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Rheumatoid Arthritis of the Cervical Spine
Article written by John Czerwein, MD
Rheumatoid arthritis is an autoimmune disease that affects less than 1% of the population. All racial groups are affected but aboriginal North Americans have a higher prevalence. Rheumatoid arthritis is a chronic, fluctuating disease that affects many joints of the body in addition to organ systems including the lungs, skin, heart, nervous system, and eyes. Of importance from a spine surgeon’s point of view is its effect on the cervical spine.
Eighty-six percent of patients with rheumatoid arthritis have cervical spine involvement. An autoimmune inflammatory process can affect and damage the ligaments, bones, and synovial joints in the cervical spine. This can lead to an unstable spine with resulting spinal cord or brainstem compression.
One of the earliest complaints is pain in the neck and base of the head (occipital neuralgia). Pain can even radiate to the ears. Pain with instability is generally worsened with neck motion, and patients may actually describe a clunking sensation or a feeling their head is falling forward. Electric shock-like sensations radiating into the body and extremities may be felt with either head extension or flexion and indicates possible spinal cord involvement. Over time, weakness in the extremities, clumsiness of the hands, and walking disturbances can occur which indicates spinal cord or brain stem involvement, also known as myelopathy.
Cervical spine x-rays can assess overall bony alignment and degree of osteopenia or bone loss. In addition, an MRI is an excellent tool in providing information about the brainstem, spinal cord, and bony structures. Imaging helps define cervical deformity and instability, but more importantly, it helps identify patients who are at risk for neurological (weakness, numbness or paralysis) injury.
The goals of treatment are to avoid development of irreversible neurologic deficit, to prevent sudden death caused by unrecognized neural compression.
Non-operative treatment includes aggressive medical management of rheumatoid arthritis, support with the use of soft collars, physical therapy, patient education, and close monitoring of neurologic status via repeated physical exams.
The most challenging patients are those that have radiographic evidence of cervical instability but have a normal neurologic examination without significant pain. One must look at the predictors of paralysis to determine which patients would benefit from prophylactic surgery. Absolute indications for surgery include patients with neurologic deficit and radiographic evidence of instability. Spine surgeons look at unique measurements when assessing stability of the cervical spine in rheumatoid patients. In the upper cervical spine, the relationship between the upper 2 cervical vertebra (C1 and C2) must be closely examined.
For these patients with significant instability, surgery is recommended to stabilize the spine, prevent further deformity, reduce pain, and stabilize or reverse myelopathy. The options for operative intervention include anterior and posterior fusion techniques using wires, screws, plates, or a combination of these techniques.
Rheumatoid arthritis can be a significant disabling disease when it affects the cervical spine. There are many forms of treatment available which could help improve the quality of life for these individuals.