associated with AAS and SMO. It can also be found in just one level or within multilevel involvement, resulting in a “staircase” deformity. Subluxation is characterized radiologically by 3.5 mm or more of translation at a given motion segment or more than 11° of angular instability, although other threshold are also found, such as 2 mm [1]. Anterior soft tissue masses, posterior ligamentous thickening as well as bony subluxation may cause osteophyte formation, ankylosis, bone collapse and kyphosis [5].
In the last decades, advances in clinical treatment with disease-modifying antirheumatoid drugs (DMARDs) and biological agents (BAs) are changing the natural history of RA and its consequent morbidity, decrease its severity and consequently improving patient's outcome, also decreasing the involvement and destruction of the cervical spine [1], [5].
Considering the importance of cervical involvement in RA, we performed a systematic literature review of the prevalence, progression and risk factors for cervical spine involvement in RA patients.
Section snippets
Material and methods
A systematic literature review was performed in the Pubmed Database. The following search mechanism was used: (“arthritis, rheumatoid” [MeSH Terms] OR (“arthritis” [All Fields] AND “rheumatoid” [All Fields]) OR “rheumatoid arthritis” [All Fields] OR (“rheumatoid” [All Fields] AND “arthritis” [All Fields])) AND (“cervical vertebrae” [MeSH Terms] OR (“cervical” [All Fields] AND “vertebrae” [All Fields]) OR “cervical vertebrae” [All Fields] OR (“cervical” [All Fields] AND “spine” [All Fields]) OR
Prevalence of cervical disease in patients with RA and risk factors for cervical instability progression
We identified 5 studies (3 prospectives and 2 retrospectives) that analyzed the prevalence of cervical involvement in a total of 1612 patients [8], [9], [10], [11] (Table 1). The follow-up reported varied from 2 months to 46 years. The prevalence of cervical spine involvement ranged from 16% to 70.4% and AAS was the most common abnormality reported (Table 1). Conventional X-ray was the most frequent method applied for diagnosis [8], [9], [10], [11], however some studies also analyzed CT or MRI
Discussion
The prevalence of cervical spine involvement in our review ranged from 16% to up to 70% in RA [8], [9], [10], [11], [14]. This wide variation can be explained by many reasons, such as: differences of follow-up period, disease duration (patients with long term RA would have a higher rate of cervical involvement), clinical treatment performed (use of DMARD, corticosteroid use, single versus combined DMARD), different criteria used for diagnosis and different radiological methods used (criteria
Conclusions
The incidence of cervical spine involvement in patients with RA is high. Our literature review reported a wide range in the prevalence of cervical spine instabilities, probably explained by the different studied populations and disease characteristics, such as treatment, disease duration and follow-up period. Systemic uncontrolled RA is probably the main risk factor for developing a spinal instability. Adequate treatment with DMARD and BA prevents development of cervical spine disease but
Take-home messages
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RA had a high rate of cervical spine involvement and routine radiological screening of the cervical spine is recommended.
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Uncontrolled RA and higher disease activity scores are probably the main risk factors for cervical instabilities
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DMARD and BA prevent de novo cervical instabilities but did not avoid progression of pre-existing lesions
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AAS is the most common form of cervical instability in RA
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Long term radiological follow-up is recommended in patients with cervical instabilities due to the risk
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2022, NeurochirurgieCitation Excerpt :RA is a chronic autoimmune inflammatory disorder, which characteristically presents as synovitis leading to bone and cartilage damage that manifests as pain and instability [1]. Involvement of the cervical spine occurs in 70–80% of patients and results in significant morbidity [2,3]. Furthermore, radiological signs of cervical involvement can be seen in 25% of patients with early RA and correlate with elevated inflammatory markers [4].
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No funds were received in support of this study. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. The authors have no financial interest in the subject of this article. The manuscript submitted does not contain information about medical device(s).
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Note: AAI, VS and SMO are used interchangeably in this manuscript.